Measuring wounds

BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC

An essential part of weekly wound assessment is measuring the wound. It’s vitally important to use a consistent technique every time you measure. The most common type of measurement is linear measurement, also known as the “clock” method. In this technique, you measure the longest length, greatest width, and greatest depth of the wound, using the body as the face of an imaginary clock. Document the longest length using the face of the clock over the wound bed, and then measure the greatest width. On the feet, the heels are always at 12 o’clock and the toes are always 6 o’clock. Document all measurements in centimeters, as L x W x D. Remember—sometimes length is smaller than width.

When measuring length, keep in mind that:

  • the head is always at 12 o’clock
  • the feet are always at 6 o’clock
  • your ruler should be placed over the wound on the longest length using the clock face.

When measuring width:

  • measure perpendicular to the length, using the widest width
  • place your ruler over the widest aspect of the wound and measure from 3 o’clock to 9 o’clock.

When measuring depth:

  • Place a cotton-tip applicator into the deepest part of the wound bed.
  • Grasp the applicator by the wound margin and place it against the ruler.

We also need to measure undermining and tunneling. Measure undermining using the face of a clock as well, and measure depth and direction. Tunneling will measure depth and direction.

To measure undermining:

  • Check for undermining at each “hour” of the clock.
  • Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator at the wound edge. Then measure against the ruler, and document the measurement.
  • Using ranges for undermining (for instance, undermining of 1.5 cm noted from 12 – 3 o’clock) tends to be less time-consuming than documenting undermining at each individual hour.

To measure tunneling:

  • Insert a cotton-tip applicator into the tunnel. Grasp the applicator at the wound edge (not the wound bed) and measure in centimeters.
  • Document tunneling using the clock as a reference for the location as well.

What wound-measurement method is used in your setting? The clock method? Greatest length x width? Tracing? Do you find inconsistencies in wound measurement? Do all staff participate in wound measurement? Or are measurement and assessment done by designated staff on all shifts? Do you document on weekly tracking forms, or does your setting use narrative notes only?

Click here to return to Wound Care Swagger

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

41 thoughts on “Measuring wounds

  1. I am a patient at a wound center and they use a regular dressmaker measuring tape to measure the wounds including depth. It is unbelievably painful and lasts for a couple of days. It appears to do damage to an already damaged area. I certainly understand the need to measure in order to assess healing and I understand that sometimes pain is necessary. This seems wrong. It also seems extremely inaccurate. What do you think

    • Chrissy, you are correct! It is NOT common practice to use a dressmaker measuring tape to measure wounds and the depth of wounds.
      I hope they are not reusing this measuring tape for all patients if so it would be a major infection control issue.
      Sorry to hear of your experience. Current standard of practice to measure depth and length and width is what you read above. Side note– the cotton tipped applicators (looks like a long q-tip with a wooden stick) we use one for each patient – we never reuse it. And to measure length and width of the wound we would use paper or plastic type rulers-single use only never reuse it. We would also measure wounds in centimeters not inches.
      Measuring really shouldn’t hurt the patient-sorry to hear this.
      If they do this again refuse it………you as a patient have the right to refuse. You can tell them what they should be using. Show them my blog and if they need some education they can email me: nancy@wcei.net.
      Thanks for your post.

  2. @Molly its not acceptable for a several reasons-it can cause tissue injury/bleeding, splinters which can leave foreign bodies in the wound and then cause issues. Its a bad habit that is in the field. Just redirect them the proper way :)

  3. I see clinicians using the wooden end of the cotton applicator to measure wound depth. Included tunneling and undermining. Nurses and Doctors. I cannot find any documentation where this is acceptable. Is it?

  4. Can anyoneadvise me please -who do I contact for ordering the cotton tipped wound depth indicators? Our current supplier has terminated prodcution of this valuable tool and we are trying to source and order from a new supplier.Help ;)

  5. Hi Cynthia,
    Good question your “gut feeling” on this is correct. You should use separate applicator for ea. wound so there is no cross contamination. Each wound should be assess and treated separately.
    You are on the Right Track! :)

  6. If the patient has three wounds on the same foot in three different locations would it ever be acceptable to use the same cotton tipped applicator to measure the depth of the wound? We have seen this done in certain practices but feel that a separate applicator should be used for each site So as not to cross contaminate the wounds?

