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Q&A: How should you stage a blood-filled blister on the heel?

By Jennifer LaBay, RN, RAC-MT - June 06, 2018

Question:  Can someone please tell me what stage a blood-filled blister on the heel is? Our wound nurse says the wound is a possible suspected deep tissue injury (DTI). Do you agree?

Answer: A blood-filled blister leads me to agree with the wound nurse’s assessment that it is a suspected deep tissue injury. 

It most certainly is not a stage 1 if it's a blister. If it was a pressure ulcer versus a sDTI, a blister is a stage 2. Please review the RAI User’s Manual definitions. A suspected deep tissue injury has symptoms around the blister itself, such as being boggy or a temperature change. 

From page M-21:

3. Examine the area adjacent to, or surrounding, an intact blister for evidence of tissue damage. If the tissue adjacent to, or surrounding, the blister does not show signs of tissue damage (e.g., color change, tenderness, bogginess or firmness, warmth or coolness), do not code as a suspected deep tissue injury.

Also, please review the definitions of stage 1 and stage 2 on pages M-9 and M-10.

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