Ask the treatment expert: tips for consistent wound measurements
What is xerosis?
Undermining is tissue breakdown that extends underneath intact skin along wound edges (margins). It is caused by shearing forces and can result in skin breakdown around the entire wound perimeter or at various locations around the wound perimeter. Due to the variable locations where undermining can occur, clinicians should always document and measure the depth and direction of the undermining.Undermining-measurement steps
1. Assess for undermining.• Start at top of wound (12:00). (Consider a wound as the face of a clock, where “12:00” points to patient's head and “6:00” points to the patient‘s feet.)
• Use a cotton tip applicator and gently probe around wound edges in a clockwise direction. 2. Once undermining has been identified, insert applicator into the area.
3. Grasp applicator where it meets the wound edge using thumb and forefinger.4. Withdraw applicator while maintaining thumb and forefinger in position.
5. Measure from the tip of applicator to wound position using a centimeter ruler.6. Measure and document the deepest area(s). (Note there should be a beginning point and ending point.)
7. Document findings by referencing the “Clock System.” Examples of documentation:• Generalized documentation – 4 centimeters (cm) undermining noted from 6:00 - 10:00
• Specific - Undermining noted from 6-10:00, ranging from 2–4 cm, deepest area is 4 cm at 10:00
• More specific – Undermining noted along wound perimeter from 6–10:00; 6:00–2.8 cm; 7:00–2 cm; 8:00–3.6 cm; 9:00–2.5 cm; 10:00–4 cm