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CHAPTER OBJECTIVES
W
ound measurement looks quantitatively at four wound assessment components: SA, undermining/tunneling, depth, and volume. These components are directly associated with the phases of wound healing and are therefore direct indicators of healing. As new granulation tissue develops, wound depth and volume decrease, the wound contracts, new epithelium covers the wound, and the area decreases in size. This chapter discusses common methods of wound measurement, including linear ruler measurements, tracings, and photography. Each has its advantages, disadvantages, and level of reliability, which are dis- cussed in this chapter. Step-by-step procedures for measuring wounds and the surrounding tissues, along with user-friendly hints and clinical “words of wisdom,” are provided.INITIAL CONSIDERATIONS IN WOUND
Arterial Ulcers Pressure Ulcers Neuropathic Ulcers Venous Ulcers Lower leg dorsum Bony prominences: Plantar surface of foot Above the ankle
Foot Occiput Metatarsal heads Medial lower leg
Malleolus Ears Heel
Toe joints Shoulder Lateral border of foot
Lateral border of foot Scapulae Midfoot deformities Sacrum
Coccyx Trochanter Ischial tuberosity Knees—condyles, patella Tibia/fi bula
Malleolus Heel
Metatarsal heads Toes
Common Locations of Chronic Wounds by Etiology 4.1
TABLE
Documenting the Wound Location
Documenting the anatomic location of the wound is the fi rst step in being able to reproduce measurements at that site. Record the anatomic name that clearly describes the wound location at the time of the wound measurement. For example, trochanter is a more precise descriptor than hip and signifi es that the wound lies over the bony prominence. A circle over the anatomic site on the body diagram gives quick, easy identifi cation of wound location on the completed wound measurement form.
The wound’s anatomic location can be an indication of the wound etiology (Table 4.1). For example, wounds located over bony prominences are usually pressure wounds, wounds on the soles of the feet are often due to pressure and insensitivity (dia- betic wounds), and wounds over the medial side of the ankle are often venous ulcers. Location also provides important informa- tion about the expected wound healing. Wounds in areas of diminished blood fl ow, such as over the tibia, heal slowly.
If several wounds are clustered close together in a location, they should be identifi ed by either different letters or references such as outer, inner, upper, and lower. It is important to keep the same reference location ID for all of the wounds by name throughout the course of care. If one of the wounds in the cluster heals, this fact should be documented, and the same reference names for the remaining wounds should be retained for further documentation. If several wounds join together to become one, this information should be recorded, with a new ID name given to the revised wound site. Exhibit 4.1 shows an example of how to document wound location for multiple wounds.
Using Measurement Forms
Measurements of wound size, extent, and changes are important to the interdisciplinary team, payers, and regulators, as well as to the patient and the family. Well-documented wound
EXHIBIT 4.1
Documenting Wound Location
Documenting Wound Location with Narrative Note Example:
1. Single wound location: coccyx 2. Multiple wounds at a location:
Initial note: Three wounds are located upper, middle, and outer side on the right trochanter.
The upper and middle wounds merge. Since they are upper to the outer wound, the same term upper is retained and the merger noted as in this example:
Follow-up note: The upper and middle wounds have merged and will in the future be referred to as the upper wound on the right trochanter.
measurements can also be used as the best legal defense. The changes and progress toward recovery can also provide positive feedback to the clinician, who can review the measurements and feel a sense of accomplishment. Alternatively, measurements can serve as the red fl ag that all is not well, triggering reevalua- tion of the wound, patient, and treatment interventions.
Because the information gathered is so important, the docu- mentation must be complete and accurate. In addition, the language used requires uniform and consistent terminology to encourage good communication among the team members;
such terminology is also benefi cial for reimbursement.
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One way to promote uniformity, consistency, and com- pleteness is with the use of forms. Forms guide the examiner in a logical sequence and assist in organizing the information gathered. Forms can be paper-and-pencil instruments or elec- tronic templates. They save time, because one simply completes the appropriate information on the preprinted form, which becomes a part of the documentation record.
