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I am trying to find some evidence on the management of an intact blister over a stage 2+ pressure ulcer on the heel.
There is a lot of evidence on what to do if the blister has burst (debride necrotic tissue, moist wound healing along with pressure removal)
But nothing on whether the blister should be burst or not. Ther is some opinion that in general they should be left alone (just protection etc.) other opinion that if the blister is taught it should be partially asperated, but no concensus, from what I have read
__________________ Stephen Tucker Eastern Health
Podiatry Manager
PURPOSE: A nurse-driven performance improvement project designed to reduce the incidence of hospital-acquired ulcers of the heel in an acute care setting was evaluated.
DESIGN: This was a descriptive evaluative study using secondary data analysis. Data were collected in 2004, prior to implementation of the prevention project and compared to results obtained in 2006, after the project was implemented.
SUBJECTS AND SETTING: Data were collected in a 172-bed, not-for-profit inpatient acute care facility in North Central California. All medical-surgical inpatients aged 18 years and older were included in the samples. Data were collected on 113 inpatients prior to implementation of the project in 2004. Data were also collected on a sample of 124 inpatients in 2006.
METHODS: The prevalence and incidence of heel pressure ulcers were obtained through skin surveys prior to implementation of the prevention program and following its implementation. Results from 2004 were compared to data collected in 2006 after introduction of the Braden Scale for Predicting Pressure Sore Risk. Heel pressure ulcers were staged using the National Pressure Ulcer Advisory Panel (NPUAP) staging system and recommendations provided by the Agency for Health Care Quality Research (AHRQ) clinical practice guidelines.
RESULTS: The incidence of hospital-acquired heel pressure ulcers in 2004 was 13.5% (4 of 37 patients). After implementation of the program in 2006, the incidence of hospital-acquired heel pressure ulcers was 13.8% (5 of 36 patients).
CONCLUSIONS: The intervention did not appear to receive adequate staff nurse support needed to make the project successful. Factors that influenced the lack of support may have included: (1) educational method used, (2) lack of organization approved, evidenced-based standardized protocols for prevention and treatment of heel ulcers, and (3) failure of facility management to convey the importance as well as their support for the project.
Hi Stephen, Im of the empty the blister school of thought especially if its increasing in size. You also have to concider the patients over all condition and vascular status but I just like to remove that pressure, use a simple dressing and then off load. Follow up in a few days and reassess.
Decreasing the Incidence of Heel Pressure Ulcers in Long-term Care by Increasing Awareness: Results of a 1-Year Program.
Frain R. Ostomy Wound Manage. 2008 Feb;54(2):62-7.
Quote:
Heel pressure ulcers are a major problem in healthcare today. They involve extended clinician time, patient discomfort, and increased healthcare costs. In an attempt to decrease the incidence of heel pressure ulcers in one long-term care facility, a 1-year program was implemented that involved residents of one long-term care unit. In addition to staff education and awareness interventions, residents' heels were assessed daily and heel pressure-relieving measures were implemented. Kites were used to identify pressure ulcer stage, photo posters helped staff visualize the stages of heel pressure ulcers, and pencils marked with "Float Heels" were used to remind staff of the importance of prevention. Ulcer incidence rates were calculated every month. All residents (n = 40, mean age 67 years) on the unit at the beginning of the program were followed for as long as they were in the facility. At the start of the program, 50% of residents were at risk for developing ulcers and 22.5% had a heel ulcer. While the at-risk profile of residents remained relatively unchanged, no new ulcers were documented during nine of the subsequent 13 months, with incidence rates in the other 4 months ranging from 2.6% to 9.1%. Program costs were minimal and the results seem to confirm previously published studies about the positive effects of a comprehensive approach to the pressure ulcer problem.
