Why Consistent Wound Measurements Matter

Abstract

 

The purpose of this study was to provide insight into the implications of inconsistent wound measurements and provide evidence that standardization of wound measurement techniques should be studied and researched using larger samples. Chronic wounds are becoming a rapidly growing problem worldwide, as well as a costly burden to the medical system and the patients. Wound measurement is an important aspect of the wound assessment and can affect what advanced modalities and treatments may be authorized and reimbursed by payer sources.  These sources include insurance companies, Medicare, and Medicaid. Consistent wound measurements will decrease the financial and physical burden of wound care by increasing the likelihood of approval for advanced wound care modalities and treatments, thereby decreasing the days to heal a chronic wound as well as decreasing a patient’s financial burden.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Why Consistent Wound Measurements Matter

The burden of patients with chronic wounds is growing rapidly due to increasing health care costs, an aging population, and a sharp rise in the incidence of diabetes and obesity.  These chronic wounds represent a major health problem.  There is a significant social and economic concern for medical society, as well as for the individual patient, as this dilemma continues to grow.  According to the Centers for Medicare and Medicaid Services (CMS) an estimated six and a half million people in the United States have had a chronic wound. The estimated cost of caring for these chronic wounds exceeds fifty billion dollars a year and continues to grow steadily. (CDC, 2011)

Those that practice within the specialty of wound care continue to seek ways of decreasing these costs, while continuing to provide the best evidence-based care.  When studying the current data regarding wound care management, there is a relatively large volume of data that examines the various processes and best practice methods for healing chronic wounds. There is also a moderate amount of information regarding the techniques for assessing and documenting wounds. However, there is much less information on the actual process of measuring wounds. According to Shaw and Bell (2011), “Historically wound measurement techniques have focused on 2-dimensional methods using linear measurement, wound tracings, and photography for wound assessment in the clinical setting. To date there is still no standardized, universally accepted method used.”

Measuring wounds is an integral part of documentation for wound care.  Although there are several excellent tools that can be used to capture precise measurements, the truth is that most wound care centers and hospitals cannot or will not purchase these due to high costs.  Most wound measurements are captured using a disposable paper ruler and cotton tipped applicators.  Although this technique is not always the most precise, with standardization of the process, the measurements can be close to precise, but more important is consistency.

The clinicians who are employed at Medical City Wound Care and Hyperbaric Center Weatherford (WCHC), are responsible for assessing and measuring many wounds a day. Each of these clinicians have accepted that certain practices, including their techniques for measuring wounds are effective.  These clinicians are using the simple linear method of measuring, using a disposable ruler and cotton-tipped swabs.  However, there is a growing concern that the wound measurements of the patients being seen within the WCHC have not been consistent throughout their treatment.

Purpose

    The purpose of this project was threefold. The first was to determine if a standardized process of measuring wounds exists, by performing a systematic inquiry of peer-reviewed journals. The second purpose was to determine if inconsistencies in wound measurements occurring in the WCHC, have implications of delays or denials of advanced treatments.  The third purpose of this project was to determine if nurses with no wound care experience could be taught basic wound measurement techniques which could be reproducible in future opportunities for wound care education.

The hypothesis of this project is that the use of an education presentation will help to standardize wound measurement techniques in the WCHC in order to produce consistent wound measurements throughout a patient’s days of admission. The hypothesis also considers the re-education of current practicing wound care providers using a standardized education program. The process would then potentially lead to the teaching of a standardized method of wound measuring techniques to all healthcare workers within the Medical City Weatherford.

P.I.C.O.

There is currently a discrepancy within the WCHC in determining what is the proper technique to utilize when measuring wounds. Because there is no standardization and there are many techniques, there is a lack of consistency in wound measurements.  This inconsistency can affect how the wound is treated, and how payer sources reimburse for procedures and treatments.  The PICO proposal includes;

P=For nurses who perform wound assessments in the WCHC, I=does using standardized wound measurement techniques yield more consistent wound measurements, C=Compared to having no standardized measurement techniques, O= The outcome of this proposal is to discover ways of decreasing the cost of wound care by achieving consistent wound measurements.

