Name of the Condition

• Pressure Ulcer of Left Heel, Stage 1
• Also known as: Pressure sore, Bedsore

Summary

Pressure ulcers are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. A Stage 1 pressure ulcer is the earliest and mildest stage, characterized by non-blanchable redness of the skin over a bony prominence, such as the heel, with the skin remaining intact.

Causes

• Sustained pressure on the skin, especially in areas with limited blood supply.
• Friction or shear, commonly from repetitive sliding or movement.
• Poor nutrition and hydration, affecting skin resilience and repair.

Risk Factors

• Limited mobility or immobility, often seen in individuals with prolonged bed rest or paralysis.
• Advanced age, as older adults have more fragile skin.
• Medical conditions affecting blood flow, such as diabetes or vascular disease.

Symptoms

• Redness on the heel that doesn’t turn white when pressed.
• Changes in skin texture or temperature, such as warmth or cooling.
• Discomfort or pain localized to the affected area.

Diagnosis

• Physical examination by a healthcare professional, focusing on skin assessment.
• Assessment of risk factors such as mobility, nutrition, and vascular health.

Treatment Options

• Relieving pressure through repositioning or specialized cushions and mattresses.
• Maintaining good skin hygiene and moisture.
• Ensuring adequate nutrition and hydration to support skin health.

Prognosis and Follow-Up

• With early intervention and proper management, Stage 1 pressure ulcers can heal without significant complications.
• Regular follow-up to reassess the ulcer and adjust care as necessary.

Complications

• Progression to more severe ulcer stages if untreated, potentially leading to infections.
• Potential impact on mobility and quality of life if the ulcer worsens.

Lifestyle & Prevention

• Regular repositioning for at-risk individuals to relieve pressure.
• Use of pressure-relieving devices such as cushions or mattresses.
• Skin inspection and care, maintaining cleanliness and dryness.

When to Seek Professional Help

• Persistent redness or signs of skin breakdown despite preventive measures.
• Increased pain or discomfort at the site of the ulcer.

Additional Resources

• National Pressure Injury Advisory Panel (NPIAP): npiap.com
• Wound, Ostomy and Continence Nurses Society (WOCN): wocn.org

Tips for Medical Coders

• Ensure the correct stage and location of the ulcer by reviewing clinical documentation thoroughly.
• Avoid common errors such as incorrect staging or laterality (i.e., left heel).
• Use ICD code L89.621 specifically for Stage 1 pressure ulcer of the left heel.