Pressure Ulcer, Stage II
Image and content excerpted from the VisualDx clinical decision support system.
VisualDx images show variation in age, skin color, and disease stage. VisualDx has 4 images of Pressure Ulcer, Stage II.
Full text and additional images for Pressure Ulcer, Stage II are available in the following VisualDx packages:
707.22 – Pressure ulcer, stage II
707.00 – Chronic ulcer of skin, unspecified site
L89.92 – Pressure ulcer of unspecified site, stage 2
SynopsisIn stage II pressure ulcers, there is partial thickness skin damage with loss of the epidermis and some of the dermis. The wound appears as a shallow, open ulcer or a superficial erosion with a wound bed that is red-pink in color. Stage II ulcers may also present as a serum-filled blister. No slough or necrotic tissue is present in the base.
Typical sites of stage II pressure ulcer formation are the sacrum followed by the heels. Constant pressure for a time period of 2 hours is all that is required to initiate an ischemic event and to cause ulceration. Risk factors that predispose to ulcer formation include immobility, incontinence, old age, nutritional deficits, and altered mental faculties.
The ulcer (stage and location according to ICD-9 codes) should be documented, and a risk assessment scale should be carried out using the Braden scale.*
When examining the ulcer, observe the following:
- Location on the body
- Staging of the ulcer
- Size of the ulcer, which should include depth, width, and the length in centimeters
- Wound bed – Appearance of the wound bed and the type of tissue visible. Observe the tissue color and whether it appears moist. The wound bed color of healthy granulating tissue is beefy red and cobblestone like. A red and smooth wound bed is indicative of clean but nongranulating tissue.
- Wound edges – Look carefully at the edge of the ulcer for evidence of induration, maceration, rolling edges, 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; exudate – If present, the color, amount, and presence of any odor.
- Presence or absence of pain
- Odor, if present or absent