Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 31

CLINICAL PRACTICE GUIDELINE

trials have not identified the optimal frequency
of reassessment, this parameter is integral to
wound evaluation. Bergstrom et al. (1994)
recommend weekly reassessment of pressure
ulcers to determine the individual's response to
the care plan, while van Rijswijk and Braden
suggested that healing should be monitored
during each dressing change and reassessed at
least weekly (van Rijswijk and Braden, 1999).
Lazarus et al. (1994) advised that wound changes
always be correlated with changes in the
individual's health status.
When determining reassessment intervals,
consideration should be given to the individual's
health status, care setting, pressure ulcer
category/stage, and other variables (van Rijswijk,
1995). Reassessment intervals may vary for
individuals in rehabilitation, acute, subacute,
extended care, or home-care settings.
Furthermore the goal of reassessment may differ
among wounds, whereas the rationale for
reassessment of category/stage II ulcers may be
to detect epithelialization, the rationale for
reassessment of category/stage III and IV ulcers
may be to detect the signs and symptoms of
infection and granulation (van Rijswijk, 1995).
An objective and thorough description of
pressure ulcers enables the development of an
appropriate treatment plan, forms the basis for
serial assessment to determine the response of
the wound to treatment, and provides a reliable
means of communicating wound status among
health-care professionals.
The anatomic location of a wound should be
clearly delineated and specified. Pressure ulcer
locations should contain the name of the bone
against which pressure is applied, for example,
the plantar aspect of the foot would not be
adequate, but the metatarsal head would be an
accurate representation of location; the medial
malleolus instead of the ankle; the trochanter,
instead of the hip. The extent of tissue loss guides
the selection of interventions and helps the
clinician determine the potential healing time.
Before assessing the wound it is important
to remove all wound debris by thorough cleansing
of wound and periwound skin. Skin involvement
may be full thickness or partial thickness. If
the wound's etiology is pressure, the wound
should be staged accordingly (see "Staging of
Pressure Ulcers").
The characteristics of the wound base may
vary within the wounds. Tissue types should be
described in percentages. Descriptors of tissue
type may include: granulation tissue, epitheal
tissue, muscle tissue, subcuataneous tissue,

eschar, or slough. There may be viable tissue,
such as granular, epithelial, muscle, or
subcutaneous tissue, as well and nonviable tissue,
such as eschar, slough, or clean, nongranulating
wound base. For example, a description of "20%
adherent and loose necrotic slough, 30%
nongranulating, and 50% granulation tissue" may
indicate the extent that a wound is or is not
progressing if performed serially. Biofilm on the
wound base should raise concern. Biofilm
consists of polysaccharide polymers bound
together by metal ions creating a viscous gel-like
substance that acts as a physical barrier
impermeable and resistant to the action of
antimicrobial agents. Biofilms can appear as a
stubborn, slimy film frequently overlying the
granulation tissue. The presence of granulation
tissue is evidence of healing in the ulcer base and
is typically beefy red, bumpy, or pearly and shiny.
Epithelialization is the regrowth of epidermis
across the surface of the pressure ulcer. The
presence of eschar and its appearance should be
documented. A black eschar is indicative of dried
necrotic tissue, while a yellow covering of the
wound surface may be indicative of a fibrin
slough. A clean, red appearance of the wound
base indicates the absence of necrotic tissue.
Wound measurement techniques include
(1) simple linear measurements of length by
width and depth;
(2) traditional wound tracings to determine
surface area;
(3) digital photo-planimetry calculating a wound
area from digital photographs;
(4) computerized assisted tablets using a wound
tracing retraced into a digital tablet; and
(5) a combination of a hand-held personal digital
assistant (PDA) and laser beams, referred to
as a scanner, to correct image scale and skin
curvature (Romanelli et. al., 2012).
Wound dimensions provide a valuable
indicator of healing progression. Although
sophisticated wound size measurement techniques
(direct measurement of volume, tracing
planimetry, and so forth) may provide the most
precise measurements of wound size (Cutler et
al., 1993; Griffin et al., 1993; Hayward et al.,
1993; Hooker et al., 1988, Haghpanah et al.,
2006), routine clinical assessment should include
measuring wound size (length, width, and depth)
with a ruler. Length should be along the longest
dimension of the wound and width is the
maximum dimension perpendicular to the length
axis. The depth of the wound should be measured
from the deepest point to the imaginary surface

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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