Q: What is the best way to measure wounds?
A: There are several different methods used to measure wounds. The linear method, wound tracings, wound molds, planimetry, digital photography and fluid instillation are a few. The most common method is the linear, which is better known as two-dimensional (length x width) and three-dimensional (length x width x depth).
Wound measurements are recorded in centimeters. Always document the alignment of the resident/patient, as well as any landmarks. The “face of a clock” and “head to toe” are two common methods. Length is measured from 12 o’clock to 6 o’clock position. The width is measured from 3 o’clock to 9 o’clock position.
Full-thickness wounds should have measurable depth since they are below the dermis. To measure depth, a moistened cotton-tipped applicator is most often used. Place the applicator into the deepest area of the wound. The gloved thumb and index finger are used to mark on the applicator at the wound’s margin. Maintain the position as you remove from the wound. Measure in centimeters with a metric ruler. Explore the wound to determine if any undermining or tunneling is present.
A moistened cotton-tipped applicator, maintaining the same technique as mentioned above, should also be used for these measurements. Use the clock figure to document, with 12 o’clock being positioned at the resident’s head and 6 o’clock at the foot.
From the September 01, 2011 Issue of McKnight's Long-Term Care News