There are numerous forms in use for documenting wound measurements. Exhibit 4.2 is a sample completed form for per- forming a wound measurement examination. A new form is used each week, and the forms are “tiled” onto pages of note paper with tape in the chart for easy reference to prior mea- surements or in paperless facilities the data can be recorded on a computer template designed for this purpose. Keeping the measurements together in one place facilitates regular monitor- ing of the size changes. The sample form uses the clock method (see below) for monitoring wound depth and undermining and includes the following items:
• Wound anatomic location (called the wound ID)
• Size, including length-by-width open area, length-by-width area of erythema (color change), depth, undermining/tunnel- ing, and overall wound size estimate (explained below)
• Period of the wound assessment: initial, interim observation week number (OB), and discharge(DC)
• Information about the wound healing phase (initials are inserted next to wound phase to identify the current wound phase—I for infl ammatory, P for proliferative, and E for epithelialization, as described in Chapters 2 and 3)
• Discharge outcome status (healed or not healed)
The sample form works well when used in conjunction with the Sussman Wound Healing Tool (SWHT),6 described in Chapter 5. Data can be entered into a computer database and program outcomes monitored.
Promoting Accuracy and Reliability of Wound Measurements
The accuracy and consistency of measurements are critical to the objective evaluation of wounds in clinical practice and for research. Many studies of the best way to measure wounds to achieve a reliable result have been published; however, no method reported is completely reliable.7,8 In other words, at this time, there is no gold standard for wound measurement. This fact presents a dilemma for the wound care provider: Accurate measurements are required to establish a wound diagnosis, plan treatment, and document results. If the measurements are not reliable, how can the clinician ensure that the wound is healing and responding to the treatment interventions in a timely fashion?
Fortunately, you can maximize the accuracy of wound mea- surements by using the following strategies:
• Defi ne the specifi c procedures you used to determine the wound edge, total wound area, and description of areas of necrotic tissue (i.e., percentage of wound area).
• Be consistent. Take the measurement the same way each time from a noted reference point on the body. Meaningful com- parisons can only be made if a standardized measurement system is used.
• Use the same terminology and units of measure for each measurement.
EXHIBIT
Completed Wound Measurement Form 4.2
Wound Measurements
Initial _____
Discharge _____
OBWK#: _____
DC Status: _____
Date: __________________________ Patient Name: _____________________________________________________________
Wound ID: ________________________________________________________ Med Rec#: ___________________________
Wound Phase: ___________________________________________________________________________________________
(all measurements in cm)
Linear Size: L(12:00–6:00) __________ X W (3:00–9:00) __________ = __________
Undermined: 12:00 (A1) ____ 6:00 (A2) ____ 3:00 (B1) ____ 9:00 (B2) ____
Overall Undermined
Estimated Area L + A1 + A2 X W + B1 + B2 = UEA
(UEA): (a) ______________________ X (b) ______________________ = ______________________
Depth 12:00 ______
3:00 ______
6:00 ______
9:00 ______
Erythema 12:00–6 :00 __________ X 3:00–9:00 __________ area = __________
(measured across wound surface)
Examiner: ____________________________________ (OBWK = the observation week # since start of care) X O
01/23/08 G. Lucky
0397 R Trochanter
Chronic inflammation
4.4 3.3 14.52 cm2
0 0.5 1.5 0
4.9 ( overall length) 4.8 (overall width) 23.52 cm2
6.5 cm 4.5 cm 29.25 cm2
B Sweet, PT 0 0 0 0.3
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Comparing the Three Methods of Wound Measurement
Table 4.2 provides an overview of the three commonly used methods for measuring wounds and monitoring wound healing.9 The table identifi es the purpose, requirements, and information derived from each method. All are discussed in this chapter, but not all will be useful in all settings. Different skills and interests will determine the methods and measurements used.
