Assessing a Patient with a Spinal Cord Injury and a Pressure Ulcer

The patient with spinal cord injury and a pressure ulcer should undergo a 2-part assessment. The first part is a comprehensive evaluation and examination of the patient. It consists of:

* performing a complete patient history

* performing a physical examination

* arranging for laboratory tests as needed

* assessing the patient's psychological health, behavior, and cognitive status

* gathering information on the patient's social and financial resources and the availability and utilization of personal care assistance

* assessing the patient's positioning and posture, and the equipment related to these.

The second part of the assessment includes a detailed description of the pressure ulcer and the surrounding tissue. These factors should be included:

* the anatomical location of the ulcer and its general appearance

* the wound size measured by width, length, and depth and wound area

* the stage/severity of the ulcer

* the quality and amount of exudates

* odor

* necrosis

* undermining and/or sinus tracts

* granulation and/or epithelialization

* the wound margins and surrounding tissue.

Photographs are often useful to augment the written description.

Patients with darkly pigmented skin are more vulnerable to undetected early stage pressure ulcers. Although areas of damaged skin appear darker than undamaged surrounding skin, also include tactile information to complement the visual data. A pressure ulcer in darkly pigmented skin may be taut and shiny, indurated, and warm to the touch. Color changes may range from purple to blue. Pressure-damaged darkly pigmented skin does not blanch when compressed.

Source: Garber SL. Wounds in special populations: spinal cord injury population. In: Baranoski S, Ayello EA, editors. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 2004. p 349-56.