  7. Hi Florence…
    When measuring wounds we always measure LxWxD in cm… we place an imaginary clock over the wound, where the head of our patient would be 12 and the toes would be 6 on the clock… on the wound we would measure length as “head to toe direction” (the 12 to 6 position on the clock) and width is side to side (the 9 to 3 position on the clock) for depth it is the deepest area in the wound bed to the surface of the skin, even with necrotic tissue you usually have depth as the skin is no longer intact; if its not measurable you can document depth as <0.1cm, if you are able to measure depth then take it from the deepest area in the wound bed to the surface of the skin. Note that as we debride necrotic wounds it is common that the depth will measure deeper.

  8. Sandie, Using the definition of standard anatomical position which is supine (lying down face up), the heels would be considered 12:00 and the toes 6:00.

  9. Hi Ladies, we are having a dicussion on how to measure the foot, we work in a wound clinic who has several podiatrists. Some of us measure in the standing position with the length still in head to toe position, some measure as if the patient was standing on tippy toe. Is the toe 12 and the heel 6? One of my nurses and I have looked in our book but cannot find this information. Thanks, and Happy New Year!!

  10. How frequent do We need to measure Wounds?. I often read to do weekly, can you give me some referrences or sites as evidence regarding this.thnks

  11. Hi Angela,
    Good question you would measure depth when you have depth. Meaning you have started with 100% necrotic tissue then you started to debride it and its starting to lift and be removed from the wound bed……….. you will have measurable depth at that time. Capture it at that moment. As you debride more it may get deeper that is ok. Your wound assessment goal is to capture what you see before your eyes at the time you are doing your assessment.
    Hope that helps!

  12. With an unstageable pressure ulcer that is covered with slough or eschar, as the slough/eschar begins to debride, at what point do you measure a depth? At first site of red, granular tissue at base? When all slough/eschar debrided? When center of wound bed visible?

  13. If a healthcare provider does not allow you to use a cotton tipped applicator in a wound, how do you recommend getting accurate measurements?

    • Hey Katie, I received your question concerning how to get an accurate measurement of a wound depth without the use of cotton tipped applicator. I would be curious to know why they do not allow this. If they are concerned about leaving fibers on the wound surface, wetting it with normal saline should take care of that so no fibers are left behind.

  14. Hi Nancy,
    We had an interesting case at the clinic today and I wanted to get your opinion. Normally, tunnelling is toward the side of the wound and it’s easy to measure using the method you described. But occasionally, you get one of those strange cases that don’t fit the norm. The lady we had today had a perfect crater in her sacralcoccyxgeal area–no undermining and 100% granulation with a thin biofilm. But–it was a good deep crater, about 3 1/2 cm deep. There was a 0.8cm tunnel/track that was maybe 0.5cm in diameter not in the BASE of the wound, but pretty close to it. Closer to the base than the wound edge. With measuring it to the wound edge, it makes it appear as though there is a >4 cm tunnel, when in fact, it was less than 1 cm. I want my nurses to be comfortable with measuring in a consistent manner. What I ended up doing was adding a narrative (we are electronic) to the flow sheet stating measure ment from base of wound to base of tunnel in addition to the measurement of the base of the tunnel to the edge of the wound. Thanks, Lisa

  15. At work we have a disagreement about measuring wounds on feet. How would you correctly measure a wound on that runs along the lateral aspect of the foot, parallel with the bottom of the foot? Thanks

    • Hi Chris,
      Measuring wounds on the feet sure can be confusing! We are going to use the same method whether the wound is on the dorsum of the foot, the plantar aspect or the lateral side of the foot. For the wound you are describing your length will still be 12 to 6; starting at the wound edge closest to the heel and measuring to the edge near the toes, your width will be 9-3 or side to side, starting at the edge closest to the plantar side of the foot and measuring up to the edge closest to the top or dorsum of the foot. Hope that helps!

