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Pressure ulcer of right heel, stage 2
ICD10CM code
Name of the Condition
- Pressure ulcer of right heel, stage 2. Also known as a bedsore or decubitus ulcer.
Summary
- Pressure ulcers are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. A stage 2 ulcer is characterized by partial-thickness skin loss, presenting as an open blister.
Causes
- Pressure ulcers are primarily caused by sustained pressure that impairs blood flow to the skin. Commonly seen in individuals with limited mobility who are bedridden or use a wheelchair.
Risk Factors
- Factors include immobility, poor nutrition, dehydration, age, medical conditions affecting blood flow (such as diabetes), and sensory issues preventing the feeling of discomfort or pain.
Symptoms
- Stage 2 pressure ulcers may appear as shallow open wounds or blisters on the right heel, with surrounding skin redness or tenderness.
Diagnosis
- Diagnosis is typically made through visual inspection by a healthcare provider, assessing the depth, size, and appearance of the ulcer.
Treatment Options
- Treatments include relieving pressure on the heel, specialized dressings, cleaning the wound, and possibly using antibiotics if infection is present. Nutritional support and physical therapy may also be important.
Prognosis and Follow-Up
- With proper care, stage 2 ulcers can heal within a few weeks. Regular follow-up is crucial to monitor healing and prevent progression or recurrence.
Complications
- Without proper management, there's a risk of infection, worsening to a stage 3 or 4 ulcer, or even systemic issues such as sepsis.
Lifestyle & Prevention
- Frequent repositioning, using supportive devices, maintaining good skin hygiene, and ensuring adequate nutrition and hydration are key to prevention and management.
When to Seek Professional Help
- Seek medical attention if the ulcer does not show improvement, worsens, or shows signs of infection such as increased redness, pus, or a foul odor.
Additional Resources
Tips for Medical Coders
- Ensure correct identification of the location and stage of the ulcer. Double-check coding guidelines to distinguish between similar codes related to different ulcer stages and locations.