STEEP

The product of this project is an education program, that when utilized, provides wound care nurses, physicians, and other healthcare workers a standardized technique for measuring patients’ wounds consistently.  There is a need to have a standardized way of measuring wounds for many reasons.  Some of these reasons include obtaining authorization for the use of advanced modalities, such as skin grafts, negative pressure therapy, debridement, and compression therapy, to name a few.  This project meets most of the elements of the acronym STEEP.

Regarding the S for Safety; this project will keep the patients safe by allowing advanced modalities to be authorized and utilized, or keep certain modalities from being used that might injure the wound bed of the patient.  For example, inconsistent measurements might hold the application of Negative Pressure Wound Therapy (NPWT).  Wounds must meet a certain criterion, including size, volume, and appearance.  NPWT allows wounds to heal secondarily, and provides for a semi permeable membrane that keeps bacteria and other pathogens out. T for timely; a wound will heal in the appropriate time, if the measurements are concise and consistent. Inaccurate assessment caused by inconsistent wound measurements can cause an inappropriate healing time to be recorded.  Inaccurate data can lead to a delay in treatments.

E for effective; to prove the efficacy of the wound healing modalities chosen, accurate data must be recorded and reported.  By standardizing wound measurements, patients may qualify for advanced modalities in order to decrease the days to heal.  In order to standardize wound measuring techniques, an effective educational tool must be devised and approved. E for equitable; money can be saved for the medical community as well as for the patient if consistent wound measurements are obtained.  Advanced modalities are generally very expensive.  Take into consideration skin grafts.  These are usually ordered according to the size needed.  If the wound measurements are much smaller than the actual wound, a thousand dollars or more may be wasted.  If the graft is too small, additional grafts may need to be ordered.  E for efficient; A wound care nurse can be more efficient if the measurement technique is standardized.  Wounds could be measured more quickly with more accuracy if a standard process were to be implemented.  Without standardization, the time spent measuring may take longer. P for Patient-centered; Any technique that can improve care of the patient should be utilized.  Some measuring techniques are time consuming, leaving the patient subjected to discomfort.  The basis for nursing is providing patient-centered care.

Methods

This project included multiple methods of obtaining data. The initial data search included a systematic literature search for randomized control studies whose full texts were published in peer-reviewed journals in English. This search was carried out January 2016 thru August 2017 utilizing the online databases PubMed, CINAHL, MEDLINE, Cochrane database of systematic reviews, and Shapiro Library. Key words and phrases used: measuring wounds, wound measurement devices, wound measurement education, healing rates of wounds, cost of wound care, standardization of wound measurement, randomized trials of wound measurement techniques, and chronic wounds.

Inclusion criteria for the literature chosen included the current cost analysis of wound care, randomized control trials, sample sizes greater than fifty patients, chronic full thickness wounds, commercially marketed wound measurement devices, current data, and statistics later than 2010 on healing rates as well as how consistent wound measurement techniques affect insurance reimbursement. Exclusion criteria for the samples chosen included data older than 2008, acute partial thickness wounds, and non-randomized control trials.

The literature chosen was based on current data to support the efficacy of standardizing wound measurement techniques.  Other literature chosen to review included definitions and descriptions of wound healing as well as associated costs.   Also reviewed were articles found in specialty literature sources written by clinicians with expertise in the specialty field of wound care.  Forty-three articles from peer reviewed journals were accessed, of which eleven were chosen for the purposes of this project, either for statistical data or for historical purposes.

