General WOUND CARE

Wound assessment
part 1: how to
measure a wound
Wound measurement is an essential part of wound
assessment. It should be recorded on initial presentation,
and at regular defined intervals as part of the reassessment
Style: Introduction
process. Changes in dimensions are a key indicator and can
even predict healing. There are various methods available
to measure wounds and it is important to use the same
method each time, with the patient in the same position.
Continuous monitoring of changes in wound size is an
important way of evaluating response to treatment.

T
his issue sees the start of a more evident, but it still relies
new series examining the on the clinician to interpret the
basic elements of a wound information (Maylor, 2003). Each of
assessment. Wound assessment these parameters will therefore be
is an essential skill for providing examined over the coming issues. “Measurements are
wound care (Dowsett, 2009). Over The series starts with a discussion indicators of whether
the next few issues we will consider of why and how to measure the wound is healing,
wound measurement, exudate, a wound. deteriorating, or
infection, the surrounding skin,
wound bed appearance, odour Wound size is usually the first
static.”
and pain. criterion on a wound assessment
chart. Despite this, studies have
The most widely used format shown relatively poor recording of
for recording wound assessment this information. Documentation
information is in a chart. Charts audits have shown dimensions
vary in design and can be in either being recorded in only 15% of
paper form or, increasingly, in patient records (Hon and Jones,
electronic form within the patient’s 1996), and in 41% of records
electronic health record, but all (Stewart et al, 2009). An audit
will contain an accepted set of of community electronic patient
parameters (Fletcher, 2010). A records (which excluded leg ulcers)
chart helps with continuity of care showed only 59.6% had a record
(Fletcher, 2010; Benbow, 2011) of length × width, and only 44.2%
and has been shown to improve recorded depth (Nichols, 2012).
the amount and consistency of
documentation (Hon and Jones, Why should wounds be
1996; Sterling, 1996). A chart measured?
can also act as a prompt, guiding There are many reasons why
clinicians through a logical process wounds should be measured
(Brown, 2006). It brings all relevant (see Box 1). Measurements are ELIZABETH NICHOLS
wound information together in indicators of whether the wound Tissue Viability Nurse Specialist, Your
one place so that progress becomes is healing, deteriorating, or static Healthcare CIC, Kingston upon Thames

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 General WOUND CARE

(Rivolo, 2015). It is probably the While reduction in surface area is the measurements are taken from
most significant wound parameter clearly a good indicator of healing, is important, however, and can
when monitoring healing progress it does not account for depth, which significantly affect the surface area
(Keast et al, 2004; Barber, 2008). is another important dimension calculation. Options include longest
Measuring a wound at first to consider. Chronic wounds heal length × greatest width, at any angle
presentation is essential in order from the base upwards as new to each other OR longest length ×
to provide a baseline to monitor collagen matrix is laid down in the greatest width, perpendicular to
progress against. Knowing the wound bed as granulation tissue each other (i.e. at 90⁰). Whether the
rate of healing will help with care (Ovington and Schultz, 2004). Some measurements are taken in head-
planning, setting short- and long- wound edge contraction still occurs to-toe orientation or at any angle
term goals and determining the during this stage, but final wound will also influence the results (see
appropriate treatment, as well as closure does not take place until Figures 2 and 3).
monitoring the effectiveness of that the wound is near to surface level
treatment. It can also be used to (Dealey, 2012). Multiplying these two
identify patients who are likely to measurements will calculate the
heal with conventional treatment How should wounds be surface area of either a square
and those who might benefit measured? or rectangle, but as wounds are
from more expensive therapies There are a number of methods usually irregular in shape (see
(Gethin, 2006). for measuring wounds, ranging Figure 4 for an example, using
from simple linear measurements a grid), this method will almost
A percentage change in wound with a ruler to more sophisticated always overestimate the surface area
surface area of 30% or greater over methods using computer software. (Langemo et al, 2008). Using a ruler,
4 weeks has been shown to be a Some will be expensive and more the longest length is 8.7 cm and the
robust predictor of healing (Kantor suitable for use in research studies, greatest width 4.5 cm. Multiplied
and Margolis, 2000; Sheehan et al, but this article will concentrate together, these measurements
2003). The initial size and duration on those that are more likely to be give a surface area of 39.1 cm2 for
of the ulcers did not influence this. available to the general healthcare the wound in Figure 4. Counting
Gethin (2006), therefore, advocates practitioner in day-to-day practice. the squares gives a surface area of
4 weeks as a good guide for 23 cm2.
clinicians in determining treatment 1. Ruler
strategies. She suggests treating The simplest and quickest method The most reliable ruler method
for 4 weeks, providing there are no is to use a disposable paper ruler and the one with the least
adverse effects, and then evaluating (Figure 1) to measure the length overestimation involves taking the
the effectiveness of the treatment by and width of the wound (Goldman greatest length head-to-toe and
calculating surface area reduction, and Salcido, 2002). Multiplying greatest width perpendicular to
and using that information to plan these together will give an length (Keast et al, 2004; Langemo
the next stage of treatment. estimated surface area. Where et al, 2008). Wounds will change

