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Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Wound assessment

Regularly assess the wound and document findings:

Wound Location

Identify specific anatomical landmark


Use NPUAP/EPUAP classification system


Length, width, depth, undermining

Other descriptors

Including peri-wound condition and wound edges, sinus tracts and tunnelling, exudate and odour

Signs of Infection

Identify signs of superficial and deep infection

Validated Tool

Use a Validated Tool to evaluate progress

The First sign of a PI is a red mark (or discoloured or darkened area) on the skin that does not change colour when pressure is applied briefly using your finger.  See Stage 1 for more information.

Reassess the wound weekly. This will, however, depend on the type of dressing used, length of time it needs to remain in place, and whether there are any complications.

Refer to Wound Care / Rehabilitation / SCI Clinical Nurse Consultant in your local health district