S - SKIN INTEGRITY
S.1.1
Consider ultrasound imaging of the tissue to confirm and monitor with suspected deep tissue injury. (Adapted from PU-ONF 2013, p.20; Level B)
S.1.2
Use pressure mapping results in conjunction with clinical findings and the individual's preference to provide education, assess support surfaces and optimize the type and duration of position changes. (CAN-SCIP 2020; Level C)
S.1.3
Determine and reassess the goals of care and healability of the pressure injury with the individual with SCI and the care team. (Adapted from WOUNDCAN 2017, p.8; Level C)
S.2.1
Provide individuals with SCI, their families, and caregivers with structured education about effective strategies for the prevention and treatment of pressure injuries. Be sure to deliver education at a grade 3 to 6 level using a variety of methods. Prior to providing education on pressure injury, assess the individual's health literacy, culture, and use an appropriate level of education to ensure the individual's understanding of the education through the use of teach-back. (Adapted from PU-ONF 2013, p.39; Level B)
S.2.2
Provide pressure injury education using a variety of methods, including written, in-person, video, and online. (CAN-SCIP 2020; Level C)
S.2.3
The education should be delivered by a trained or experienced healthcare professional and include:
- the causes of a pressure injury
- the early signs of a pressure injury
- ways to prevent a pressure injury
- the implications of having a pressure injury (for example, for general health, treatment options and the risk of developing pressure injuries in the future)
- skin cleansing and care techniques
- management of incontinence
- frequency and techniques of skin inspection
- frequency, duration, and techniques of recommended position changes
- frequency, duration, and techniques of recommended pressure redistribution
- nutrition as it relates to maintaining skin integrity
- techniques and equipment used to prevent a pressure injury (i.e., support surfaces including mattresses and cushions).
S.2.4
Ensure that the individual with SCI and their primary caregiver or attendant understands and acknowledges their central role in the prevention of pressure injury. (Adapted from PU-ONF 2013, p.41; Level C)
S.3.1
Reassess gross motor skills, abilities, and current pressure management strategies if gross motor function declines or a pressure injury develops. (PU-ONF 2013, p.136; Level C)
S.3.2
Select and train transfer techniques for all surfaces necessary for daily activities to ensure safe repositioning and minimize skin and tissue damage during movement. (PU-ONF 2013, p.138; Level C)
S.3.3
Teach transfers to all surfaces necessary for daily activities, as risks and abilities are context-dependent. (PU-ONF 2013, p.138; Level B)
S.3.4
Individualize pressure-redistributing strategies using a variety of weight-shifting approaches, including automatic pressure redistribution with functional movement, active lifting or shifting, dynamic weight shifts (tilt and recline), with and without power-assist and use of gel/air cushions. Encourage leaning forward or to the side, as this produces more complete and prolonged pressure reductions than lifting vertically. (PU-ONF 2013, p.141; Level B)
S.3.5
Use manual palpation, observation, and pressure mapping, as appropriate, to evaluate the effectiveness of weight-shifting strategies. (PU-ONF 2013, p.141; Level C)
S.3.6
Provide information about the effective use of weight-shifting strategies, including demonstrations, into the individual's pressure management plan. Work with the individual to select a technique (lifting or leaning) and frequency that best meets the individual's needs. (Adapted from PU-ONF 2013, p.141; Level C)
S.3.7
Ensure that an individual who does not use active or dynamic intentional weight shifts to redistribute pressure performs more frequent skin checks if activities or daily routines change. Educate the primary caregiver or attendant on conducting frequest skin checks. (Adapted from PU-ONF 2013, p.141; Level C)
S.4.1
Implement pressure injury prevention strategies as part of the comprehensive management across the continuum and review all aspects of risk when determining prevention strategies. (Adapted from PU-PVA 2014, p.17; Level A)