Review of Literature

         Although little information was found regarding the need for consistent and accurate measurements, there are some studies that provide insight into the importance of consistent wound measuring.  Barber (2008) found that there is not a uniform wound measurement technique among clinicians which provides for accuracy or reliability. In an attempt to develop a system, she developed The Barber Measuring Tool, for evaluation of her patient’s wound progression or digression. This tool utilizes the simple method of measuring using a disposable ruler and cotton-tipped applicators. Once the measurements are taken, they are placed into a computer program that applies the formulas in order to find the area of the wound. This study appears to be biased, as there were only five patients tracked and there appears to be no other methods that were used to compare this particular method of wound measurement and tracking. Although the sample size of five patients for the study appears to be too small for correlation, the author has incorporated this tool for tracking the healing progression of more than four hundred patients within her facility, and has found this tool to appropriately represent healing progression. There is a great deal of emphasis by professionals regarding wound measurements. Advance Tissue (2016), a corporation that produces skin substitutes, wound dressings, and clinician education discusses in a current blog, “Doctors and clinicians use measuring to gather information to develop and sometimes modify, a patient’s personalized treatment plan… this knowledge lets doctors cater a treatment plan to a patient’s specific progress, which can help prevent needless medical procedures and avoid unwarranted pain and discomfort.”

The above-mentioned literature discusses why wound measurement is an important part of the wound care treatment plan. However, there are many tools that are used within wound care centers for measuring wounds. Some require the use of complicated and/or expensive equipment. Bilgin and Ulku (2013) realized that clinicians have had to rely on their observations in order to assess the healing progress of wounds. The authors were unable to find any scientific methods that could determine which patients might heal or who may fail to heal. Knowing that consistent and concise wound measurements are an important way of determining the progression or regression of wounds, they embarked on a study that was to examine three commonly used techniques.    This was comprised of the ruler method, wound tracing method, and digital planimetry method. Each wound was measured using all three techniques and all measurements were repeated three times, utilizing an average of the three as the result.

This study concluded that the use of the ruler method overestimates the wound size when compared to the other methods. This was especially true when measuring larger, irregular shaped wounds. All three techniques were reported to be adequate when measuring smaller, more regularly shaped wounds.  The acetate tracing and planimetry techniques were found to offer the most accurate, but were also found to be more cumbersome and time consuming than ruler measurements. The acetate drawing method also has the drawback of cross contamination, as the acetate is in contact with the wound itself, increasing the possibility of contaminating the acetate.

 Gethin and Cowan (2005) understood the need for producing consistent wound documentation within the wound care field. Wound measurement is an important piece of wound care documentation.  These authors conducted a study that was designed to compare two different ways of measuring wounds, utilizing the gold standard of acetate tracing with a newly presented technique of digital planimetry using Smith and Nephew’s Visitrak™system. The method used was a retrospective, randomized selection of tracings of superficial leg ulcers.  The goal was to determine which method was more appropriate to implement as a standard as a part of the patient’s permanent chart. The results concluded that in smaller wounds less than ten centimeters squared the difference was not significant.  However, with wounds greater than ten centimeters squared the difference in methods was significant, with the Visitrak™ system being much more accurate.

Harding, Troyer, and Bailey (2014) also recognized that concise and consistent wound documentation was important enough that they developed a mock trial in order to emphasize the role of high quality documentation in the event of litigation.

. Bradshaw, Gergar, and Holko (2011), designed an educational activity intended to develop wound photography competencies for wound care physicians and clinicians.  As experienced wound care clinicians, within their very own facility there was also a noticeable variation in wound assessments, in particular wound photography. During their efforts to glean information for this project, there was little evidence available regarding wound photography in nursing journals. The authors understood the importance of appropriate wound assessment and documentation and they believed that by standardizing photography by incorporating digital imaging would enhance conventional wound assessment and documentation.

Some of the improvements in photography and documentation of wounds through charting were recognized.  Some of these improvements included a modified patient consent form, patient identification in the photographs, standardization of photograph labels, image storage and retrieval, increased confidence and skill of the clinicians, and the greatest of all improvements was the uniformity of wound photography by all wound care staff.

