Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 33

CLINICAL PRACTICE GUIDELINE

invade the healthy tissue, overwhelm host
resistance, and create cellular injury leading to
local or systemic symptoms. The classic signs of
infection are increased purulent exudate,
induration, warmth, pain, tenderness, and
periwound erythema. Chronic wounds may not
necessarily show signs of infection, but its
presence is evident from delayed healing,
discolored granular tissue, breakdown at the
wound base, and foul odor. Clinically significant
wound infection (as distinct from colonization) is
felt to be an important cause of delayed wound
healing. Gross exudate should not be routinely
cultured. Deep tissue biopsy is the most accurate
means of determining soft tissue infection.
Wound pain may indicate infection or wound
deterioration in persons with preserved sensation
at the level of the pressure ulcer. Pain should be
measured routinely and frequently using validated
pain assessment scale such as the International
Pain Basic Data Set (http://www.iscos.org.uk/
international-sci-pain-data-sets). In persons with
SCI who are prone to autonomic dysreflexia from
a noxious stimulus occurring below the level of
injury, the development of autonomic dysreflexia
especially when there is coincident irritation of a
pressure ulcer from either direct or shear
pressure, indicates that something should be done
emergently to relieve this pressure. In this
situation, autonomic dysreflexia may be
considered a proxy to pain as may be experienced
in persons with greater preservation of the pain
pathways. For more information on autonomic
dysreflexia, see Acute Management of Autonomic
Dysreflexia: A Clinical Practice Guideline for
Health-Care Professionals (2001).
Initial wound assessment and reassessment
provide the basis for pressure ulcer management.
While reassessment intervals may vary for
individuals in rehabilitation, acute, subacute,
extended care, or home-care settings, it should
nevertheless be performed on a regular basis
according to a consistent protocol. Inadequate
healing progression, such as a stalled or
worsening wound, should trigger a re-evaluation
of the current plan of care and wound
management strategy.
Quantitative measurements can be achieved
by using any of the well-established tools
published in the literature (Mullins et al., 2005)
reporting the validity, reliability, strengths, and
limitations of each, to monitor healing: (1)
Pressure Ulcer Scale for Healing (PUSH) Tool, (2)
Sessing scale, and (3) the Bates-Jensen Wound
Assessment Tool (BWAT), previously known as
the Pressure Sore Status Tool (PSST).

The PUSH tool, designed to assess ulcer
progression over time, monitors healing using
three domains:
(1) surface, by multiplying the greatest length
and width;
(2) the exudate amount; and
(3) the types of tissue that are present in the
wound bed. It has been found to be easy to
use (Berlowitz et al., 2005) and to be a valid
measure of the healing progress (Gardner et
al., 2005; Stotts et al., 2001).
The Sessing scale is an observational scale
that assigns a numerical value (0 to 6) associated
with seven descriptions of the wound surface,
without including the size and depth of the ulcer.
The scale assesses the following:
1. granulation tissue
2. infection
3. necrosis
4. drainage
5. odor
6. surrounding skin
7. eschar
The scale is scored by calculating the change
in numerical value over successive wound
assessments over a period of time (Ferrell et al.
(1995a).
The Bates-Jensen Wound Assessment Tool
(BWAT) contains 13 items that assess the
following:
1. wound size
2. wound depth
3. wound edges
4. undermining
5. necrotic tissue type
6. necrotic tissue amount
7. exudate type
8. exidate amount
9. periwound skin color
10. peripheral tissue edema
11. peripheral tissue induration
12. granulation tissue
13. epithelialization (Harris, et al., 2010)
With the advances in technology the
assessment and monitoring of pressure ulcers
may be performed via telemedicine.

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