Table 4.3 is a guide to the frequency with which the different wound measurement techniques are used clinically. For exam- ple, a measurement of length by width is always performed, but a video is rarely used. This table will become more useful to you as you learn about each technique.
Most clinical wound measurements are approximations rather than precise measurements. Although sophisticated
• When possible, have the same person take repeat measurements.
• Record even small changes indicating improved or deterio- rated wound status.
• When possible, use an assistant to record measurements as they are taken and help position the patient.
• Use a prepared form, and fi ll in a measurement number at each space indicated on the form. This form can be pre- printed or handwritten so nothing is forgotten. Record as soon as each parameter is measured; memory is not accurate.
• If a characteristic is assessed and found absent, record a zero to confi rm that you observed the characteristic and assessed it. For example, partial-thickness wounds are superfi cial, so a zero should be written next to the depth measure spaces.
A blank space does not show that this characteristic was assessed.
Purpose Photo Tracing/Planimetry Measurements
Objective Establishes baseline wound status and tracks changes throughout recovery
Records shape and size changes at baseline and throughout recovery
Linear: estimates size
Wound size measurement Wound size area Perimeter: estimates boundary
Records change in recovery phase or wound stage
Digitization: approximates surface area
Treatment planning
Validates overall treatment plan Demonstrates short-term response to treatment plan
Demonstrates rate of recovery Frequency Baseline, weekly, or change in
phase/condition, discharge
Baseline, weekly, or change in phase/
condition, discharge
Baseline, weekly, or change in phase/condition, discharge
Time reference Prospective Prospective Prospective
Ongoing/interim Ongoing/interim Ongoing/interim
Requirements Photo Tracing Measurements
Conditions Correct light, body position, and device to indicate relative size; adjust for curvature and position
Use of standard anatomic landmarks and method to transfer tracing to medical record
Use of standard anatomic landmarks
Equipment Camera and digital recording card or fi lm
Tracing kit or digital recording Measurement tool and recording form
Graph paper or grid
Information Photo and Flash Tracing Measurements
Type Displays full-color picture Gives black-and-white picture of size and shape
Provides numeric information Comparison Provides color comparison
of phase, size, and tissue attributes
Represents topographic effects, size, and change
Summarizes quantitative changes for use in a graph
Use Clinical medical review, program management, referral source, reports, survey team, legal, patient compliance
Clinical medical review, program management, referral source, reports, survey team, legal, self-care, patient compliance
Clinical medical review, program management, referral source, reports, survey team, legal, self-care, patient compliance
Monitoring Recovery of Chronic Wounds: Photo, Tracing, Measurements 4.2
TABLE
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and sometimes are the only linear measurements recorded (see Table 4.3).
The clock method is another way to measure the SA of wounds. In this method, you imagine the wound as the face of a clock. Select a 12:00 reference position on the wound; this posi- tion is usually toward the patient’s head. Then, take the mea- surement from 12:00 to 6:00 and from 3:00 to 9:00. The four steps of the procedure are as follows:
1. Establish the 12:00 position by choosing an anatomic land- mark that is easy to identify and document it for all follow- ing measurements (e.g., 12:00 toward head).
2. Mark 12:00 with arrow on the skin. Repeat with marks at 6:00, 3:00, and 9:00.
3. Measure from wound edge at 12:00 to wound edge at 6:00 position.
4. Measure from wound edge at 3:00 to wound edge at 9:00 position.
In situations such as severe contractures of the trunk and lower extremities, it may be more convenient and easier to reproduce the measurements if another convenient anatomic landmark is selected as the 12:00 reference point; for example, measurements in the foot may use the heel or toes. In a person whose body is con- tracted in the fetal position, a trochanteric pressure ulcer may be more easily tracked if the 12:00 reference point is toward the knee.
computer-assisted technologies can increase precision, infor- mation about measuring with such equipment has been omit- ted from this chapter because these devices are usually research tools and are not commonly available in clinical practice settings.