Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - xii

xii

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

9. Provide adequate nutritional intake to meet
individual needs, especially for calories (or
energy), protein, micronutrients (zinc, vitamin C,
vitamin A, and iron), and fluids.
10. Provide individuals with SCI, their families,
significant others, and health-care professionals
with specific information on effective strategies
for the prevention and treatment of pressure
ulcers. This should include the following:


Pressure ulcer etiology



Reducing pressure ulcer risk



Skin cleansing and care techniques



Management of incontinence



Frequency, duration, and techniques of
recommended position changes



Frequency, duration, and techniques of
recommended pressure redistribution

Activities of daily living (ADLs), mobility,
and transfer skills, as related to maintaining
skin integrity

Assessment and Reassessment
of the Pressure Ulcer
12. Describe and document in detail an existing
pressure ulcer and its treatment. Include the
following parameters:

Frequency and techniques of skin inspection







Anatomical location and general appearance



Category/Stage



Characteristics of the wound base
* Viable tissue (granulation, epithelialization,
muscle, bone, or subcutaneous tissue)
* Nonviable tissue (necrotic, slough, eschar)



Size of wound-length x width x depth



Exudate amount and type



Nutrition as it relates to maintaining
skin integrity



Odor



Wound edges



Use and maintenance of support surfaces
(mattresses and cushions)



Periwound skin



Skin changes to be reported to the healthcare team



Wound pain



Documentation of current treatment
strategies and outcomes to date.

Assessment and
Reassessment
Following Pressure
Ulcer Onset

13. Monitor, assess, document, and report any
observable/visible change in wound status.


Monitor the pressure ulcer with each
dressing change or if there is no dressing,
then routinely.



Conduct a comprehensive assessment
as described in recommendation 12 at
regular intervals

Assessment of the Individual
with a Pressure Ulcer
11. Perform an initial comprehensive assessment
of the individual with a pressure ulcer, to include
the following:


Complete history and physical examination



Complete skin assessment



Laboratory tests (evaluate for infection and
nutritional status)



Psychological health, behavior, cognitive
status, and social and financial resources



Availability and utilization of personal
care assistance



Positioning, posture, and equipment



Nutritional status

Treatment
Nonsurgical
CREATI NG A PHYSI OL OGI C WOUND ENVI RONME NT

14. Cleanse pressure ulcer with each dressing change
without harming healthy tissue on the wound bed:


Use normal saline, sterile water, pH-balanced
wound cleansers, or lukewarm potable tap
water.



Use diluted sodium hypochlorite ¼ strength
to ½ strength solution for wounds with
heavy bioburden for limited time only, until
clinical evidence of bioburden is resolved.
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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