How do you suggest positioning a resident for wound measurement when the wound edges sag over the wound bed?
Sagging of the wound edges generally occurs with wounds that have undermining.
Position the resident comfortably with the wound as far from the sleep surface as possible. For example, for a right trochanter wound, position the resident on left trochanter for measurement.
While measuring, have an assistant apply uniform tension to both edges to keep sagging to a minimum. Do not apply so much tension that the wound looks over-stretched but rather just enough so the edges look consistent and the wound bed can be visualized.
How do you chart the depth measurements when tunneling into a wound that requires more than one cotton swab?
When measuring tunneling or undermining, use a gentle probing technique. Do not force the cotton swab into the wound as this could cause further breakdown. If a tunnel is deeper than the cotton swab or measuring device, document the length of your measuring device and add a plus (“+”) symbol. Example: 14+ cm tunnel noted at 3:00 in wound bed.
Tunneling often can progress into the development of a sinus tract that opens up a pathway for potential
infection.
From the January 01, 2009 Issue of McKnight's Long-Term Care News
