Name of the Condition

• Pressure ulcer of sacral region, stage 2
• Commonly referred to as a sacral bed sore or decubitus ulcer.

Summary

• A pressure ulcer is a localized injury to the skin and/or underlying tissue, typically over a bony prominence, as a result of prolonged pressure. A Stage 2 pressure ulcer involves partial-thickness skin loss with exposed dermis.

Causes

• Prolonged pressure on the skin, especially over bony areas like the sacrum, due to immobility.
• Friction and shear forces on the skin.
• Poor circulation to the affected area, often secondary to immobility or tightly-fitted medical devices.

Risk Factors

• Limited mobility due to confinement to a bed or wheelchair.
• Advanced age, which often comes with softer or thinner skin.
• Chronic conditions such as diabetes or vascular diseases that affect circulation.
• Incontinence that results in moisture, increasing skin vulnerability.

Symptoms

• Redness and soreness in the sacral area.
• Partial-thickness skin loss looking like an open blister or abrasion.
• Pain or tenderness in the affected area.

Diagnosis

• Physical examination of the skin.
• Assessment of skin color, texture, and integrity.
• Staging of the ulcer based on visible tissue damage.

Treatment Options

• Relieving pressure on the affected area by repositioning regularly.
• Use of special mattresses or cushions to reduce pressure.
• Wound care, including cleaning and bandaging, to promote healing and prevent infection.
• Topical or systemic antibiotics if an infection is suspected.

Prognosis and Follow-Up

• With appropriate care, Stage 2 ulcers can often heal within weeks.
• Regular follow-up is crucial for evaluating healing progress and adjusting treatment for complications.

Complications

• Infection which could lead to more severe health issues.
• Worsening of the ulcer to stage 3 or 4, involving deeper tissues, muscle, or bone.
• Chronic pain and reduced quality of life.

Lifestyle & Prevention

• Regular repositioning to alleviate pressure points.
• Maintaining good nutrition and hydration to improve skin health.
• Keeping skin clean, dry, and moisturized to prevent irritation or breakdown.

When to Seek Professional Help

• If you notice signs of infection, such as increased redness or pus.
• If there is no improvement within a few days or if the ulcer appears to be worsening.
• Sudden increase in pain or discomfort.

Additional Resources

• National Pressure Ulcer Advisory Panel (NPUAP)
• Wound, Ostomy and Continence Nurses Society (WOCN)
• Websites like MedlinePlus or Mayo Clinic for further reading.

Tips for Medical Coders

• Ensure accurate staging of the ulcer to apply the correct ICD code.
• Document both location and stage clearly in the medical record.
• Verify the ulcer’s cause is due to pressure; other types of ulcers have different codes.