July 11, 2012

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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?

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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.

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56 thoughts on “Measuring wounds”

  1. Tammy says:

    That does help, as the entire area is open I am measuring all of it.

    There is such a disparity in measurements that I was questioning my reasoning. Thank you very much for the fast response.

  2. Sarah Beth Rogers says:

    When measuring large sacral wounds, some nurses pull the tissue and measure with the wound spread open, some measure it without holding it open. What is best practice?

  3. Nancy Morgan says:

    Sarah yes that is done however just as long as it’s consistent you just have to remember the spread of tension that was applied on the last measurement . That way your measurements are more consistent week to week.

  4. Maria says:

    I have a patient with wound to coccyx with tunnel is 100% slough my question is when documenting should the depth of wound be documented from tunnel which has deepest depth even though its 100% slough or measure deepest on pink/granulation of wound debate is can’t measure depth at tunnel since 100% slough

  5. Nancy Morgan says:

    Hi Maria

    There has to be some measurable depth if you know it has a tunnel present . So measure what you can measure at that time of assessment . And if you are removing any necrotic tissue continue to measure to show progress.

    Hope that helps

  6. Gunasekar says:

    Hi,

    I have an doubt related coding for laceration,the patient sustaining 12X5 Cm laceration on his back.In this case we have to code for 12 cm length laceration repair only or else we have to add both length and breath and code for 17 cm laceration repair. Kindly any one you clarify it. Thanks

  7. Kim says:

    First let me thank you for your wonderfully educational site. You provide such an important and needed service.

    My question is, when measuring undermining on the plantar surface of the foot, how exactly is is visualized? Say the wound is on the first met region and has undermining on the medial aspect. I know the toes are 6:00 and heel is 12:00, however, do we visualize “through” the foot from the front to call the undermining

    8:00-10:00 or do we visualize the undermining from the backside (as if the person is hanging) and call the undermining 2:00-4:00? This seems to be an area of great controversy in our clinic, not to mention VERY different descriptions of the same wound.

  8. Erica says:

    Nancy my question is when you have multiple wounds on the same person can you use the same paper tape measure or do u need to change tapes for every wound?
    Also on the same person is it acceptable to change gloves between wounds and not wash hands between wounds on the same person. I have changed my gloves between wounds but have not washed my hands. My residents are in pain being in certain positions and i try to keep it clean with different gloves but not washing hands. I would like to know the standard of practice. Of course when I am done with the wound care I wash my hands to go to the next person.

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