This project validates the need for uniformity and standardization of procedures in order to preserve uniformity for consistency.  By assessing the skills of the clinical staff prior to and following the implementation of projects like this study, proves that clinical education should be a continual process.  Always reaching, searching, and looking for ways to improve the current healthcare standards.

Cardinal, Eisenbud, Phillips, and Harding (2007) shared a common interest in discovering early markers that might be related to wound healing.  According to the authors, in order to assess the final outcome in relation to complete closure of a wound following an advanced modality, the patient would have to be followed for an extended period of time.  The authors performed a study to determine if there are any early predictors of wound closure or wound failure.

There has been an urgency in the past ten years to improve the field of wound care, not only in procedures and products, but also in assessment and documentation.  These are a vital element in managing wounds. There is also a necessity of improving education for wound care specialists and other health care staff that are to manage wounds.  Without standardization and continued growth in education regarding wound management, this important area of healthcare will suffer drastically.

Timeline

The timeline for this proposal included the performance of the review of literature September, 2016 thru January, 2017.  Also included was the development of the written multiple-choice exams which occurred prior to March, 2017. This process included the assistance of other expert wound care specialty nurses. A power point presentation was also developed which was used for pre-test/post-test designed to determine knowledge of wound care measuring techniques of ten randomly chosen medical/surgical floor nurses. A chart review of twenty-five charts from WCHC then ensued in order to unearth any discrepancies in wound measurements over an eight-week period. This process was complete by December 2017. The pre-test was administered in December, 2017 to the ten randomly chosen nurses who are admittedly inexperienced with wound care. The instruction with the power point presentation to occur on the same day.  The post-test occurred immediately following the presentation. The results of the tests were calculated in January, 2018. These results can be found in Appendix C.  Three weeks were spent compiling the information and preparing this proposal.

 

Participants and Stake Holders

The participants included the ten volunteer nurses who took the tests and sat for the education portion of the project. Other participants included the nurses and physician who are specifically trained in the field of advanced wound care modalities. They participated by reviewing the test questions and the power point presentation and offering advice and guidance. Another participant included the clinic director for the wound care center who acted as a mentor during the development and implementation of the pilot study.  This mentor also provided insight and support during the literature reviews. Other potential stakeholders include the future nurses who will learn how to measure wounds accurately and consistently. As well as the patients, themselves who will enjoy the rewards of having consistent wound measurements, which could potentially affect what types of treatments they might be able to receive, and how much it could potentially cost them financially.

Ethical Considerations

This author had no monetary stake related to the proposal or its outcomes.  The results are merely to test the hypothesis that healthcare professionals can learn how to consistently measure wounds. There was no disclosure of the patients’ identities whose charts were audited.

Permission was obtained from Toni Rodriguez, CHT, Clinic Director for Medical City Wound Care Weatherford to proceed with the study utilizing registered nurses employed at the same facility. No patients were utilized in facilitating this study. The nurses who participated agreed in advance to participate.

Other Methods

A second method of obtaining information also involved a literature review, however the literature assessed were non-peer reviewed articles such as informal blogs, “YouTube” videos, and live streaming webinars. These less formal forms of literature contained the most education regarding the actual process of measuring wounds.  These pieces of literature were produced by experts in the specialty field of wound care.

A third method of obtaining data related to discrepancies in wound measurements included a review of twenty-five patient’s charts who had been treated in a wound care specialty clinic. According to Bonnel and Smith (2014), chart reviews are a “nonintrusive strategy for collecting data”. The twenty-five charts were chosen randomly from current patients who had been admitted longer than eight weeks. The chart information was obtained using the electronic health record (EHR) that is utilized in the clinic.  This EHR program was designed specifically for following the progress of current admissions. Within this EHR, there is a page that is solely dedicated to the progression of the wound measurements, including a graph of the progression based on the wound measurements.

Upon close assessment, twenty-two of the twenty-five charts, revealed discrepancies in wound measurements from one week to the next, excluding changes in overall size due to the healing process or digression of the wound. A more detailed examination showed that these discrepancies occurred when the patient was assessed by multiple nurses within an eight-week period.