S.4.2
Individuals with SCI, clinicians, and caregivers should conduct comprehensive head-to-toe visual and tactile skin inspections. (Adapted from PU-PVA 2014, p.17; Level C)
S.4.3
Directed by the individual with SCI, caregivers, clinicians, nurses, occupational therapists, assistive technologists, prosthetists, and orthotists should evaluate and monitor the individual with SCI and all of their support surfaces for optimal maintenance of skin integrity as directed by the individual with SCI. (Adapted from PU-PVA 2014, p.20; Level C)
S.4.4
If skin irritation due to moisture develops or persists, pursue a consultation with a health care provider with continence training for evaluation, topical treatment, and review of the bowel and bladder program. (Adapted from PU-ONF 2013, p.26; Level B)
S.4.5
Immediately after SCI, as emergency medical and spinal stabilization allow, review individual risk factors and implement appropriate pressure injury strategies, including using cervical, thoracic, lumbar precaution, limit the time the individual is on a spine board, and employ intraoperative pressure reduction strategies. (Adapted from PU-ONF, p.26; Level A/B)
S.4.6
Provide an individually-prescribed seating system designed to redistribute pressure and employ a power weight-shift system when manual pressure redistribution is not possible. (Adapted from PU-PVA 2014, p.21; Level A)
S.4.7
Assess nutritional status including dietary intake and losses, anthropometric measurements, nutritional and hydration-related blood work, ability to self-feed or dependence on others for eating and drinking, and other barriers to optimal food and fluid intake, regularly across the continuum of care as nutrition is a critical aspect for prevention of pressure injury. (Adapted from PU-PVA 2014, p.23; Level B)
S.4.8
Provide adequate nutritional intake to meet individual needs, especially for calories (or energy), protein, micronutrients (zinc, vitamin C, vitamin A, and iron), and fluids. (PU-PVA 2014, p.26; Level A)
S.4.9
Ensure that a qualified registered dietitian or nutritionist with experience in SCI performs the nutritional assessment, determines and recommends the appropriate interventions, and assesses the outcomes across the continuum of care. (Adapted from PU-ONF 2013, p.51; Level C)
S.5.1
Prescribe wheelchairs and seating systems specific to the individual with SCI that allow the individual to redistribute pressure sufficiently to prevent the development of pressure injuries. Obtain specific body measurements for optimal selection of seating system dimensions (postural alignment, weight distribution, balance, stability, and pressure redistribution capabilities). Prescribe a power weight-shifting wheelchair system for individuals who are unable to independently perform effective pressure relief. Use wheelchair tilt-in-space and/or recline devices effective enough to offload tissue pressure. Use standing wheelchairs to remobilize individuals with an existing pelvic pressure injury. Full-time wheelchair users with pressure injuries located on a sitting surface should limit sitting time and use a gel or air surface that provides pressure redistribution. (Adapted from PU-PVA 2014, p.58; Level A)
S.5.2
Prescribe wheelchair seating systems for each individual with an SCI individualized to anthropometric fit that:
- provide optimal ergonomics
- provide maximal function
- redistribute pressure
- minimize shear
- provide comfort and stability
- reduce heat and moisture
- enhance functional activity
- inspect and maintain all wheelchair cushions at regularly scheduled intervals
- replace wheelchair seating systems that are no longer effective.
S.6.1
Ensure proper bed positioning by using devices and techniques that are appropriate for the type of support surface and mattress and the individual's health status. Use pillows, cushions, and positioning aids to:
- Bridge contacting tissues, including bony prominences
- Unload bony prominences
- Protect pressure injuries and vulnerable areas of skin. Do not use closed cut-outs in mattresses or donut-type cushions.
