Prior to assessing a wound, it may be necessary to irrigate and/or debride the wound so that the actual size of the wound can be determined, as well as the wound characteristics. Ideally, the same person should assess the wound each time, with the patient positioned in the same manner, to maximize the reliability of the wound assessment.
Location of the Wound
It is important to describe the location of the wound as accurately as possible, using the correct anatomical terminology. Why is wound location important? Wound location can provide information regarding the etiology of the wound. For example, a wound on a patient’s coccyx is likely due to pressure, while a wound on the lower leg may be due to venous insufficiency. The location of the wound will also guide dressing selection and other interventions, such as use of pressure-relieving devices.
You should document as specifically as possible the area of the body (i.e. lower leg), the side of the body (right or left) and the surface on which the wound is located (i.e. anterior, medial, posterior). If there are multiple wounds present, you can label the wounds alphabetically (i.e. wound A and wound B) and describe their location relative to specific anatomical landmarks (i.e. wound A is located 2 cm distal to the tibial tuberosity, wound B is located 3 cm above the medial malleolus).
Size of the Wound
There are several methods that can be used to measure wound size. More important than the method you use is that you use the same method consistently, as changes in wound size can be used to determine whether a wound is improving or getting worse over time.
Direct measurement– Direct measurement involves measuring the wound at its longest length and its widest width. Width should be measured perpendicular to the length. By multiplying the length times the width (l x w), you will obtain the surface area of the wound. To measure wound depth, you will need a probe. Insert the probe gently into the deepest part of the wound and note the measurement at the point where the probe is level with the skin surrounding the wound. For wounds with an irregular depth at different points, use the clock method to measure wound depth, with the top of the wound (12:00) being the part of the wound that faces the patient’s head. Direct measurement is easy to learn, simple to perform and is also cost effective.
Wound tracing– Wound tracings are another popular method to determine wound size. This method uses wound tracing sheets comprised of two layers: a layer that contacts the wound, and a layer that is adhesive that can be affixed to the patient’s record or chart. To perform a wound tracing, you must first clean the transparent contact layer to prevent contaminating the wound. Then place the transparency against the wound, ensuring it makes contact with the entire wound, and trace the wound in its entirety. The contact layer is discarded, and the outer (permanent) layer is placed in the patient’s record/chart. Surface area is calculated by multiplying length times width, as in direct measurement. You should make sure to label the recording with the patient’s name, the date and time, the wound location and the measured size. You must measure wound depth directly and this too should be recorded, as well as other characteristics. Note that some commercial transparencies will have premeasured marks in a grid pattern, which makes calculation of wound size a simple matter of counting the number of squares contained within the wound outline. Wound tracing may be more reliable than direct measurement because they present a more accurate depiction of wound size, particularly when wounds are round or irregularly shaped. Of course, wound tracing is only as accurate as the clinician performing the tracing.
There are other wound measurement methods that are sometimes used, such as photographic measurement and volumetric measurement, but these are less common.
If you enjoy learning about wound care management, or your job requires you to manage clients with wounds, you might consider becoming a certified wound care professional. The online wound care certification education offered by Wound Educators allows you to study in the comfort of your own home, at your own pace.
Sources
Meyers, B (2008). Wound Management: Principles and Practice. 2nd edition. Pearson Prentice Hall. Upper Saddle River, New Jersey. pg. 48-50.
Morgan, N. Measuring wounds. Wound Care Advisor, July 11, 2012 http://woundcareadvisor.com/measuring-wounds/
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