July 11, 2012


Measuring wounds


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.


56 thoughts on “Measuring wounds”

  1. Maureen Hester says:

    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” !!

    1. Nancy Morgan says:

      Hi Maureen,
      Yes there is a few places for this.
      1. http://www.woundcentral.com look at the laminated cards they are 8×10 in size
      2. Wound Central AP (for iphone & droids only) the guide in that AP as well.
      Hope that helps!

      1. Maureen says:

        Thanks, Nancy! Will have a look.

  2. Susan says:

    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!

    1. 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

      1. Susan says:

        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!

  3. Cheryl says:

    If you have an unstageable wound, do you document a depth?

    1. Nancy Morgan says:

      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,

      1. Keirsten says:

        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?.

        1. Nancy Morgan says:

          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!

  4. Shirley Oddy says:

    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.

  5. Nancy Morgan says:

    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!

  6. Chris Jones says:

    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

    1. Nancy Morgan says:

      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!

      1. Patti Meyer says:

        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,

        1. Patti Meyer says:

          Sorry, I should have put this comment on your initial note on how to measure a wound. Patti

        2. Donna Sardina says:

          Patti, Here is a citation from NPUAP for measuring wound length and width.When length and width ruler measurements are used, wounds are to be measured with a
          head to toe orientation, the longest length head to toe, and the widest width side to side, perpendicular (90°Ð) to length,encompassing the entire wound. http://www.npuap.org/wp-content/uploads/2012/05/Fall07.pdf

  7. Lisa Hezel says:

    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


  9. Katie says:

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

    1. Nancy Morgan says:

      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.

  10. Angela White says:

    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?

  11. Nancy Morgan says:

    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. Lina says:

    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

  13. Nancy Morgan says:

    Hi Lina, the guidelines stated a min of every 7 days. Its located in National Pressure Ulcer Advisory Panel’s guidelines here is the link they have a new APP now too. http://www.npuap.org/

    1. Lina says:

      Thank you nancy, but is there any other references i can use asap? If i buy the book from npuap.org it takes 2-4weeks to wait. Thanks

      1. Donna Sardina says:

        Lina, Here is a free online link to the NPUAP/EPUAP Treatment of pressure ulcers: Quick Reference Guide. On the bottom of page 8 , the guidelines state to reassess and document finding at least weekly. http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf

  14. Sandie Leamer Newhouse says:

    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!!

  15. Donna Sardina says:

    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.

    1. Jules Anderson says:

      Correction – the standard anatomical position is standing up, not supine.

  16. How can one measure a round wound that has slough and necrotic tissue.

  17. Nancy Morgan says:

    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.

  18. Cynthia says:

    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?

  19. Nancy Morgan says:

    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! 🙂

  20. Kate says:

    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 😉

    1. Nancy Morgan says:

      Hi Kate,
      I am not sure of the “brand” you are using or looking for, but here is a link from a Google search I did. Just copy and paste it and you will have a starting point. Good luck!


      1. Kate says:

        Thanks a million.Your link was spot on,such a help.
        I appreciate your speedy response.
        Kate 😉

  21. Molly Morgan says:

    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?

  22. Nancy Morgan says:

    @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 🙂

  23. Chrissy says:

    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

    1. Nancy Morgan says:

      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.

  24. Joanne says:

    When would you measure a friction/burn wound?

  25. Nancy Morgan says:

    @Joanne upon admission and discharge and weekly

  26. Nancy Morgan says:

    @Joanne……and for any change in condition too

  27. Maureen says:

    Do you measure a wound from edge to edge?

  28. Maria says:

    Does this method of measurement also apply to wounds in the oral mucosa after extraction of tooth? We are thinking of formulating a material or solution that would help in the wound healing in tooth extraction sites. It is for our thesis. We were wondering if there are some means on how to measure the healing without histologic methods of measurement because all of the studies that we have read used histologic means.

  29. Tammy says:

    I have a patient with a radiation burn from skin cancer treatment. The wound has one side with <0.1 depth where outer layer of skin was burned and is exposed. Inside this area is a deeper crater measuring 0.6 cm depth. My question is this: Do you measure length and width of the entire area with tissue loss, or do you just measure the smaller inner wound that is being packed? The other nurses are apparently just measuring the smaller inner part, but it seems to me that the entire wound should be measured as there is tissue loss over a greater area.

  30. Nancy says:

    Hi Tammy the key to this is it sounds like all of this area is connecting and is open. If this is true the whole area should be measured as one site as you would want that captured for true measurement.

    Hope that helps have a nice day!

  31. 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.

  32. 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?

  33. 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.

  34. 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

  35. 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

  36. Gunasekar says:


    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

  37. 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.

  38. 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.

Leave a Reply

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