S.6.2
Protect the heels of all individuals with SCI while supine or reclined and while using adaptive devices (e.g., soft silicone gel sheet, soft padded anke foot orthosis (AFO)). (Adapted from PU-ONF 2013, p.89; Level C)
S.6.3
Use a side-lying position at a 30° angle from supine that does not position the individual directly on either hip. (PU-ONF 2013, p.90; Level C)
S.6.4
Avoid elevating the head of the bed above 30°. If raising the head of the bed is medically necessary, raise the foot of the bed before the head and limit the amount of time in this position as much as possible. (Adapted from PU-ONF 2013, p.92; Level C)
S.6.5
Avoid sitting in bed. Transfer the individual to a sitting surface that is designed to distribute pressures properly in the seated position. (PU-ONF 2013, p.93; Level C)
S.6.6
Turn and reposition individuals who require assistance at least every 2 hours initially. Adjust the repositioning schedule based on the individual's skin response, determined by frequent skin checks, until an appropriate repositioning schedule is established. (Adapted from PU-ONF 2013, p.94; Level C)
S.6.7
Use repositioning techniques that prevent injury to the caregiver and reduce friction and shear of soft tissues when the individual with SCI is moved. (Adapted from PU-ONF 2013, p.95; Level C)
S.6.8
Avoid bed rest to treat pressure injuries in individuals with SCI. If necessary, use bed rest to offload pressure completely for a specific and limited time, such as after surgical repair of pressure injuries. (Adapted from PU-ONF 2013, p.96; Level C)
S.7.1
Use a support surface with advanced pressure-redistributing properties, compared with a standard hospital foam mattress, to minimize peak pressure areas around bony prominences and protect soft tissue from bruising and injury. (PU-ONF 2013, p.101; Level C)
S.7.2
Select a reactive support surface for individuals who can be positioned without weight-bearing on a pressure injury and without bottoming out on the support surface. (PU-ONF 2013, p.101; Level C)
S.7.3
Select an active support surface if the individual cannot be positioned without pressure on a pressure injury, when a reactive support surface bottoms out, if there is no evidence of pressure injury healing or if new pressure injuries develop. (PU-ONF 2013, p.101; Level C)
S.7.4
Re-evaluate the suitability of the support surface for pressure injury prevention and treatment at least every 4 years and sooner if the individual’s medical condition changes. (PU-ONF 2013, p.102, Level C)
S.7.5
Select smooth, low-friction, breathable fabrics for bedding and clothing to optimize microclimate control and minimize friction. (PU-ONF 2013, p.103; Level C)
S.8.1
Use a support surface (seat cushions and backrest) with advanced pressure-redistributing properties, compared with standard seat cushions and backrests, to minimize peak pressure areas around bony prominences and protect soft tissue from bruising and injury. (Adapted from PU-ONF 2013, p.109; Level C)
S.8.2
Address pelvic asymmetry, postural instability, kyphosis, and spasticity, using postural management and support surfaces. Evaluate the effects of posture, deformity, and movement on interface pressure distribution and the influence of subdermal tissue loads on sitting support surfaces. (PU-ONF 2013, p.112; Level B)
S.8.3
Consider the effects of clothing, shoes, and additional layers on the surface’s microclimate and pressure-redistributing properties. (PU-ONF 2013, p.112; Level C)
S.8.4
Recommend support surfaces and equipment based on observations and client and caregiver feedback during the sitting simulation and trial. (PU-ONF 2013, p.113; Level C)
S.8.5
Implement a trial of at least 24 hours and ideally of several days to ensure the equipment addresses pressure and microclimate issues, as well as functional and lifestyle needs. (Adapted from PU-ONF 2013, p.113; Level C)
S.8.6
Provide an individually prescribed wheelchair and pressure-redistributing seating system in collaboration with the individual who will be using the equipment. Ensure wheelchair configuration, postural supports, and sitting surfaces facilitate optimal wheelchair positioning and function. (PU-ONF 2013, p.117; Level B)
S.8.7
Consider a variety of factors for comprehensive pressure management when selecting a wheelchair cushion:
- influence of cushion characteristics, including weight, on wheelchair performance
- pressure-redistributing or offloading characteristics at bony areas
- positioning capabilities for postural management in resting and dynamic positions
- maintenance of a supported and symmetrical resting posture to prevent postural deterioration over time
- adequate stability for function and prevention of long-term postural deterioration
- microclimate management
- shear and friction reduction at the user-cushion interface
- comfort
S.8.8
Avoid placing additional layers between a support surface and individual with unless deemed essential. If an additional layer is necessary, the layer should be thin, breathable and stretchable. (Adapted from PU-ONF 2013, p.120; Level C)
S.8.9
Consider power weight-shifting technology (tilt-in-space, reclining) when other methods, such as active pressure redistribution or pressure redistribution through functional movements, are not effective or not possible. (Adapted from PU-ONF 2013, p.122; Level C)
S.8.10
Encourage the use of power weight-shifting technology, such as tilt, recline, and stand, frequently throughout the day to reduce the effects of sitting pressure on bony prominences of the buttocks. Individualize these strategies for each individual using pressure mapping, palpation, and skin response. Start with a position change that can be maintained for 2 minutes, at least once every 15 minutes. (PU-ONF 2013, p.123; Level C)
S.8.11
Add full tilt gradually where possible to increase blood flow over the ischial tuberosities. A minimum of 30° tilt is required to adequately redistribute pressure and increase blood flow. (PU-ONF 2013, p.123; Level B)
S.9.1
Assess and prescribe options for other seating needs and provide recommendations for transfers and repositioning as part of the seating assessment to ensure that these surfaces and their use do not cause pressure injuries. These needs may include:
- bathroom surfaces, such as a commode, toilet, shower bench, or other surfaces
- seating options for travel
- sports wheelchairs and seating for recreational and other activities
- any other surface the individual may use other than the wheelchair.
