Pressure Ulcer

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L89.91 – Pressure ulcer of unspecified site, stage 1
L89.92 – Pressure ulcer of unspecified site, stage 2
L89.93 – Pressure ulcer of unspecified site, stage 3
L89.94 – Pressure ulcer of unspecified site, stage 4
L89.95 – Pressure ulcer of unspecified site, unstageable

420226006 – Pressure ulcer


Pressure ulcers, previously termed decubitus ulcers, are also commonly referred to as pressure sores and bed sores. The ulcer is an area of ischemic ulceration or tissue necrosis that generally occurs over bony prominences in locations situated below the waist. Pressure ulcers affect from 1.5-3 million people in the US at an annual cost of approximately 5 billion dollars.

They occur more commonly in certain subsets of patients such as the elderly (over the age of 70), patients who have had surgery for hip fracture, and patients with spinal cord injury.

Factors promoting pressure ulcer formation include the following:
  • Pressure: This is the primary contributive factor leading to formation of ulcers. The length of time over which high pressures are sustained is just as important as the degree of pressure. Thus, relieving pressure regularly prevents tissue damage or tissue death.
  • Friction: This occurs when 2 surfaces resist movement at their interface, resulting in damage to superficial layers of skin. Intraepidermal blisters can result that then lead to superficial skin erosions. Friction can occur when a patient is dragged across a bed sheet or when a patient wears a badly fitting prosthetic device.
  • Shearing forces: This is generated by the motion of bone and subcutaneous tissue relative to the skin, which is prevented from moving due to friction (as seen when the head of the bed is raised to more than 30 degrees or when a seated patient slides down a chair).
  • Moisture: Moist surfaces predispose to ulcer formation in 2 ways. First, they increase the effects of pressure, friction, and shear. Second, they cause maceration of the skin, thereby increasing the incidence of ulcer formation fivefold. These conditions may arise due to perspiration, urinary or fecal incontinence, or leakage from a wound site.
Pressure ulcers are classified according to the extent of tissue damage:
  • Stage I: Nonblanching erythema of intact skin.
  • Stage II: Partial thickness skin loss, with loss of the epidermis and some of the dermis. No slough or necrotic tissue present.
  • Stage III: Full thickness loss of skin, with the epidermis and dermis gone and damage to or necrosis of subcutaneous tissues. Damage extends down to but not through the underlying fascia.
  • Stage IV: Full thickness loss of skin with extensive destruction, tissue necrosis, and damage to bone, muscle, or other supporting structures.
Two additional stages of pressure ulcer formation were added in 2007 (National Pressure Ulcer Advisory Panel;
  • Deep tissue injury: Localized area of discolored skin that is purple or maroon-red in color. It is nonblanching with an intact dermis, and skin has a boggy feel to it.
  • Unstageable pressure ulcers: Full tissue thickness loss in which the base of the ulcer is covered by slough or an eschar, and therefore the true depth of the damage cannot be estimated until these are removed. (Note: stable eschar – no erythema present, dry, and adherent – on the heels should not be removed, as it serves as a natural cover.)
Risk factors leading to pressure ulcer formation are as follows:
  • Limited mobility
  • Malnutrition
  • Anemia
  • Advanced age
  • Fecal or urinary incontinence
  • Smoking
  • Dry skin
  • Altered skin perfusion – Decreased in cases of shock or increased if patient has fluid edema due to overhydration.
  • Acute illness leading to temporary immobility
  • Chronic systemic illness
  • Terminal illness
  • Degenerative neurologic disease
  • Increased weight
  • Sudden decrease in weight
  • Altered mental status
  • Prolonged pressure
Simultaneous treatment with the following medications can also predispose to ulcer formation:
  • Corticosteroids
  • Sedatives
  • Analgesics
  • Antihypertensives
When a patient presents with a pressure ulcer, the following criteria should initially be followed:
  1. Assess and record the stage of the ulcer and the location according to ICD codes.
  2. Carry out an assessment using the Braden or Norton scales. These are tools for predicting pressure ulcer risk; this should be done for patients who have not yet developed an ulcer but could be susceptible to one and those who have already developed one. This is an important assessment, as it determines the prevention measures taken and the type of pressure-reducing support surfaces consequently used.
  3. Monitor the progress daily.
When assessing a pressure ulcer, take note of the following factors:
  • Location of the ulcer.
  • Size of the ulcer, including the length, width, and depth.
  • Stage of the ulcer.
  • Appearance of the ulcer bed, if visible. Observe the tissue color and whether it appears moist. The wound bed color for healthy granulating tissue is pink-red and cobblestone like. A red and smooth wound bed is indicative of clean but nongranulating tissue. Unhealthy granulation tissue is dark red and bleeds on contact.
  • Wound edges – Look carefully at the edge of the ulcer for evidence of induration, maceration, rolling edges, and redness.
  • Skin around the edges of the ulcer. The periwound skin should be assessed for color, texture, temperature, and integrity of the surrounding skin.
  • Drainage – If exudate is present, note the color and amount.
  • Presence of necrotic tissue or eschar.
  • Presence of complicating features, such as undermining, tunneling, and tracts.
  • Any odor emanating from the ulcer.
  • Presence or absence of pain.

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