In this article, Dr. Japa Volchok, DO explains how to accurately and consistently measure wounds. Volchok discusses the importance of proper measurement and documentation in the wound healing process.
Disclaimer: This demonstration was performed by a trained wound care physician for educational purposes only and should not be tried at home.
Tools to Use
We will examine the correct measurement of a wound. For wound measurement, you will want to have a disposable paper or similar measuring device as well as a cotton-tipped applicator.
The measuring device is either a paper or plastic disposable measuring tape. It is generally marked in centimeter markings with sub-markings in millimeters. A cotton-tipped applicator is useful for measuring depth and checking for any undermining.
Measuring the Wound
This model demonstrates a wound. By convention, the superior aspect of the wound would also usually coincide with the head. The inferior aspect would be the foot. We measure length from a head to foot direction. Width is measured from left to right or right to left. Depth is measured at the maximum location of depth in the wound.
The left to right or right to left convention does not matter in terms of the documentation. It is important however, that length and width are correctly measured and documented. As the convention from head to feet for length and left to right for width are important in being able to reproduce measurements between measurers.
In this instance, we would start off by measuring the wound in the length dimension. Where there is the maximum length of this wound of approximately 5.7 centimeters. The width would then be measured at its maximum point of width which is 2.5 centimeters.
The depth we then would determine by probing the wound with our cotton-tipped applicator using the cotton end. We would probe all areas of the wound to determine where the most depth was located. It appears to be approximately in the middle of the wound.
We would then slide our finger down the cotton-tipped applicator to where it is flush with the intact skin. Pinch the applicator at that point and withdraw from the wound. This can then be laid over your measuring device and the depth determined. In this instance, it appears to be 1.8 or 1.9 centimeters.
Checking for Undermining
Once the length, width and depth of the wound have been measured, it is important to then record any evidence of undermining and what the dimensions of that undermining are. In determining undermining, gently probe the wound with your cotton-tipped applicator circumferentially around the wound. On one side of the wound, we are start to see some undermining. It appears at this location, the cotton-tipped applicator slips deeper under the wound then it does at any other point. This would be the maximum area of undermining.
As you can see, by convention, the superior aspect of the wound or the head aspect of the wound would be 12 o’clock. If we then progress clockwise around a clock face, the area of maximum undermining is approximately 10 o’clock. Similar to how we measured the depth of the wound, you would want to slide your finger down the cotton-tipped applicator.
Pinch it with your nail. Then, bring it up to your measuring device. In this instance, it appears that the undermining is approximately 1.7 centimeters. As you will recall from the last image, the undermining is located at 10 o’clock. This will be recorded as 1.7 centimeters of undermining at 10 o’clock.