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Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Validated Tool

Wound Assessment Validated Tool

A validated wound assessment tool helps to systematically evaluate and document details of the wound to improve treatment planning and re-assessment. To date, there is limited evidence for SCI and SB-specific tools for pressure injury assessment.

The most appropriate selection of tools is listed here.

Downloadable Tool

Photographic Wound Assessment Tool (PWAT)

  • Developed by Houghton et al (2000) and modified from the BWAT.
  • Consists of six questions and can be rated on photographic assessment rather than physical assessment. Recent reliability and validity study performed using digital photography (Thompson et al 2013) on the revised version of the tool (revPWAT) demonstrated that the tool has maintained good inter- and intra- rater reliability and construct validity during the transition from film photography to digital photography, using both professional photographers and wound-care clinicians with access to basic cameras/ photographic equipment.
  • Obtain consent from the person and consult the relevant policy in your organisation regarding digital photography

Downloadable Tool

Bates-Jensen Wound Assessment Tool (BWAT)

  • Developed by Bates-Jensen.
  • Consists of 15 items to assess the wound, allows for detailed reassessment and monitoring of healing process.
  • 13 of the 15 items are scored on a 1-5 scale (where 1 is best score).
  • Total score related to one of four categories of risk and severity.

Downloadable Tool

Pressure Ulcer Scale for Healing (PUSH)

  • To measure the dimensions and parameters of the wound and graph results over time to demonstrate progress.

Acetate tracing

A two-layer acetate sheet can be used to trace the perimeter of the wound. The layer which comes into contact with the skin is discarded. Retain the other layer with date and location and orientation of wound. Ensure the tracing is done with the person in the same position each time.

Serial photographs

  • Document date, time and location
  • Ensure the person is in the same position each time
  • Cover sensitive areas and identifying features
  • Place a disposable measure ruler approximately 1cm from wound edge to show scale
  • Take two photos, one close up and one from a distance showing body part for anatomical orientation and identification of left Vs right side. To further assist orientation, use an arrow to point in the direction of the person’s head
  • Take the ‘close up’ photo at 90o to wound surface, about 30-50 centimetres from wound
  • Review photo to determine whether flash is required
  • Consult the relevant policy in your organisation regarding digital photography

The clinical features of pressure ulcers that are captured in four commonly used tools1


Tools for measuring the severity of pressure ulcers







Tissue type



Undermining and tunnelling


Surrounding skin characteristics


Psychometric properties of tools for measuring pressure ulcers2







Pearson’s r 0.95;

P < 0.00013

Agreement among the personnel was 95%; no other available data4

PUSH scores decreased significantly from week 1 through to week 5 in the healing ulcers indicating that the PUSH is sensitive to change over time (P = 0.001)4

Acetate tracings:

Pearson’s r 0.83;

P < 0.0013


NPUAP stage:

Pearson’s r 0.61;

P < 0.0015

Inter-rater: intra-class coefficient 0.92;

Intra-rater: intra-class coefficient 0.98;6

No available data


Bedside assessment:

intra-class coefficient: -0.89; 95% CI: 0.83 to 0.937


intra-class coefficient 0.71;


intra-class coefficient 0.937

No available data


1. Arora, M. (2017). Management of complications in people with spinal cord injury (Unpublished doctoral thesis). The University of Sydney, Sydney, Australia (p. 18)

2. Arora, M. (2017). Management of complications in people with spinal cord injury (Unpublished doctoral thesis). The University of Sydney, Sydney, Australia (p. 20).

3. Gardner et al., 2005

4. Stotts et al., 2001

5. Bates-Jensen, 1997

6. Bates-Jensen et al., 1992

7. Thompson et al., 2013