Documentation of Reopened Unstageable Coccygeal Pressure Injury
Document this as a new unstageable pressure injury at the coccyx, not as a recurrence of the previous stage 3 wound. 1, 2
Core Documentation Principle
Pressure injuries cannot be "reverse staged" or downgraded based on healing progress. 2 When a previously healed stage 3 pressure injury reopens and is now obscured by slough or eschar (making it unstageable), you must document it according to its current presentation, not its historical staging. 1, 3
Proper Documentation Components
Stage Classification
- Document as "Unstageable Pressure Injury" because the wound base is obscured by slough and/or eschar, preventing visualization of the true depth of tissue damage. 3
- Do not reference the previous stage 3 classification in the current staging designation. 1
- The unstageable classification remains until debridement allows visualization of the wound base, at which point it can be staged as 3 or 4 based on the deepest tissue layer visible. 1, 3
Required Documentation Elements
- Anatomic location: Specify "coccyx" or "coccygeal region" as the precise anatomic site. 1
- Wound dimensions: Length, width, and depth (if measurable after debridement). 4
- Wound bed characteristics: Amount and type of necrotic tissue (slough vs. eschar), percentage of wound bed covered. 4
- Exudate characteristics: Amount, color, consistency, and odor. 4
- Surrounding skin condition: Presence of erythema, induration, or maceration. 4
- History notation: Include in the narrative (not the staging) that this location had a previous stage 3 injury that healed, as this indicates higher risk for complications including osteomyelitis. 1, 5
Clinical Assessment Priorities
Infection Evaluation
- Use NERDS/STONES assessment tools to evaluate for wound infection, particularly important given the history of previous injury at this site. 6, 4
- Look for secondary signs including wound dehiscence, bridging, undermining, and pocketing to increase diagnostic specificity. 6
- Obtain wound cultures only if infection is suspected using the Levine technique for swab collection. 4
Underlying Bone Assessment
- Consider imaging (MRI preferred) to evaluate for osteomyelitis given the coccygeal location and history of previous stage 3 injury, as the lower sacral segments have subcutaneous bone with poor blood supply predisposing to deep tissue injury and infection. 1
- This is particularly important because recurrent coccygeal pressure injuries may benefit from coccygectomy to prevent future recurrence. 5
Common Documentation Pitfalls to Avoid
- Never document this as "stage 3 pressure injury, recurrent" - pressure injury staging reflects the current wound presentation, not historical depth. 2
- Do not stage the wound until debridement allows visualization of the base; premature staging of an eschar-covered wound is incorrect. 1
- Avoid outdated terminology such as "decubitus ulcer" or "bedsore"; use "pressure injury" or "pressure ulcer." 1
- Do not assume the wound depth matches the previous stage 3 classification - the reopened wound may be deeper (stage 4) or shallower, which cannot be determined until the wound base is visible. 3
Immediate Management Considerations
Debridement Priority
- Sharp debridement should be performed to remove necrotic tissue and allow proper staging and assessment. 6, 4
- Enzymatic debridement can be considered if sharp debridement is contraindicated. 6