experience –
Pressure sore classificationRating: (votes: 0) If it's truly pressure related it would be a stage II as well. Is it over a bony prominence? Comment:
it's on the hand
Comment:
Actually should a ruptured non-serum-filled blister be classified as a wound/pressure sore?
Comment:
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.
Comment:
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?
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Stage 2. The definition is clear. If it has ruptured the liquid drains... You can't have one without the other
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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.
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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.
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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.
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Quote from tkyeunghow 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.
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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.
Comment:
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.
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