A fourth method for obtaining data included a Quasi-experiment using a pre-test/post-test design.  The question was whether ten nurses, with no wound care experience, would be able to return demonstration standardized measurement techniques. This was a small pilot test to determine the knowledge base of non-wound care specialty nurses. The participants were ten randomly chosen nurses from the hospital affiliated with the WCHC.  The nursing supervisor chose five nurses with ten or more years of experience, and five nurses who had graduated from nursing school in one year or less.

This data collecting method included a pretest (Appendix A). There were ten multiple choice questions, with accompanying illustrations. These questions were developed with the assistance of five wound care specialty nurses, and a wound care specialty physician. The questions reflected simple wound measuring techniques.

Following the pre-test, the nursing volunteers sat for a thirty-minute power point presentation, also developed with the assistance of the afore mentioned wound care specialty staff. There was time for questions by the nurses, both during and after the presentation. Following the presentation, the nurses sat for the post-test, which was the same as the pre-test.

           Setting

The setting included a wound care specialty clinic. Within this setting is where the chart information was obtained.  The other setting included a medical-surgical unit in the hospital with which the wound specialty clinic is an out-patient department of. Within the hospital setting is where the ten nurses participated in the pilot study.

Steps

The steps taken for this proposal began with the literature review. The next step included assessing other literature with which to assess the appropriate methods for measuring wounds. Each of these steps were taken at different intervals of the project.

The next step was to assess current and relative data from an enhanced chart review of twenty-five patient’s charts. These charts were accessed through a special EHR designed for the specialty of wound care.  This step was taken in order to evaluate a need for a program designed to teach medical staff a standardized method of measuring wounds in order to achieve consistently accurate wound measurements.

The next step was to implement the pilot study, utilizing ten volunteer nurses from a medical-surgical unit of a local hospital. The nursing supervisor selected five nurses with ten or more years of nursing experience, and five nurses who had graduated from a nursing program in one year or less. The ten nurses assembled in a small conference room. The reason for their participation was explained to them. They were each given a numbered test. This test consisted of ten questions with illustrations pertaining to wound measurement techniques. Once the nurses had completed this step, a thirty-minute power point presentation (Appendix B) was provided. There were opportunities for questions to be answered. Following the program, the nurses were then given a second numbered test, making certain that each nurse received the same number as the pre-test numbered test.

The following step included analyzing the pre-tests. First each test was examined individually. Then each test question was analyzed for trends. The same approach was given for the post-tests.

The test scores were analyzed by finding the mean, median, and mode of the scores from the pre-test and the post-test. A bar graph (Appendix C) was then created showing how each individual question was answered during the pre-test and the post-test.

Data Analysis

Evaluation

For this project three different methods were used to evaluate the data that was obtained. The first being the literature review, which was a search through peer-reviewed journals.  The second was a chart audit of twenty-five charts from the Weatherford Wound Care and Hyperbaric Center. The third was a pilot study that tested ten nurse’s knowledge of wound measurements, an education presentation teaching simple wound measurements, and a post-test to identify if the nurse’s understood the presentation.

Data

When analyzing the data found in the peer reviewed journals, simple measurement techniques using a disposable ruler and cotton-tipped applicator were minimally discussed.  Much of the literature regarding wound measurements studied other techniques such as planimetry and acetate tracings. This review yielded mostly expert opinion, but no confirmed evidence based studies regarding guidelines or standardization of measurement techniques. The commonality of the literature reviewed, revealed that consistency in wound measurements is the key to improving patient outcomes and decreasing the cost of treating wounds.  Many of the articles found, also discussed the need for standardizing measurement techniques for consistency.

The results of the chart audit revealed that within the wound care and hyperbaric center (WCHC), there were inconsistencies in wound measurements. In twenty-two of the twenty-five charts viewed there were two or more discrepancies discovered in each chart. The chart audit included patients with wounds who had been admitted to the WCHC for a period longer than four weeks. Over this four-week period a combination of five wound care specialty nurses assessed these wounds, including documentation of the wound measurements.

