Name of the Condition

• Pressure Ulcer of Right Buttock, Stage 4
• Also known as: Decubitus ulcer, bed sore, pressure sore

Summary

Stage 4 pressure ulcers are severe wounds that penetrate through the skin's deeper layers to muscles, tendons, or bones. They typically form on bony areas subjected to prolonged pressure, like the buttocks.

Causes

Pressure ulcers are caused by sustained pressure that impairs blood flow to the skin. This can occur from sitting or lying in one position for too long. Additional causes include friction and shear, which can damage the skin.

Risk Factors

• Immobility or limited mobility
• Advanced age
• Poor nutrition or hydration
• Medical conditions affecting blood flow (e.g., diabetes, vascular disease)
• Incontinence that leads to moist skin

Symptoms

• Deep wound reaching muscle or bone
• Blackened or dead tissue
• Drainage and odor
• Severe pain around the area

Diagnosis

Diagnosis typically involves a visual and physical examination by healthcare professionals. Assessment of wound depth and the presence of necrotic tissue help determine the stage.

Treatment Options

• Debridement: Removal of dead tissue to promote healing.
• Wound dressings: Specialized dressings to protect and promote a moist healing environment.
• Antibiotics: To treat or prevent infection.
• Surgical intervention: In severe cases, surgery may be needed to close the wound.
• Positioning and support surfaces: Repositioning and the use of pressure-relieving mattresses or cushions to reduce pressure.

Prognosis and Follow-Up

With appropriate treatment, healing is possible, though it may take months. Regular follow-ups are crucial to prevent recurring wounds and ensure healing progress.

Complications

• Infections (e.g., cellulitis, osteomyelitis)
• Sepsis
• Prolonged healing and potential for chronic wounds

Lifestyle & Prevention

• Regular repositioning to alleviate pressure
• Adequate nutritional support and hydration
• Skin inspections for early detection
• Use of cushions or mattresses designed to reduce pressure

When to Seek Professional Help

• Signs of infection (e.g., increased redness, swelling, pus)
• Wound deterioration or new ulcers
• Uncontrolled pain

Additional Resources

• National Pressure Injury Advisory Panel (NPIAP)
• Wound, Ostomy and Continence Nurses Society (WOCN)
• Mayo Clinic: Pressure ulcers

Tips for Medical Coders

• Ensure the correct laterality and staging is documented.
• Double-check codes for complications such as infections.
• Be mindful of updates in ICD-10 codes and guidelines.