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?
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.