Box 1: Reasons to measure wounds

(Gethin, 2006).

8 Monitor healing progress

8 Monitor rate of healing
8 Can predict which wounds are
unlikely to heal with conventional
treatment
8 Can help set wound care goals
8 Monitor effectiveness of treatment
8 Identify delayed healing/static
wounds and prompt reassessment
of the patient
8 Provide positive feedback to the
patient, helping with motivation Figure 1. Ruler and probe. A disposible paper ruler is the simplest and
and concordance. quickest method of measuring wound length and width.

52 Wound Essentials 2015, Vol 10 No 2

shape as they heal, and the head- With the rise in electronic patient
to-toe orientation ensures the records replacing paper-based
length and width points remain records, the use of tracings appears
constant. Caution must be used to have declined, perhaps because
when interpreting surface area they cannot easily be scanned into
from linear measurements. electronic records. Digital software
is available that can provide detailed
2. Tracing information on wound dimensions,
Tracing a wound is an easy and e.g. Silhouette by Aranz Medical
inexpensive method and has (Kieser and Hammond, 2011),
advantages over length × width however such software is expensive
measurements. It gives more and not likely to be available in
information about the shape of every-day practice. With the rise
the wound, but still has limitations of digital technology, it is quite
(Dealey, 2012). In this method, possible that more options will
a clear film layer is applied over become available and affordable in Figure 2. Longest length × greatest
the wound and an acetate layer the future. width perpendicular to length,
is applied on top. A fine-tipped regardless of orientation.
permanent marker is used to draw 3. Depth
around the wound outline (see It is important to establish the
Figure 5), and then the wound depth of a wound as part of
contact layer is disposed of in the the assessment process, and to
clinical waste and the acetate sheet determine whether there is any
stored in the patient’s record after sinus or undermining present.
being clearly dated and labelled. The recommended method for
The direction of the head end must measuring depth is to use a sterile
be labelled. More than one sheet cotton tip swab, gently insert it
can be used and overlapped for into the area of undermining, then
large wounds. Most acetate sheets grasping it at the wound edge
will have a grid marked in 1 cm2 measure against a ruler (Morgan,
squares. The number of squares 2012). Plastic probes are also
within the outline of the wound is available that are pre-marked with
then counted to provide the overall cm markings (see Figure 1). The
Figure 3. Longest length × greatest
surface area in cm2. cavity should be gently explored to
width perpendicular to length,
establish any areas of pocketing or using head to toe orientation. Note
There is subjectivity in deciding undermining, and then the depth the difference between Figures 2
whether to include partial squares. should be recorded at the deepest and 3.
Gethin and Cowan (2006) advocate part of the wound. It is also good
including squares where at least practice to record the amount of
50% is inside the tracing of the dressing required to fill the cavity o’clock (Morgan, 2012). It is also
wound. Defining the wound (Dealey, 2012), as reduction in the important to note which position
margins can also be difficult and volume of packing required will also the patient is lying in and to ensure
subjective and they are not always indicate healing progress. the same position is adopted at
clearly visible when performing the each reassessment.
tracing. Gethin (2006) advises not If there is tracking or undermining
leaning too heavily on the border present, then the direction and If the wound bed is covered with
while tracing as this can distort depth must be recorded. The necrotic or sloughy tissue, the depth
the shape. accepted way of describing will not be visible until the wound
direction is to use the clock face and has been debrided (Dowsett, 2009).
It is possible to mark areas of assume 12 o’clock is at the patient’s
devitalised tissue on the tracing head end to describe the direction Reassessment
and a reduction in the percentage of the sinus, e.g. 2 cm at 4 o’clock; How often wounds should be
of necrotic or sloughy tissue over if it is an area of undermining remeasured will depend on local
time is an important indicator of then this can be described as a guidelines. Dealey (2012) notes
wound progress. range, e.g. 2 cm between 4 and 6 that acute wounds progress more
Wound Essentials 2015, Vol 10 No 2 53
 General WOUND CARE

