Pressure sore classification

[tkyeung]

I know that if a wound is a serum-filled blister, it should be classified as stage II pressure sore. How about if the blister is already ruptured and all the serous fluid has drained out of the blister, such that no more serous fluid is left inside, then how should this wound be staged?

[CWONgal]

If it's truly pressure related it would be a stage II as well. Is it over a bony prominence?

[tkyeung]

it's on the hand

[tkyeung]

Actually should a ruptured non-serum-filled blister be classified as a wound/pressure sore?

[edmia, BSN, RN]

A blister, ruptured or not, is a stage 2 in my understanding - I'm not a wound care specialist but I do find this area fascinating.

Now the more important question is whether this was a pressure related injury. On the hand: was it related to a device? Was is related to IV medication? Too many things are classified with the pressure ulcer staging when they are not pressure related... A blister on the hand sounds more like chemical or heat related injury to me. But I'm just speculating based on the info you've given.

[tkyeung]

Suppose that the blister is caused by prolonged pressure,but the definition of stage 2 pressure sore is as follows:

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. If all the serum has left the blister after rupturing, how should it be staged?

[edmia, BSN, RN]

Stage 2. The definition is clear. If it has ruptured the liquid drains... You can't have one without the other

[tkyeung]

but how should i interpret the term "ruptured serum-filled blister"? after ruptured, how come it can be serum-filled based on the rationale that if ruptured, the liquid drains.

[MunoRN, RN]

Ulcers are defined by the wound bed, so if the wound bed cannot be assessed (if it's covered with exudate, eschar, etc) then it is considered "unstageable". A "suspected deep tissue injury" is also now a stage and it's the one exception to needing direct visualization of the wound bed.

[tkyeung]

how about the term "ruptured serum-filled blister"? after ruptured, how come it can be serum-filled based on the rationale that if ruptured, the liquid drains.

[edmia, BSN, RN]

how about the term "ruptured serum-filled blister"? after ruptured, how come it can be serum-filled based on the rationale that if ruptured, the liquid drains.

I'm not sure why you are obsessing on these words. What happened is that they clarified that blisters are to be considered stage 2. It does not matter if the skin is ruptured or not. I guess a blister could be blood filled in which case it is not a pressure ulcer. The point is that a blister is a break in the skin integrity, not just non-blanching erythema (stage 1). The serum is the result of the separation of the skin layers : stage 2.

If the blister pops, then clearly there's a break in the skin. I believe people were staging blisters as stage 1 or unstageable because you couldn't visualize the wound bed. Now it is clear. If you see a blister then you call it a stage 2.

[AMN74]

Since the "blister" was on the hand...was it a pressure ulcer at all? Pressure ulcers, even "blisters" have to start with being a pressure point, or a source where the pressure started. Did something rub or put pressure on the hand to cause the blister in the first place? If I spilled boiling water on my hand and got a blister from a burn, then it is not and never was a pressure ulcer of any sort. If I had an IV canula taped down on my hand for days and it caused pressure and I develop a blister then it is a pressure area. The fluid filled blister is considered a stage II pressure ulcer. When the blister pops and the fluid is gone, then if the first layer of my skin is gone it is still a stage II pressure area. if the area develops in such that it becomes deeper, and muscle is exposed then it could be a stage III or a stage IV if you could see bone tendon in that area. Since there is not much flesh on the hand it could easily develop into a deeper sore. But calling it a pressure ulcer at all has to start with the root cause of the reason the blister is on the area. It is not a pressure sore if the blister was not caused by pressure. It would be a traumatic blister.