What is the appropriate management of pressure‑related blisters in a bedridden patient with decreased level of consciousness?

Management of Blisters in Bedridden Patients with Low Sensorium

In bedridden patients with decreased consciousness who develop blisters, these should be recognized as pressure ulcers requiring immediate pressure relief, gentle blister puncture with roof preservation, application of petrolatum-based products, non-adherent dressings, and vigilant infection monitoring, as these patients are at extremely high risk for polymicrobial infection and mortality. 1, 2

Immediate Assessment and Classification

• Document the extent of blistering using body surface area (BSA) calculation: <10% BSA indicates localized pressure injury, 10-30% BSA requires dermatology consultation, and >30% BSA necessitates immediate hospitalization with multidisciplinary care. 2, 3

• Identify all blister locations with particular attention to areas over bony prominences (sacrum, ischium, greater trochanter, heels) where pressure ulcers most commonly develop in bedridden patients. 1, 3

• Assess blister characteristics including whether they are tense or flaccid, presence of surrounding erythema, and any signs of infection (purulent discharge, warmth, foul odor). 3, 4

Critical First Step: Pressure Relief

• Immediately eliminate all pressure from affected areas through patient repositioning every 2 hours, use of pressure-reducing surfaces, and keeping the head of bed at the lowest safe elevation to prevent shear forces. 5

• This is the single most important intervention, as continued pressure will cause progression from superficial blistering to deep tissue necrosis regardless of local wound care. 1, 5

Blister Management Technique

For intact pressure-related blisters:

• Pierce the blister at its base with a sterile needle (bevel facing up) at a site where gravity will facilitate drainage to prevent refilling. 1, 2, 4

• Apply gentle pressure with sterile gauze to absorb fluid completely. 1, 2

• Critically, leave the blister roof intact as it acts as a natural biological dressing that reduces infection risk and promotes re-epithelialization—this is essential in immunocompromised bedridden patients. 1, 2, 4

• Do not deroof the blister unless there are clinical signs of infection (see below). 1, 2, 4

For already ruptured blisters without infection:

• Leave remnants of the blister roof in place to serve as biological coverage. 6

• Gently cleanse with antimicrobial solution without causing further trauma. 1, 2, 4

For ruptured blisters with clinical signs of infection:

• Remove the blister roof completely and obtain bacterial and viral cultures. 1, 6

• Perform surgical debridement if necrotic tissue is present, as this is necessary to remove devitalized tissue in infected pressure ulcers. 1

Topical Treatment Application

• Apply petrolatum-based emollient (such as 50% white soft paraffin with 50% liquid paraffin) to all blister areas to support barrier function, reduce transcutaneous water loss, and encourage re-epithelialization. 1, 2, 4

• Alternatively, apply petrolatum-based antibiotic ointment which eliminates bacterial contamination within 16-24 hours and accelerates healing. 2

• Cover with non-adherent dressing held in place with soft elasticated bandage, changed using aseptic technique. 1, 2

Infection Prevention and Monitoring (Critical in This Population)

Bedridden patients with low sensorium are at extremely high risk for polymicrobial pressure ulcer infections involving both aerobes (S. aureus, Enterococcus, Proteus, E. coli, Pseudomonas) and anaerobes (Bacteroides, Clostridium), which can lead to sepsis and death. 1

• Perform daily washing with antibacterial products to decrease bacterial colonization. 1, 2

• Monitor daily for infection signs including increased erythema, purulent discharge, fever, worsening pain (though pain assessment is limited in patients with low sensorium), or foul odor. 1, 2, 4

• Obtain bacterial and viral cultures from any erosions showing clinical signs of infection. 1, 4

• Apply topical antimicrobials (such as silver-based products) only to areas with clinical signs of infection, not prophylactically, and only for short periods. 1, 4

• Initiate systemic antibiotics if there are signs of spreading cellulitis, systemic infection, or sepsis—these infections are typically polymicrobial requiring broad-spectrum coverage against Gram-positive, Gram-negative, and anaerobic organisms. 1

Nutritional and Systemic Support

• Assess nutritional status and provide supplementation as poor nutrition is a major intrinsic risk factor for pressure ulcer development and impaired healing in bedridden patients. 5

• Maintain fluid balance, thermoregulation, and hemodynamic stability as these patients often have skin failure requiring intensive nursing care. 1

Pain Management

• Administer analgesia prior to dressing changes as many patients report burning sensation during blister care, even those with decreased sensorium may experience discomfort. 1, 2

• Provide background analgesia with acetaminophen or NSAIDs as tolerated. 2

Common Pitfalls to Avoid

• Do not assume simple friction blisters in bedridden patients—these are pressure ulcers until proven otherwise and require aggressive pressure relief. 1, 5

• Do not routinely deroof intact blisters as the roof provides optimal biological coverage in this high-risk population. 1, 2, 4

• Do not apply topical antimicrobials prophylactically to all blisters, as this can promote resistance; reserve for clinically infected areas only. 1, 4

• Do not delay systemic antibiotics if there are any signs of spreading infection or systemic involvement, as these patients can rapidly progress to sepsis. 1

• Do not neglect repositioning schedules as continued pressure will cause progression regardless of excellent local wound care. 5