L89.311 Pressure ulcer of right buttock, stage 1

ICD10CM code

#### Name of the Condition
- Pressure ulcer of the right buttock, stage 1
- Also known as decubitus ulcer, pressure sore, or bedsore.

#### Summary
- A pressure ulcer is an area of skin that has been damaged due to prolonged pressure. At stage 1, the skin is intact but may show signs like redness or discoloration on the right buttock that does not fade when pressed.

#### Causes
- Prolonged pressure from sitting or lying in one position, which restricts blood flow to the skin and underlying tissues.

#### Risk Factors
- Limited mobility, such as in individuals who are bedridden or use wheelchairs.
- Poor nutrition and hydration.
- Advanced age.
- Conditions that affect blood flow, such as diabetes or vascular disease.

#### Symptoms
- Red or discolored skin that may be warm to the touch.
- The skin may feel firmer or softer than the surrounding area.
- The affected area may be painful or tender.

#### Diagnosis
- Diagnosed through a physical examination by a healthcare professional, focusing on the appearance of the skin.

#### Treatment Options
- Relief of pressure on the affected area through position changes and use of supportive surfaces (e.g., cushions, mattresses).
- Keeping the area clean and dry to prevent progression.
- Ensuring proper nutrition and hydration.

#### Prognosis and Follow-Up
- With appropriate care, stage 1 pressure ulcers can heal completely. Regular monitoring is important to prevent worsening.

#### Complications
- If untreated, may progress to more severe stages leading to deeper tissue damage or infection.

#### Lifestyle & Prevention
- Regular repositioning to relieve pressure.
- Ensuring adequate nutrition and hydration.
- Using supportive devices such as specialized cushions and mattresses.
- Maintaining good hygiene.

#### When to Seek Professional Help
- If there is no improvement with initial care.
- If signs of infection develop (e.g., increased redness, warmth, swelling, or drainage).

#### Additional Resources
- National Pressure Injury Advisory Panel (NPIAP): [npiap.com](http://npiap.com)
- Wound, Ostomy, and Continence Nurses Society: [wocn.org](http://wocn.org)

#### Tips for Medical Coders
- Ensure the correct stage and location are documented in the patient's medical record.
- Avoid upcoding; confirm that the ulcer is indeed stage 1 and limited to the right buttock.

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