Toolkit

Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Stage

Wound Assessment Stage

Images reproduced with permission of AWMA. All rights reserved.

Normal Skin

Skin is our body’s largest organ
Skin is 0.3-3mm thick, consisting of layers; Epidermis, Dermis, Subcutaneous
The function of the skin is for protection, sensation, thermoregulation, excretion, secretion, synthesis of Vitamin D
The condition of the skin often reflects a person’s overall state of health.
Good skin health increases tolerance to external forces and reduces the likelihood of skin breakdown.

Image Credit: Reproduced with permission of Wounds Australia . All rights reserved.

For more information visit the:

Wounds Australia website
HETI education modules.

Stage 1

Intact skin with a localised area of non-blanching redness, usually over a bony prominence.
Redness persists > 20 mins after relieving pressure.
NB: Darkly pigmented skin may not have visible blanching, but colour may differ from the surrounding area.
The area may be painful, firm, soft, warmer or cooler than adjacent tissue.

Stage pressure injury on heel Stage 1 pressure injury: non-blanchable erythema

Image Credit: Reproduced with permission of Wounds Australia . All rights reserved.

Spinal Tip

If you catch a Stage 1 pressure injury, you may avoid skin breakdown if pressure is removed. Advise the person to stay off the area and remove all pressure, keep the area clean and dry, determine the cause and eliminate other contributing factors to promote healing.

Depending on the location, cause and contributing factors a seating assessment may be necessary.

If the cause and contributing factors can be addressed effectively and a management plan initiated immediately, healing should occur in 3-7 days.

For more details visit:

Wounds Australia or access the HETI education modules.

Stage 2

Partial thickness loss of dermis presenting as a shallow open wound with a red-pink wound bed.
May present as an abrasion or a serum-filled blister (may be intact or open/ruptured).
The epidermis and possibly the dermis will be breached.
Presents as a shiny or dry shallow ulcer without slough or bruising.
NB: not skin tears, tape burns, perineal dermatitis, maceration or excoriation.

Stage 2 pressure injury partial thickness skin loss Heel with stage 2 pressure injury

Image Credit: Reproduced with permission of Wounds Australia . All rights reserved.

Spinal Tip

If signs of wound healing are not observed after 2 weeks, reassess cause, contributing factors and wound management plan.

Thinking beyond the wound requires a comprehensive assessment and management plan and the involvement of multiple health professionals. This may include: GP, Community Nurse, Wound / Spinal or Rehab Clinical Nurse Consultant, Occupational Therapist, Seating Therapist, Dietitian, Social Worker, Physiotherapist, Case Manager and Psychologist. An increase in personal care, domestic assistance, nutritional support and pressure management equipment is usually necessary.

Review regularly to identify new risks and refer to the tertiary service if the PI is not responding to treatment, multiple PIs develop or complex comorbidities exist.

For more details visit:

Wounds Australia or access the HETI education modules.

Stage 3

Wound extending through epidermis and dermis into the fatty subcutaneous layer.
Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss.
May include undermining or tunnelling (NB: Undermining is a separation of tissue beyond the wound margin.)
The actual depth of a stage III pressure injury varies by anatomical location.
Refer to tertiary service. See NSW SSCIS Pathway for Management of PI in SCI

Stage 3 pressure injury full thickness skin loss stage 3 pressure injury full skin thickness loss

Image credit: Reproduced with permission of Wounds Australia. All rights reserved.

Spinal Tip

Tertiary referral is recommended for people with Stage 3 wounds

If signs of wound healing are not observed after 2 weeks, reassess cause, contributing factors and wound management plan.

Successful management of a Stage 3 wound requires a comprehensive assessment and management plan and the involvement of multiple health professionals. This may include: GP, Community Nurse, Wound / Spinal or Rehab Clinical Nurse Consultant, Occupational Therapist, Seating Therapist, Dietitian, Social Worker, Physiotherapist, Case Manager and Psychologist. Maximum personal care, domestic assistance, pressure management equipment, nutritional support and specialist wound dressings are required.

Regularly review the wound and assess for new PI risks

For more details visit:

Wounds Australia or access the HETI education modules.

Stage 4

Full thickness tissue loss extending into underlying tissues such as muscle and possibly bone.
Visible or palpable exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed.
Extension to muscle, tendon or joint capsule increases the risk of osteomyelitis. See Complications of would healing for more information.
The depth of a stage IV pressure injury varies by anatomical location. For example a relatively shallow wound overlying the Achilles tendon or 5th metatarsal head, may progress rapidly to a stage IV if pressure is not removed rapidly after early signs of developing a pressure injury.
May include undermining and sinus tracts.
Refer to tertiary service. See NSW SSCIS Pathway for Management of PI in SCI

Stage 4 pressure injury full thickness tissue loss

Image credit: Reproduced with permission of Wounds Australia. All rights reserved.

Spinal Tip

Tertiary referral is recommended for people with Stage 4 wounds

The maximum amount of resources, equipment and support are required

If signs of wound healing are not observed after 4 weeks, reassess cause, contributing factors and wound management plan

Regularly review the wound and assess for new PI risks

For more details visit:

Wounds Australia or access the HETI education modules.

Deep tissue injury

Purple or maroon localised area, an area of discoloured intact skin, or a blood filled blister.
Deep tissue injury (DTI) is due to damage to the underlying soft tissue from pressure and/or shear forces.
The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
DTI may be more difficult to visually detect in people with darker skin tone. Gently palpate suspected areas.
Evolution may include a thick blister over a dark wound bed. The PI may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Suspected deep tissue injury depth unknown diagram

Spinal Tip

Tertiary referral is recommended for people with Deep Tissue Injury (DTI)

DTI may occur before any damage to superficial tissue (Houghton et al 2013).

Obesity can increase the risk of deep tissue injury after SCI, possibly due to increased internal stress / forces combined with muscle atrophy (Elsner and Gefen 2008) and vascular compromise.

Consider ultrasound imaging of the tissue overlying the ischial tuberosity (IT) to identify potential deep tissue injury (Canadian Best Practice Guidelines Recommendation 1.7 Level III).

Successful management of a DTI requires a comprehensive assessment and management plan and the involvement of multiple health professionals. This may include: GP, Community Nurse, Wound / Spinal or Rehab Clinical Nurse Consultant, Occupational Therapist, Seating Therapist, Dietitian, Social Worker, Physiotherapist, Case Manager and Psychologist. An increase in personal care, domestic assistance, nutritional support and pressure management equipment is usually necessary.

For more details visit:

Wounds Australia or access the HETI education modules.

Unstageable

Full thickness tissue loss in which the base of the pressure injury is covered by slough or eschar.
- Slough: colour yellow, tan, grey, green or brown.
- Eschar: colour tan, brown, or black.
Until enough slough/eschar is removed to expose the base of the pressure injury, the true depth is not known, and therefore the stage cannot be determined.
Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural biological cover and should not be removed.

Unstageable pressure injury depth unknown diagram Unstageable pressure injury photo

Spinal Tip

All stage 3, 4, DTI or unstageable wounds in people with SCI, should be referred to tertiary spinal cord injury services.

Nutritional support is required for people with stage 3 stage 4 or unstageable wounds due to loss of protein from the wound.

For more details visit:

Wounds Australia or access the HETI education modules.