The Chi-square test was considered as an evaluation tool for the pilot study, however to use this method there would need to be a larger number of participants.  Other results found for the pre-test from the pilot study include a mean of thirty, the median of thirty-five, and the mode of thirty. The results of the post-test include a mean of ninety-two, a median of ninety, and a mode of ninety. The study, although there was a small number of participants, confirmed the idea that a simple thirty-minute presentation teaching basic wound measurement techniques can be successful. Because standardization of wound measuring techniques is an important aspect of providing the best care for the patients, nurses should have the opportunity to increase their level of competency in documenting wound sizes.

Project Outcomes  

One goal of wound care specialists is to provide the best evidence-based practice while considering cost containment. The patients expect the best care at the most affordable cost. Many of the advanced modalities offered in the wound care setting, such as negative pressure therapy (NPWT), skin grafts, and hyperbaric treatments, are either approved or denied by the patient’s payor source. These payor sources follow the Centers for Medicare and Medicaid Services (CMS) guidelines. These advanced modalities are very expensive. The authorization for these modalities, many times, relies on wound measurements. For example, one of the leading NPWT distributors relies on wound measurements to authorize the initial placement of the device. They also require weekly updates on the progress of the wound.  If there are discrepancies that cannot be explained by progress, digression, or sharp debridement, this company will revoke the authorization, leaving the patient two options. The patient could be treated without this important modality to assist with wound closure, using basic dressings and wound care techniques. Or, the other option is for the patient to pay out of pocket for the expensive modality..

The outcome of the literature review revealed that wound care specialists have an obligation to report consistent and accurate wound measurements. The outcome of the chart audits revealed that five nurses within the WCHC do not obtain consistent wound measurements over a four-week period for twenty-five patients’ charts.  The outcome of the pilot project revealed that any nurse, including general staff nurses can easily learn how to obtain accurate wound measurements, with the hope that they will retain this knowledge for future consistent wound measuring.

Interpretation

Because of the inconsistencies found in a small number of random charts that were audited in the WCHC, there is a need to search out best practice methods for consistency in wound measurements.  At this time there are more than two hundred active charts found in the electronic health record utilized by WCHC. There is a potential of finding many more discrepancies in the charts that were not audited. Further evaluation is needed to assess for these inconsistencies.  The wound care specialty nurses are in need of evaluating their knowledge of wound measuring techniques. The program designed for the pilot study may be beneficial for the staff.

The pilot study tested wound measurement knowledge of staff nurses from the WCHC’s affiliated hospital. These nurses had little to no wound care experience and they did quite poorly on the pre-test. The highest score of the pre-test was five out of ten. The lowest scores were two out of ten. During the power point presentation, these nurses had many questions. These same ten nurses scored much higher on the post-test. There was one ten out of ten, and the lowest score was seven out of ten.  These results prove that given the opportunity, any nurse or other medical staff can be taught simple measurement techniques that have the potential to decrease the discrepancies of wound measurements. Thus, increasing the potential for consistency in wound measurements. The results for the individual questions for the pilot study are found in Appendix C.

Changes

There were multiple changes made to the methods section. As the project took a different

direction, the methods for obtaining information needed to change. The original literature review remained, with the exception of the removal of a small portion of the articles studied.

The chart review was added. The focus of the overall project changed from the large-scale point of view of standardizing wound measurement techniques for every wound care center in the nation, to focusing on improving the wound measurement competencies of nursing staff within the WCHC and affiliated hospital.

The importance of the testing and education project decreased from its high importance.  However, it remains an important data obtaining method for the project. The data gleaned from that portion of the project was utilized as more of a pilot study of what an education program for teaching basic wound measurement techniques might look like.

