How do you measure and document a wound?

Appropriate Wound Measurement and Documentation

Following debridement, measure and record the wound size, the extent of surrounding cellulitis, and the quality and quantity of any drainage (including color and odor) to aid all clinicians treating the patient in their assessment of healing progress. 1

Comprehensive Wound Measurement Technique

Step 1: Measure Basic Dimensions

• Length and Width: Measure the greatest length (head-to-toe direction) and the greatest width (side-to-side) perpendicular to each other, regardless of wound shape 1
• Depth: Use a sterile, blunt metal probe to measure the depth and extent of the wound 1
• Area Calculation: For simple documentation, multiply length × width to estimate wound area in cm² 1

Step 2: Assess and Document Additional Characteristics

• Undermining/Tunneling: Use the probe to detect and measure any undermining, tunneling, sinus tracts, or communication with joint cavities or tendon sheaths 1
• Bone Involvement: Note if bone is palpable with probe (has a characteristic stony feel) 1
• Exudate: Document quality (serous, sanguineous, purulent) and quantity (none, light, moderate, heavy) 1
• Odor: Document presence and characteristics after wound cleansing 1
• Surrounding Tissue: Document extent of surrounding cellulitis or erythema 1

Step 3: Document Wound Bed Characteristics

• Tissue Type: Document percentage of:
  • Necrotic tissue/eschar (black)
  • Slough (yellow)
  • Granulation tissue (red)
  • Epithelialization (pink/white at edges)

Advanced Measurement Methods

For more precise measurements, especially in research or when tracking complex wounds:

1. Wound Tracing: Trace wound perimeter on transparent acetate sheet and calculate area 2
2. Digital Photography: With measurement reference in frame for scale 3
3. Digital Planimetry: More precise than conventional methods for calculating wound area 4
4. Structured Light Devices: Advanced technology that accounts for skin curvature 3

Standardized Documentation Systems

Several validated systems exist for standardized documentation:

1. PUSH Tool (Pressure Ulcer Scale for Healing): Validated for pressure ulcers, diabetic foot ulcers, and venous leg ulcers 5, 6

   • Measures three parameters: surface area, exudate amount, and tissue type
   • Generates a total score (0-17) that decreases as wound heals

2. DFI Wound Score: For diabetic foot infections, includes measurements of:

   • Size (cm²): <1 (0 points) to >30 (10 points)
   • Depth (mm): <5 (0 points) to >20 (10 points)
   • Undermining (mm): <2 (3 points) to >5 (8 points) 1

Documentation Best Practices

• Use consistent measurement techniques across all assessments
• Document at regular intervals to track healing progress
• Include date and time of assessment
• Use standardized terminology for accurate coding and reimbursement 7
• Document wound location precisely, using anatomical landmarks
• Include any signs of infection based on clinical criteria (erythema, warmth, tenderness, pain, induration, or purulent secretions) 1

Common Pitfalls to Avoid

• Inconsistent Measuring Technique: Always measure in the same direction and with the same method
• Failure to Document All Parameters: Incomplete documentation leads to poor tracking of healing progress
• Inaccurate Depth Measurement: Ensure probe reaches deepest part of wound without applying excessive pressure
• Overlooking Undermining: Carefully probe wound edges in a clock-face pattern to detect hidden undermining
• Neglecting to Document Surrounding Tissue: Changes in periwound area can indicate improvement or deterioration

By following these comprehensive wound measurement and documentation practices, clinicians can accurately track healing progress, adjust treatment plans accordingly, and improve patient outcomes through early detection of complications.