Posts Tagged ‘linear measurement’

Wound Care Minute: How to Measure Wounds on a Foot

Friday, April 14th, 2017

In this 90-second video, WCEI co-founder Nancy Morgan explains how to use the clock method to measure wounds on the foot.

 

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Top Wound Measurement Techniques

Thursday, September 24th, 2015

 

Wound Measurement Techniques

 

Every clinician knows that a vital part of wound care is weekly wound assessment. This, of course, tracks healing progress and provides important information that can help with treatment plans and health goals.

But there is more than one measuring technique used to assess wounds, which is why it’s important to not only understand them, but to also make sure that the technique of choice is used consistently and performed accurately. Here is a rundown on some of the most standard measurement types.

Linear Measurement

Linear measurement is the most common, but you might know it simply as the clock method. The name is due to the fact that you measure the greatest length, greatest width, and greatest depth of the wound while referencing the face of an imaginary clock.

In other words, when using the clock method, you would document the longest length of the wound by imagining 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 at 6 o’clock. Document all measurements in centimeters, as L x W x D. It’s also important to remember that sometimes the length will be smaller than the 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 where it meets the wound margin and place it against the ruler.
  • All wounds must have a depth recorded.
  • For wounds without depth (Stage I and DTIs), record depth as “0 cm.”
  • For wounds that are open but appear to have no depth, record depth as “<0.1 cm.”

Undermining and Tunneling

As part of the wound assessment routine, you will also need to measure undermining and tunneling. The clock image comes in handy once again as you determine depth and direction of the wound.

To measure undermining:

  • Check for undermining at each location, or “hour,” of the clock.
  • Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator where it meets the wound edge. Then measure against the ruler, and document the results.
  • 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, and is an acceptable procedure.

To measure tunneling:

  • Insert a cotton-tip applicator into the tunnel. Grasp the applicator at the wound edge (not the wound bed) and measure its depth in centimeters.
  • Document tunneling using the clock as a reference for the location as well.

How Do You Measure Wounds?

There are a variety of methods to measure wounds, and we are interested to know what you use in your clinical setting. Is it the clock method, indicating the greatest length x width? What works best for you, and which method provides you with the greatest consistency in wound measurement? Do all staff participate in wound measurement? Please tell us about your experiences and leave your comments below.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.