Implications

The results of the literature review, chart audit, and pilot project, confirm the need for further education regarding wound measurement techniques. According to Gethen and Cowman, (2006) “Wound measurement should become part of routine practice…Accurate and objective wound measurement is a vital component of wound management. It is essential that nurses have adequate training and skills in wound measuring to assess wounds correctly and objectively.”

Further research is needed to determine if other wound care clinics also have an issue with inconsistency, and if this inconsistency is postponing or inhibiting the use of advanced modalities.  There were also a small number of charts audited, and a small number of participants in the pilot study. Because of these small numbers a larger-scale research project should be performed.

Beyond this small-scale proposal, this project has the potential to be implemented in wound care centers and hospitals throughout this nation.  If consistent wound measurements are not being obtained, the resulting implications could create more payor source rejections. This could potentially cause a deterioration of wound progress by denying the much-needed advanced modalities that can heal these wounds quickly and safely, thereby reducing the potential for infection. There is a great possibility of increasing the cost of wound care for both the patient and the facility.

Wounds have been under much study in the past thirty years. Many advances have been made in understanding cellular regeneration and tissue repair, yet we continue to see great variation in approaches to assessing chronic wounds. Wounds are indiscriminate, inflicting every ethnic group, young and old, rich and poor, male and female alike. Wounds are a

worldwide pandemic. Perhaps nurses can lead the way for health care providers to standardize

wound care practices and utilize evidence-based protocols to take us beyond the dark ages of

wound care.

.

Appendix A

Wound Measurement Pre/Post Test

1. Which of the following measurements are the most accurate based on the accompanying picture.

           

1. 15 cm x 9 cm x 0.3
2. 14.6 cm x 8.5 cm x 0.3 cm
3. 8 cm x 14 cm x 0.3
4. 0.3 cm x 8.5 cm x 14.6 cm

2. When measuring a wound, one should measure 3:00 to 9:00 first, then 12:00 to 6:00.

1. True
2. False

3. What is the difference between measuring a diabetic foot ulcer to the left great metatarsal head, when compared to measuring a pressure injury to the coccyx?

1. A diabetic foot ulcer is always measured from the deepest part first.
2. The coccyx pressure injury should never be measured using the clock face method.
3. A diabetic foot ulcer is measured with the consideration that the toes are the head (12:00).
4. A diabetic foot ulcer should never have the depth probed.

4. It is not necessary to have consistent wound measurements, as most advanced wound modalities generally use an average of the wound measurements.

1. True
2. False

5. Where on this wound would undermining be more likely?

1. From 11:00 to 1:00
2. At the deepest area of the wound
3. At 12:00
4. This wound has no undermining

6. For a more accurate measurement of the depth of a wound you should use _______.

1. The cotton tipped end of a Q-tip
2. Your finger
3. The wooden end of a Q-tip
4. Tongue depressor

7. To measure the true depth of a tunnel, which lies inside a deep wound, where would you hold your fingers?

1. At the skin surface
2. From the base of the wound
3. At approximately the skin surface
4. From one point on the clock face to another.

8. For a more precise measurement of depth of tunneling you should_________?

1. Hold the tongue depressor between your fingers.
2. Remove your gloves
3. Hold the Q-tip with your index finger
4. Hold the Q-tip cupped with fingers and guided by your thumb.

9. Which of the following would be the most likely measurements of the following wound?

1. 15.4 x 5.6 x 0.3
2. 5.6 x 5.6 x 0.3
3. 16 x 6
4. 0.3 x 15.4 x 5.6

10. How would this hand wound be measured?

1. From 9:00 to 3:00, then 12:00 to 6:00.
2. As multiple wounds.
3. As one wound, from 12:00 to 6:00, with the tips of the fingers being 12:00.
4. As one wound, from 12:00 to 6:00, with the tips of the fingers being 6:00.

Developed by Yvonne M. Erwin RN, BSN, CWCA, CHRN. 2017

Appendix B

Power Point Education Program for Standardized Wound Measurement techniques

Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11

Appendix C

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