Name of the Condition

• Pressure ulcer of other site, stage 2
• Also known as bed sore, decubitus ulcer

Summary

A stage 2 pressure ulcer is an area of skin damage caused by prolonged pressure. This stage involves partial thickness skin loss with exposed dermis, often appearing as an open blister. It commonly affects areas of the body with bony prominences, under sustained pressure.

Causes

• Prolonged pressure on the skin, especially over bony areas
• Shear and friction forces during movement
• Inadequate blood flow due to pressure constriction

Risk Factors

• Limited mobility or confinement to bed or a wheelchair
• Age, particularly older adults
• Poor nutrition and hydration
• Chronic conditions, like diabetes or vascular disease
• Incontinence leading to skin moisture

Symptoms

• Open wound or blister on the skin
• Redness or discoloration around the area
• Pain or tenderness at the site of the ulcer
• Possible clear fluid drainage

Diagnosis

• Visual examination by healthcare provider
• Assessment of risk factors and medical history
• Pressure ulcer staging determination

Treatment Options

• Regular repositioning to alleviate pressure
• Use of specialized mattresses or cushions
• Cleaning and dressing the wound to promote healing
• Use of wound care products like occlusive dressings or hydrocolloids
• Nutritional support and hydration

Prognosis and Follow-Up

• With appropriate care, stage 2 pressure ulcers can heal within weeks
• Regular follow-ups are crucial to monitor healing and prevent progression
• Maintaining skin care and mobility as part of long-term management

Complications

• Infection leading to cellulitis or sepsis
• Progression to deeper wound stages (stage 3 or 4)
• Extended hospital stays or need for advanced medical care

Lifestyle & Prevention

• Frequent repositioning, at least every 2 hours for bed-bound individuals
• Use pressure-relieving devices
• Maintain good skin hygiene and moisture control
• Ensure adequate nutrition and hydration
• Regular skin assessments for early detection

When to Seek Professional Help

• Unusual redness or warmth around a wound
• Development of new or worsening sores
• Signs of infection such as pus, odor, or fever
• Pain that increases in intensity

Additional Resources

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

Tips for Medical Coders

• Accurately identify and capture the correct stage of the ulcer
• Note the specific location of the ulcer as "other site"
• Be alert to possible complications or secondary diagnoses that should also be coded