S.9.2
Use a pressure-redistributing surface on the commode or toilet to minimize pressure injury risk. (Adapted from PU-ONF 2013, p.124; Level C)
S.9.3
Optimize the bowel care routine to minimize time using the commode and reassess the bowel program if more than 1 hour is required. (PU-ONF 2013, p.124; Level C)
S.9.4
Consider a tilt commode if postural instability results in sliding or uneven pressure distribution on the sitting surface. (PU-ONF 2013, p.124; Level C)
S.9.5
Advise and provide written information to an individual with SCI about equipment options and appropriate preventive strategies during travel. (Adapted from PU-ONF 2013, p.126; Level C)
S.10.1
Conduct an assessment of pressure injury risk factors in individuals with SCI on admission and reassess on a routine basis, as determined by the healthcare setting, institutional guidelines, and changes in the individual's health status.
- demographic
- SCI-related, such as incontinence
- comorbid medical
- nutritional
- psychological, cognitive, contextual, and social
- support surface for bed, wheelchair, and all durable medical equipment surfaces, such as shower/commode chair or bathroom equipment related. Use both a validated risk-assessment tool and clinical judgment to assess risk.
S.11.1
Determine energy needs through indirect calorimetry with appropriate correction to avoid overfeeding. (Can-SCIP 2020, Level B)
S.11.2
Provide 30 to 35 kcal/kg energy daily for individuals with pressure injuries. (PU-ONF 2013, p.56; Level B)
S.11.3
Provide 1.0 to 2.0 g/kg protein daily for individuals at risk of developing pressure injuries. (PU-ONF 2013, p.57; Level A)
S.11.4
Provide a daily protein intake at the higher end of the range for individuals with severe pressure injuries. (PU-ONF 2013, p.57; Level A)
S.11.5
Consult with a qualified dietician or nutritionist regarding supplementation of arginine, vitamin E, zinc and other vitamins and minerals as appropriate to improve pressure injury healing. (Adapted from PU-ONF 2013, p.58; Level B)
S.12.1
Upon identification of a pressure injury, perform an initial comprehensive assessment of the individual with a pressure injury, to include the following:
- complete history and physical examination
- complete skin assessment
- laboratory tests (evaluate for infection and nutritional status)
- psychological health, behaviour, cognitive status, and social and financial resources
- availability and utilization of personal care assistance
- positioning, posture, and equipment (e.g., wheelchair)
- nutritional status
- activities of daily living (ADLs), mobility, and transfer skills, as related to maintaining skin integrity
- Home or living environment assessment
S.12.2
In the community, if a new pressure injury is identified, a primary care provider should be contacted immediately to initiate a care plan and make a referral to an SCI healthcare professional. (CAN-SCIP 2020, Level C)
S.13.1
Describe and document in detail an existing pressure injury and its treatment. Include the following parameters:
- anatomical location and general appearance
- size of wound (length x width x depth)
- category/stage
- characteristics of the wound base: viable tissue (granulation, epithelialization, muscle, bone, or subcutaneous tissue), nonviable tissue (necrotic, slough, eschar)
- infection (redness of the wound bed, temperature in the wound bed area, moisture and odour)
- exudate amount and type
- odour
- wound edges (e.g., colour, raised, thickened, undermined, connected to wound bed, fistulas, pockets under the skin)
- periwound skin (colour, temperature, dry, oily, intact, cracked, oedema).
