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Toolkit

Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Size

Wound Assessment Size

Wound Location Stage Size Other Descriptors Signs of Infection Validated Tool

Consistently measure the dimensions of the wound to evaluate progress and ensure accurate communication of wound information between clinicians and health services.

  • Length (measure longest length from head to toes).
  • Width (measure perpendicular angle to length).
  • Depth (gently insert a moistened cotton tipped applicator to the gentle point of resistance, mark cotton tip at skin level and measure).
  • Depth of undermining (documented using clock face method).

Spinal Tip

Positioning for wound assessment is important

  • The position of the person can distort the soft tissue and change the appearance of the wound. For example, consider the amount of trunk rotation and leg flexion when measuring the wound.
  • Ensure each re-assessment occurs in the same position.
  • Use slide sheets to reposition the person to avoid friction and shear.

Online Resources