To debride......or not to debride

[hanoverianfever]

We have a patient who is 93 years old. She is well nourished, but has been failing over the past few weeks. She has just acquired a Blister/pressure area to her heel. The area a few days ago appeared to have serous fluid inside. The blister is approx 4cm in diameter. Today, the blister looks darker containing serosanguinous fluid. She also has some edema to her legs.

Do we debride the area or not? These are my thoughts.

I would like to leave the area covered for at least a week. With the diuretic, I am hoping that circulation will improve and the fluid will reabsorb. Also, with the blister intact we are providing a sterile environment which will prevent infection. Presently we are 'floating' the heel so as not to have any pressure to the area. I am definately conflicted because, if I leave it for a week the area may get worse. Does anyone have any thoughts on this?

[SuesquatchRN, BSN, RN]

I wouldn't debride anything without necrosis.

[jnette, ASN, EMT-I]

We had a doc pull a 6 cm fluid filled blister off one of our patients from the top of her foot, and I want you to know we spent the next ELEVEN MONTHS trying to get that thing finally healed up !!!

I'd leave it and continue to very closely monitor......

[Murse901, MSN, RN]

I'm not a wound care nurse, but I've NEVER heard of debriding a blister (i.e. stage 2), especially an unbroken blister. I always thought debriding was for eschar.

Do you mean should you drain the blister?

I would just leave it alone either way unless it looks like the tissue is crapping out on you. The precautions you're taking sound fine.

[Merlinsmom]

Never "pop" a blister, That is what I have been taught/learned. Basically, you have a sterile environment now and if you open it...you are inviting bacteria in to party it up (warm and moist, they love that). Continue to float the heel, also where I uses to work, we gently cleansed the area with saline and applied skin prep as a sort of "second skin" BID. This is what I learned and from my experience...it has been helpful for my patients, I hope it helps you. Good luck!

[achot chavi]

Do not debride!!! This is a medical decision at any rate, I think you should send the pt for a dupler/duplex ( checks circulation) to assess any venous or arterial blockages.

You must control the swelling by elevating the leg, using stretch gauze or TED stocking- whatever the doctor feels is appropriate.

You Must Make Sure that there is NO PRESSURE to the area or it will impede healing.

We use a doughnut like cushion which we wrap around the ankle when the pt is in bed.

Check that her shoes arent causing the pressure or irritation,. I once had an alzheimers ambulatory pt who got fake Crocs as a gift and they caused a heel blister that never healed- became infected... next thing we know he had osteomyelitis... died with the darn ulcer ( he was diabetic).

Make sure her bed has a pressure- relieving cover- I love sheeps skin but air or eggcrate is fine too.

Keep the skin well moisturized, moniter- in all probablity it will dry up and fall off within a couple of months.

Depending on her other diagnoses= diabetes, obesity, PVD or other circulatory problems etc.

For healing - Vit C and Zinc are good. Make sure her protein/ albumin levels are normal- (not all good eaters have good protein levels)

Give her pain killers for any pain- as per MD order.

if you want - take its picture and follow its progress on camera for a future in- service.

[CapeCodMermaid, RN]

The standard of practice for blisters....leave it be..off load pressure and watch it. As my grandmother would have said "God put that blister there to keep the skin underneath clean"...

[hanoverianfever]

yes thanks, we are using a donut like cusion and making sure that we are not putting any pressure to the area. I had the doctor look at it, but doctors usually are not the greatest at wound care lol!! The picture idea is great, never thought of that. In any case , we are not going to touch it. Thankyou all for your opinion, it just reinforces what I have already thought.

[CapeCodMermaid, RN]

Please NO donuts...they only create more pressure around the wound. A foam boot which suspends the foot or a foam wedge which keeps the foot off the bed is better. And be careful about taking pictures. Most facilities around here have stopped taking pictures due to liability or HIPAA.

[achot chavi]

it depends on if you see more than the ankle in the picture- most of our pts signed a release (yours too- probably- ask your SW), in any case you can ask if they mind before you click.

Yes sometimes there is increased pressure in the area by the donut IF YOU DONT DO T&P properly. in any case- if you see the begining of pressure- obviously change positions and take the donut off.

[hanoverianfever]

Please NO donuts...they only create more pressure around the wound. A foam boot which suspends the foot or a foam wedge which keeps the foot off the bed is better. And be careful about taking pictures. Most facilities around here have stopped taking pictures due to liability or HIPAA.

Actually, it is a circular foam piece which sits around the calf. The pressure/blister area is on the heel, so we are not creating any pressure. I am a nurse who works in Canada, and I have not heard of any liability issues r/t pictures of wounds etc...especially if it is for the benefit and wellbeing of the resident in pursuing the primary goal of wound healing. Thanks for your feed back though!

[dressagediva]

to hanovarian fever , sounds like you are well in control over the issue , however if it remains fluid filled after observing it for a week , and no absorption is happening , I would be concerned about the healthy tissue underneath ..