      • Do you know if you are not using the clock method but you are using the longest length by the longest width…6 years ago our company said we were supposed to measure the longest length and measure width by measuring the longest distance perpendicular (90 degrees) to the length–even if it meant it wasn’t in the middle of the wound. Does that sound right? Any resource to cite procedure on this method?
        Thank you,
        Patti

  16. Hi Shirley,
    The stage “Unstageable” I think of like a “holding stage”. Once we remove that necrotic tissue (slough / eschar) we can accurately assess the true tissue destruction and then Stage the PU based on the tissue we see in the wound bed, stage III or stage IV. For our DTI’s its the same, once the ulcer opens up you would reassess and re-stage accordingly based on the tissue present, but remember if you see necrotic tissue or granulation tissue in your wound bed that is indicative of full thickness loss and would be staged as at least a stage III or stage IV. It is not considered back staging, more as “accurate” staging once we are able to visualize the wound bed. I hope that helps!

  17. If a wound presents as Unstageable and then either the slough or necrotic tissue is removed, can we then stage it as a Stage 3 or 4 pressure ulcer? I know we are not supposed to back stage. What about DTI’s. if a blood blister opens, drains and then there is granulation tissue beneath it, is it now a stage 2 oralways a DTI? Thank you.

    • Hi Cheryl :)
      Unstageable wounds can be a little tricky, if the necrotic tissue comes up close to the skin surface then you can document it as “depth unknown”, until you debride further you won’t be able to tell how truly deep the wound measures, you need to be able to get to the wound base for depth measurement :)
      Hope that helps,
      Nancy

      • Just to clarify, if I have a wound that had eschar/unstagable and was debrided so now it has depth ( pretend 0.5cm) but still unstageable due to 100% yellow slough, I should document the depth, right?.

        • Hi Keirsten,
          Every wound should have documented depth, even if you are unsure of the “true” depth. Our assessment is all about what is before our eyes at that moment.
          So you are correct, even know there is slough still in the wound bed, and you aren’t sure how much deeper the wound will be, you still measure depth. Our assessment is about what the wound is right at this moment and like our length and width, the depth can change week to week too.

          For wounds with intact epidermis – Pressure ulcers -stage I and SDTI the measurement would be Lx Wx 0cm as the skin is intact.
          Some wounds will have eschar or slough to just below the skin surface or just be so superficial you can’t get an accurate depth. For those we record LxWx<0.1cm. This lets other clinicians know that the wound is open and the skin is no longer intact.
          For other wounds with measurable depth you measure the actual depth.
          Hope that helps!
          Nancy

  18. Nancy, how do you perform linear measurement on a wound that is situated diagonally? A strict 12-6 and 3-9 orientation may not adequately depict the expanse of the wound. I was always taught to never tilt your ruler to accommodate the slant of a wound. Thanks!

    • Good question Susan. This is going to be hard to do with no picture but I will give it a shot. When using the clock method, you are correct that you never slant the ruler to accommodate the greatest measurement. You only do that when using the other method of linear measurement called Greatest Length and Greatest Width. To measure a wound lying diagonally on the body by the clock method, you begin by picturing the face of a clock lying over the wound with the 12 pointing towards the head and the 6 pointing towards the feet. You then locate the part of the wound that is furthest towards the 12, and draw a line (in your mind only) from that point straight across the body. Do the same when you locate the part of the wound that is furthest towards the 6, making that line come straight across from that point. You should now have 2 parallel lines. Place your ruler between those 2 lines to measure length. The same procedure is followed to measure width. Make a straight line up and down (in your mind) from the point that is furthest in the direction to 9 o’clock position and one that is furthest at the 3 o’clock position. Then width is measured between those parallel lines. When this is done, you will have large measurements that look more like a box than the wound itself. But to be consistent, if your policy says you use the clock method, then this must be done just this way. A picture is worth a thousand words is if this don’t make sense email me I have a picture we use in class that will help you visual this better. nancy@wcei.net

      • Nancy, you have explained this method clearly and I get the picture. Thanks so much for your help and have a fun and safe Labor Day weekend!

  19. Does anyone have a good reference for a
    simple anatomical chart showing the basic orientation of the surfaces of the body and their appropriate medical names. e.g anterior lower leg.
    I’d like something to hang on our wall that our Medical assistants can refer to – e.g.I have a hard time having “‘pointer” finger being used on the chart instead of “index finger” !!

Leave a comment

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

Featured Sponsors

© 2014 HealthCom Media. All rights reserved.

Password Reset

Please enter your e-mail address. You will receive a new password via e-mail.