Pressure Ulcer, Stage II

Image and content excerpted from the VisualDx clinical decision support system.


Image of Pressure Ulcer, Stage II

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:

Complete

See descriptions of all packages available or sign up for a Free 30-Day Trial of the Essentials Package.


ICD Codes

ICD-9-CM:
707.22 – Pressure ulcer, stage II

707.00 – Chronic ulcer of skin, unspecified site

ICD-10-CM:
L89.92 – Pressure ulcer of unspecified site, stage 2

Synopsis

In 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
*See the Pressure Ulcer (Decubitus Ulcer) diagnosis in VisualDx.

Try VisualDx FREE for 30 days

VisualDx is your key to a faster, more accurate diagnosis.

Sign up today and receive a FREE 30-day trial to the VisualDx Essentials Package.

Your VisualDx subscription includes mobile access via our Apple and Android apps.

VisualDx is a web-based clinical decision support system used in over 1,500 hospitals and large clinics. Learn more.

Get your FREE 30-day trial