What is the appropriate treatment for a patient with an open blister, following Centers for Medicare and Medicaid Services (CMS) guidelines, in the absence of a specific treatment order?

Management of Open Blisters Without a Specific Treatment Order

For open blisters without a physician order, leave any adherent blister roof remnants in place, apply petrolatum-based ointment, cover with a non-adherent dressing, and monitor daily for infection—this approach follows evidence-based wound care principles that can be implemented under standard nursing protocols. 1, 2

Initial Assessment and Wound Preparation

When encountering an open blister, first determine whether the blister roof has completely detached or if remnants remain:

• If small areas of old blister flaps remain adherent without signs of infection, leave them in place as they serve as a natural biological dressing that protects the underlying wound bed, reduces bacterial contamination, and promotes re-epithelialization 2, 3
• Clean the affected area gently with antimicrobial solution, taking care not to cause further trauma 1
• Only remove blister roof remnants if the tissue is clearly necrotic, devitalized, or if clinical signs of infection are present (increasing erythema, purulent discharge, warmth, fever, or worsening pain) 1, 2

Critical caveat: The blister roof acts as a biological dressing—removing intact or adherent portions unnecessarily increases infection risk and delays healing 1, 2.

Topical Treatment Application

After cleaning, apply appropriate topical therapy:

• Apply petrolatum-based products (such as 50% white soft paraffin and 50% liquid paraffin) to support barrier function and reduce transcutaneous water loss 1, 2
• Alternatively, petrolatum-based antibiotic ointment (such as bacitracin) may be applied 1 to 3 times daily, which has been shown to accelerate healing and eliminate bacterial contamination within 16-24 hours 1, 4
• Do not use prophylactic antibiotics systemically or topically on clean wounds without infection, as this provides no beneficial effects and promotes antimicrobial resistance 2

Dressing Selection and Technique

• Cover the affected area with a low-adhesion, non-adherent dressing (such as Mepitel or Atrauman) held in place with soft elasticated viscose 1, 2
• Change dressings using aseptic technique 1
• The dressing reduces bacterial superinfection risk and promotes healing 2

Daily Monitoring Protocol

Establish a daily assessment routine that can be documented without requiring a specific order:

• Perform daily washing with antibacterial products to reduce bacterial colonization 1
• Monitor daily for signs of infection: increased erythema beyond wound margins, purulent discharge, fever, or worsening pain 1, 2
• If infection develops, notify the physician immediately as antibiotics and possible debridement of necrotic tissue will be required 2

Body Surface Area Considerations

The extent of blistering determines escalation needs:

• <10% BSA with asymptomatic blisters: observation and local wound care only are necessary 1
• 10-30% BSA: consider dermatology consultation and high-potency topical corticosteroids 1
• >30% BSA: immediate hospitalization with systemic corticosteroids is required 1

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs for pain control, which are well-tolerated 1

Key Pitfalls to Avoid

• Never remove adherent blister roof remnants without clear indication (infection or necrosis)—this is the most common error that increases infection risk 2, 3
• Avoid prophylactic systemic antibiotics in clean wounds, as evidence shows no benefit and promotes resistance 2
• Do not delay physician notification if signs of infection develop or if the patient has extensive blistering requiring escalation of care 1, 2

This approach aligns with standard wound care protocols that can be implemented under nursing scope of practice while ensuring appropriate physician notification for complications or conditions requiring advanced intervention.