Name of the Condition

• Pressure Ulcer of Sacral Region, Stage 1
• Also known as a sacral bed sore or decubitus ulcer.

Summary

• A pressure ulcer, or bed sore, is a localized injury to the skin and/or underlying tissue usually over a bony prominence, like the sacral region. Stage 1 indicates non-blanchable redness, where the skin is not broken.

Causes

• Pressure ulcers are primarily caused by prolonged pressure on the skin, reducing blood flow to the area, leading to tissue damage.

Risk Factors

• Limited mobility, age (elderly), poor nutrition, dehydration, incontinence, and medical conditions affecting blood flow (e.g., diabetes).

Symptoms

• Redness that doesn’t fade when pressed, skin may feel warm or cool to the touch, discomfort or pain in the affected area.

Diagnosis

• Physical examination by a healthcare provider, assessing the skin for signs of pressure damage.

Treatment Options

• Relieving pressure on the affected area using cushions or specialized mattresses.
• Keeping the area clean and moisturized.
• Improving nutrition and hydration to support skin health.

Prognosis and Follow-Up

• Early-stage pressure ulcers can heal with proper care; however, they require diligent management to prevent progression.
• Regular follow-ups to monitor healing and prevent recurrence.

Complications

• If untreated, Stage 1 can progress to more severe stages, potentially leading to infection and severe tissue damage.

Lifestyle & Prevention

• Regularly changing positions to alleviate pressure.
• Maintaining good hygiene and skin care.
• Following a balanced diet and staying hydrated.

When to Seek Professional Help

• If redness persists despite repositioning, if there is an increase in pain, or if there are signs of skin damage or infection such as swelling or pus.

Additional Resources

• National Pressure Injury Advisory Panel (NPIAP) - Website
• Wound, Ostomy and Continence Nurses Society - Website

Tips for Medical Coders

• Ensure correct stage coding by verifying documentation explicitly states 'Stage 1.'
• Pay attention to the anatomical site being coded; confirm it matches 'sacral region.'