There is now some "expert opinion" that suggests that a stable blister should be left intact and a growing blister aspirated a little with a syringe and resealed with opsite, then once burst, debride. But still no evidence on what promotes faster healing
__________________ Stephen Tucker Eastern Health
Podiatry Manager
Prevention of heel pressure sores with a foam body-support device. A randomized controlled trial in a medical intensive care unit
Cadue JF, Karolewicz S, Tardy C, Barrault C, Robert R, Pourrat O. Presse Med. 2008 Jan;37(1 Pt 1):30-6.
Quote:
BACKGROUND: To assess in a prospective controlled study the efficacy and safety of a specific foam body-support device designed as to prevent heel pressure ulcers.
METHODS: A randomization table was used to allocate 70 patients into 2 groups. The control group was treated with our standard pressure sore prevention protocol (half-seated position, water-mattress and preventive massages 6 times a day); the experimental group was treated with the same standard protocol as well as with the foam body-support device being evaluated. Patients were included if their Waterlow score was >10, indicating a high risk of developing pressure ulcers and if they had no skin lesion on the heels. Foam devices, covered with jersey, were constructed for the legs and allowed the heels to be free of any contact with the bed; another foam block was arranged perpendicularly to the first, in contact with the soles, to prevent ankles from assuming an equinus position (to prevent a dropfoot condition). The principal criterion for efficacy was the number of irreversible skin lesions on the heel (that is, beyond the stage of blanching hyperemia, reversible after finger pressure); these lesions were assessed every day until the end of the study (up to 30 days).
FINDINGS: The number of irreversible heel pressure ulcers was lower in the experimental (3 patients, 8.6%) than in the control group (19 patients, 55.4%) (p<0.0001). Mean time without any pressure ulcer was higher in the experimental group (5.6 days, compared with 2.8 days, p=0.01). The groups did not differ in the number of pressure sores on the sacrum and leg.
CONCLUSION: An anatomical foam body-support is effective in preventing heel pressure ulcers in patients on a medical intensive care unit and is well tolerated.
OBJECTIVE: To provide health care organizations with strategies for decreasing the prevalence of hospital-acquired pressure ulcers.
DESIGN: Hospital-acquired pressure ulcer prevalence was measured every 6 months for 4.5 years while multiple strategies were implemented. SETTING: The study took place in a not-for-profit, 548-bed, 2-hospital system in Southwest Florida. PATIENTS: All adult patients with the exception of those admitted for obstetric or mental health care. INTERVENTIONS: An assortment of interventions were implemented, including electronic medical records, risk assessment tied to automatic consults, pressure relief measures including new equipment and personnel augmentation, and an interdisciplinary team to decide on protocols.
MAIN RESULTS: Hospital-acquired prevalence rate for all pressure ulcers was reduced by 81%. The rate for heel ulcers alone was reduced by 90%.
CONCLUSION: A pressure ulcer prevention program has been developed, which has shown a trend toward improved patient outcomes with a resultant cost savings.
based on the idea that the blister is sterile inside, opening it via aspiration or daianage woudl allow a portal for possible infection, especially in a patinet who is already in a risk situation form having the pressure lesioal already. Possiby some firm, but not tight, general compresion with a crepe bandage to encourage re-absprption of blister may help? Maybe also use with a cot wedge to redece any focal pressure on the area and reduce friction forces?
Nice picture though... mind if I use it in a seminar?
Cheers!
__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
That's such a nice picture, you just like posting it up don't you? :)
Even though it's performed under sterile conditions, my concers is that it is still a break in the epidermis in what is obviously a compromised patient. Then again, if the blister is superficial enough? Still dont know if i'd drain it though.......
Cheers Stephen!
__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
based on the idea that the blister is sterile inside, opening it via aspiration or daianage woudl allow a portal for possible infection, especially in a patinet who is already in a risk situation form having the pressure lesioal already. Possiby some firm, but not tight, general compresion with a crepe bandage to encourage re-absprption of blister may help? Maybe also use with a cot wedge to redece any focal pressure on the area and reduce friction forces?
Nice picture though... mind if I use it in a seminar?
Cheers!