- wound pain
- general condition (body temperature, autonomic dysreflexia changes, change in spasticity)
- documentation of current treatment strategies and outcomes to date.
S.13.2
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)
S.14.1
An individual with SCI and their care team, if appropriate, should perform a comprehensive assessment of posture and positioning to evaluate pressure injury risk when using new surfaces or identifying a new pressure injury. Consider all surfaces in both recumbent and sitting positions that an individual uses to participate in daily activities over the entire 24-hour period. (Adapted from PU-ONF 2013, p.70; Level C)
S.14.2
Evaluate the progress of healing using an instrument or quantitative measure that has been shown responsive to change in wound status, such as acetate tracing, the Photographic Wound Assessment Tool (PWAT) or the Pressure Ulcer Scale for Healing (PUSH). (PU-ONF 2013, p.158; Level A)
S.15.1
Establish a mechanism for a regular reassessment of the performance of sitting support surfaces specific to pressure injury prevention and treatment. Schedule reassessment at least every 2 years, or sooner if any of the following occur:
- health status changes, including weight or medical changes
- changes in functional status
- equipment wear or disrepair
- pressure injury development
- changes in living situation.
S.15.2
Replace seating equipment and support surfaces according to manufacturer’s recommendations, or sooner if equipment demonstrates any signs of deterioration, including but not limited to wear, cracking, and allowing bottoming out. (PU-ONF 2013, p.127; Level C)
S.16.1
Consider replacing the recumbent support surface with one that provides better pressure redistribution, offloading capabilities, shear reduction, and microclimate control for individuals who:
- cannot be positioned off the pressure injury
- have pressure injuries on at least two turning surfaces
- fail to heal or demonstrate pressure injury deterioration despite appropriate comprehensive care
- have a high risk of developing additional pressure injuries
- bottom out on the existing support surface.
S.16.2
Assess the suitability of existing sitting support surfaces for treatment in an individual with a pressure injury. Evaluate the current sitting surface or cushion to determine if an alternative choice would better meet the individual’s needs during treatment of the pressure injury. (Adapted from PU-ONF 2013, p.167; Level C)
S.17.1
Cleanse pressure injury with each dressing change without harming healthy tissue on the wound bed:
- use normal saline, sterile water, pH-balanced wound cleansers, lukewarm potable tap water.
- use diluted sodium hypochlorite ¼ strength to ½ strength solution for wounds with heavy bioburden for a limited time only, until clinical evidence of bioburden is resolved.
- use the following mechanical wound cleansing techniques to remove wound debris, exudates, surface pathogens, bacteria, and residue from topical creams and ointments.
- 4–15 pounds per square inch (psi) pressure irrigation with angiocatheter attached to a syringe, spray bottle or pulsatile lavage.
- gentle scrubbing of the wound bed with wet gauze.
- cleanse peri-wound skin with normal saline, sterile water, pH-balanced skin cleanser, or lukewarm potable tap water with dressing changes.
