Pressure sore classification

anonymurse · Feb 25, 2014

Ask your wound care nurse. Local documentation conventions rule. And as everyone's been saying, make darned sure the cause was pressure before staging it.

MunoRN, RN · Feb 25, 2014

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.

It was once the case that all blisters were stage 2, which has since been changed: Update on Blister Pressure Ulcer Staging from CMS for MDS 3.0 Section M: Skin Conditions - Jeffrey M. Levine MD | Geriatric Specialist | Wound Care | Pressure Ulcers

nurseprnRN, BSN, RN · Feb 25, 2014

Is there some reason that you can't chart it as "ruptured blister, no evidence of fluid at this time"?

edmia, BSN, RN · Feb 25, 2014

It was once the case that all blisters were stage 2, which has since been changed: Update on Blister Pressure Ulcer Staging from CMS for MDS 3.0 Section M: Skin Conditions - Jeffrey M. Levine MD | Geriatric Specialist | Wound Care | Pressure Ulcers

Right. That's the serum filled differentiation vs. blood filled.

Still not sure the OP is getting this though...

CWONgal · Feb 25, 2014

Ruptured serum filled blister is different than the other blister you could see w/ a deep tissue injury which is filled w/ blood. Two different types of blisters, two different stages of PU's. I would recommend looking at the NPUAP guidelines for staging. Stage II can be a serous filled blister, a ruptured blister that was serous filled initially, or you will see what I describe as "skinned knee" look. The epidermis is gone and you see the red tissue beneath. It is painful and often appears moist. With staging, according to the guidelines you must identify it is due to pressure which can and does happen w/ medical devices as well. I see too many examples of incorrect staging and many people have difficulty differentiating between moisture associated dermatitis and pressure ulcers.

CWONgal · Feb 25, 2014

BTW, I am a certified wound and ostomy nurse if that helps.

tkyeung · Feb 26, 2014

but i still don't get the definition of ruptured serum-filled blister right. does it make sense that we see a ruptured blister filled with serum? if serum drains after the rupture

CWONgal · Feb 26, 2014

You are overthinking it....it's a serum filled blister that ruptured. You can tell it was serum filled from the initial presentation, the appearance of the exudate on a bandage, or maybe there is dried exudate to help you differentiate.

tkyeung · Feb 26, 2014

how about a blister that has ruptured and dried up, can it be still regarded as stage II?

CWONgal · Feb 26, 2014

Yes, see below.

Category/Stage II: Partial thickness

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 or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

*Bruising indicates deep tissue injury.

tkyeung · Feb 26, 2014

I see. if there is a small opening/rupture in the blister, how should i care for the blister, should i drain out all the serous fluid to promote healing?

tkyeung · Feb 26, 2014

Also, as ruptured blisters are already empty of fluid, using the words ruptured serum-filled blisters is misleading, right?