Far out, Newsbot, is there some sort of record in here?
No disrespect Adrian, I am enjoying your posts, keep it up.
I tend to agree with the theory not to break the epidermis for the said reasons
BUT
If the blister is such that the patient is experiencing severe difficulties in mobilising because of the pain that can't be remedied by any other means then perhaps a re-think and a drain is advisable??
I have reading this debate with interest and feel the need to add my 2 cents.
Should we taking into account the vascular status of the patient and whether there are staff/carers available to change dressings if we do create a portal of entry?
I would also think if the blister is filled with clear, serous fluid it is more superficial than one with haemoserous fluid which would indicate a breakdown into the dermis and may indicate the need for further investigation.
The height of the blister and it's 'turgidity' may be worth measuring (not sure how) as the higher it is the more likely it is to burst and create a non sterile field anyway. Ie: if it is more than 5mm in height, perhaps its better to drain in a more controlled environment with sterile instruments than wait for it to pop.
My gut feeling is if it fluctuates, drain it, if not just protect and monitor it.
Heel Blister: Minimal heamoserous fluid, no erythema, no infection
. Cover and protect the ulcer with a semipermiablefilm or contoured adhesive foam or hydrocolloid heel dressing
. Review daily, leave dressing in place for 1-2 weeks
Heel Blister: Tense, moderate heamoserous fluid, no erythema, no infection
. Aspirate small amount of fluid to relieve tension
. cover with semi permiable film
. review daily, leave dressing in place for 1 week
. Should blister rupture, debride non-viable tissue (Blister roof)
. cover with foam or hydrocolliod review 3-4 days
__________________ Stephen Tucker Eastern Health
Podiatry Manager
The height of the blister and it's 'turgidity' may be worth measuring (not sure how) as the higher it is the more likely it is to burst and create a non sterile field anyway. Ie: if it is more than 5mm in height, perhaps its better to drain in a more controlled environment with sterile instruments than wait for it to pop.
I agree with this. If your Ax of the blister indicates that it is likely to burst anyway wouldnt it be more favourable to drain it with a syringe or small scalpel incision at the base of the lesion, leaving the area relatively intact, rather than it bursting in a patient's shoe which is a completely un-controlled environment? God knows what is kicking around in some people's shoes!
Also, I have always been advised to leave the "roof" of the blister in tact as much as possible rather than "de-roofing" upon drainage. what are people's thoughts on this?
On another note, the use of lambs wool rugs/mats in bed to lie under the heel in order to offload/cushion the area that is under increased pressure?
Decreasing the incidence of heel pressure ulcers in long-term care by increasing awareness: results of a 1-year program.
Frain R Ostomy Wound Manage. 2008 Feb;54(2):62-7
Quote:
Heel pressure ulcers are a major problem in healthcare today. They involve extended clinician time, patient discomfort, and increased healthcare costs. In an attempt to decrease the incidence of heel pressure ulcers in one long-term care facility, a 1-year program was implemented that involved residents of one long-term care unit. In addition to staff education and awareness interventions, residents' heels were assessed daily and heel pressure-relieving measures were implemented. Kites were used to identify pressure ulcer stage, photo posters helped staff visualize the stages of heel pressure ulcers, and pencils marked with "Float Heels" were used to remind staff of the importance of prevention. Ulcer incidence rates were calculated every month. All residents (n = 40, mean age 67 years) on the unit at the beginning of the program were followed for as long as they were in the facility. At the start of the program, 50% of residents were at risk for developing ulcers and 22.5% had a heel ulcer. While the at-risk profile of residents remained relatively unchanged, no new ulcers were documented during nine of the subsequent 13 months, with incidence rates in the other 4 months ranging from 2.6% to 9.1%. Program costs were minimal and the results seem to confirm previously published studies about the positive effects of a comprehensive approach to the pressure ulcer problem.
Heel Presure Ulcers
Re: Heel Pressure Ulcers
Linear Mode
