Can-SCIP Coach App
  1. Can-SCIP
  2. Recommendations
  3. Guidelines
  4. Section 2 - MANAGEMENT OF SCI COMPLICATIONS

S - SKIN INTEGRITY




Describe and document in detail an existing pressure injury and its treatment. Include the following parameters:

  1. anatomical location and general appearance
  2. size of wound (length x width x depth)
  3. category/stage
  4. characteristics of the wound base: viable tissue (granulation, epithelialization, muscle, bone, or subcutaneous tissue), nonviable tissue (necrotic, slough, eschar)
  5. infection (redness of the wound bed, temperature in the wound bed area, moisture and odour)
  6. exudate amount and type
  7. odour
  8. wound edges (e.g., colour, raised, thickened, undermined, connected to wound bed, fistulas, pockets under the skin)
  9. periwound skin (colour, temperature, dry, oily, intact, cracked, oedema).
  10. wound pain
  11. general condition (body temperature, autonomic dysreflexia changes, change in spasticity)
  12. documentation of current treatment strategies and outcomes to date.
(Adapted from PU-PVA, p.30; Level C)
Monitor, assess, document, and report any observable/visible change in wound status. Monitor the pressure injury with each dressing change or if there is no dressing, then routinely depending on the setting. Conduct a comprehensive assessment as described in S.13.1 at regular intervals. (Adapted from PU-PVA 2014, p.30; Level B)