In this 90-second video, WCEI co-founder Nancy Morgan answers a common measurement question: how do you measure wound depth when there’s slough or eschar in the way?
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 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:
When measuring width:
When measuring depth:
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:
To measure tunneling:
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.