advantages of a photograph Wound Care 19(3): 155–65

are that it can provide greater
information about the wound, Dealey C (2012) The Care of
such as tissue type and condition Wounds: A Guide for Nurses. 4th
of the surrounding skin. The value edn. Wiley Blackwell, Oxford
of a photograph for monitoring
progress is dependent on certain Dowsett C (2008) Using the TIME
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have a ruler in them to provide an
objective view of size and should Dowsett C (2009) Use of TIME to
ideally be taken at the same distance improve community nurses’ wound
from the wound each time, with care knowledge and practice.
the patient in the same position. Wounds UK 5(3): 14–21
Photography is a useful method
of recording wound assessment, European Tissue Repair Society
Figure 4. Counting squares on a but should not be used in isolation (2003) ETRS Working Group State-
grid tracing. (Brown, 2006). Measurements ments. ETRS Bulletin 10(2 and 3):
are still required otherwise the 10–3
photograph becomes meaningless.
Fletcher J (2010) Development of
Conclusion a new wound assessment form.
In conclusion, measuring wounds Wounds UK 6(1): 92–9
is an essential part of assessment
and provides important information Gethin G (2006) The importance
about the progress of the wound of continuous wound measuring.
over time and the prediction of Wounds UK 2(2): 60–8
time to healing. There are various
methods available to measure Gethin G, Cowan S (2006) Wound
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limitations with all options, these acetate tracings and Visitrak™ digital
can be reduced by adopting the planimetry. J Clin Nurs 15(4): 422–7
same method at each reassessment,
with the patient in the same Goldman RJ, Salcido R (2002) More
position. All measurements, than one way to measure a wound:
tracings and photographs must be an overview of tools and tech-
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in measuring chronic wounds hospital setting. Br J Nurs 5(17):
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mendations for wound assessment. tation using an electronic patient Box 2: Tips for measuring wounds.
Wound Repair Regen 12(3 Suppl): record system. Unpublished MSc
S1–17 thesis, University of Hertfordshire 8 Ensure the patient is in the same
position each time
Kieser DC, Hammond C (2011) Ovington LG, Schultz GS (2004) 8 Use the same method for each
Leading wound care technology: the The physiology of wound healing. In: re-measurement; methods are not
ARANZ medical silhouette. Adv Skin Chronic Wound Care: A Problem- interchangeable
Wound Care 24(2): 68–70 based Learning Approach (eds.)
8 Include a ruler in any photograph
Morison MJ, Ovington LG, Wilkie K.
to give perspective and try to
Langemo D, Anderson J, Hanson D, Mosby, London
ensure the same distance on each
Hunter S, Thompson P (2008) Meas-
subsequent photograph
uring wound length, width and area: Rivolo M (2015) Clinical innovation:
which technique? Adv Skin Wound SEE & WRITE – a new approach for 8 Measure seprately any areas of
Care 21(1): 42–5 effective recording. Wounds Interna- devitalised tissue, bone, tendon,
tional 6(2): 6–10 etc, within the wound bed; these
Maylor ME (2003) Problems identi- can be marked on a tracing.
fied in gaining non-expert consensus Sheehan P, Jones P, Caselli A, Giurini
for a hypothetical wound assessment JM, Veves A (2003) Percent change
form. J Clin Nurs 12(6): 824–33 in wound area of diabetic foot ulcers Sterling C (1996) Methods of wound
over a 4-week period is a robust assessment documentation: a study.
Morgan N (2012) Measuring wounds. predictor of complete healing in a Nurs Stand 11(10): 38–41
Wound Care Advisor. Available at 12-week prospective trial. Diabetes
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Sperring B, Baker R (2014) Ten top one facility’s approach to standard-
Nichols E (2012) An audit of district tips for taking high-quality digital izing skin impairment documenta-
nurses’ and community hospital images of wounds. Wound Essentials tion. Ostomy Wound Manage 55(12):
ward nurses’ wound care documen- 9(2): 62–4 49–53