S.18.1
Debride devitalized tissue using a method or a combination of debridement methods appropriate to the status of the pressure injury. Debride eschar and devitalized tissue with the exception of a stable heel eschar. Debride areas in which there are unstable eschar and devitalized tissue. (PU-PVA 2014, p.35; Level B)
S.19.1
Use a dressing that achieves a physiologic local wound environment that maintains an appropriate level of moisture in the wound bed:
- control exudate
- eliminate dead space
- control odour
- eliminate or minimize pain
- protect the wound and the periwound skin
- remove nonviable tissue
- prevent and manage infection
S.19.2
Avoid using daily dressing changes if at all possible by using absorbent dressings that manage exudate and odour and remain in place for as long as possible. (PU-ONF 2013, p.169; Level A)
S.19.3
Consider the use of antimicrobial dressings if signs of infection are present. (PU-ONF 2013, p.170; Level C)
S.19.4
Consider adding the following adjunctive therapies to a standard wound care program to speed healing of stage II, III, or IV pressure injuries, including electromagnetic energy IB, ultraviolet-C light lb. Consider the use of pulsatile lavage hydrotherapy debridement for Stage III & IV pressure injuries secondary to SCI. (Adapted from PU-ONF 2013, p.171; Level A)
S.20.1
Use electrical stimulation combined with standard wound care interventions to promote closure of category/stage III or IV pressure injuries, unless contraindicated in the cases of untreated, underlying osteomyelitis or infection. (Adapted from PU-PVA 2014, p.43; Level A)
S.20.2
Modify the treatment plan if the pressure injury shows no evidence of healing within 2 to 4 weeks. Review individual factors associated with non-healing of pressure injuries, such as the following:
- incontinence
- infection
- carcinoma
- abnormal wound healing
- nutrition
- medication
- support surfaces
- transfers
- noncompliance
S.21.1
Consider the use of an occlusive hydrocolloid dressing, instead of cream or dressing, for the healing of stage I and II pressure injuries. (CAN-SCIP 2020; Level A)
S.21.2
Consider the use of topical phenytoin for the healing of stage I and II pressure injuries post-SCI. (CAN-SCIP 2020; Level A)
S.21.3
Consider using Medihoney to improve the healing rate and residual soft, elastic scars in persistent stage III and IV pressure injuries in individuals with SCI. (CAN-SCIP 2020; Level C)
S.21.4
Assemble an interprofessional team to ensure optimal management of the individual and the pressure injury before, during, and after surgery, including:
- selecting appropriate surgical candidates
- performing a comprehensive assessment
- implementing appropriate preoperative management
- selecting the best surgical option and implementing it with expertise
- planning and implementing optimal postoperative care.
S.21.5
Refer appropriate individuals with complex, deep, stage III pressure injury, which may include pressure injuries with undermining or sinus tracts and those with stage IV pressure injury for surgical evaluation. (Adapted from PU-ONF 2013, p.175; Level B)
S.21.6
Involve a registered dietitian to assess nutritional status and correct preoperatively nutritional imbalances that are anticipated to have a significant effect on the success of surgical repair. (PU-ONF 2013, p.177; Level B)
S.21.7
Know and implement appropriate postoperative care after all pressure injury surgical repair:
- assess and manage pain
- evaluate support surfaces
- position the individual to keep pressure off the surgical site
- consider using an active bed surface when pressure on the surgical flap is unavoidable
- consider using a Clinitron® air fluidized therapy bed after surgery
- arrange a seating and postural assessment at the appropriate time during the postoperative mobilization period
- progressively and gradually mobilize the individual to a sitting position over at least 4 to 8 weeks to prevent re-injury of the pressure injury or surgical site
- provide education on pressure management and skin inspection.
S.22.1
Screen for common conditions, such as anemia, inflammation, diabetes, and hypothyroidism, which are known to delay healing, to ensure appropriate treatment. Perform the following tests:
- complete blood count, including hemoglobin, hematocrit, white blood cell count, absolute lymphocyte count, serum albumin and description of red blood cell morphology
- iron profile, including ferritin, serum iron, percentage saturation, and total iron-binding capacity
- inflammatory markers: C-reactive protein, prealbumin and erythrocyte sedimentation rate
- endocrine factors, including fasting or random blood glucose, hemoglobin A1C, and thyroid function tests.
S.22.2
If an individual with SCI is at risk of pressure injury development as indicated by biochemical, anthropometric and lifestyle factors, the registered dietitian should implement aggressive nutrition support measures. The range of options may include medical food supplements and enteral and parenteral nutrition. Research suggests that improved nutrition intake, body weight and biochemical parameters may be associated with reduced risk of pressure injury development. (NUTR 2009, p.36; Level A)
S.23.1
Provide training to healthcare professionals on preventing a pressure injury, including:
- who is most likely to be at risk of developing a pressure injury
- how to identify pressure damage
- what steps to take to prevent new or further pressure damage
- who to contact for further information and for further action.
S.23.2
Provide further training to healthcare professionals who have contact with anyone who has been assessed as being at high risk of developing a pressure injury. Training should include:
- how to carry out a risk and skin assessment
- how to reposition
- information on pressure redistributing devices
- discussion of pressure injury prevention with patients and their caregivers
- details of sources of advice and support.