Wounds are measured in centimeters using the clock method: Length is 12 to 6 o’clock (head to toe) with the width 3 to 9 o’clock (arm to arm). Wound management: Principles and practice. Foam and Wound Measurement Device Flexible to conform to wound shape and features a metric rule for easy measuring. Undermining is measured by the use of the clock hand positions. March 25, 2017 February 25, 2020 Wound Care Advisor. Related posts . When underminingis present, the direction (using the clock method) and extent (measured in cms) should be documented. Wound Watch: Assessing Pressure Ulcers. Silk wound dressing helps eliminate scar tissue formation The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Consequently this area is … For packing the cavity, undermining, sinus or tunnel: o Sterile or clean cotton tipped applicator or sterile metal probe. A critical step in the wound assessment is measurement. pg 52-53. (2008). Nurses must also document the location and depth of any tunneling or undermining. Measurement: The size of the wound should be measured in centimeters and listed in the wound care treatment chart as length times width times depth. Tunneling. Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care. Sign up for our newsletter and enjoy a Free Preview of our Wound Care Certification Course! Clock terms can also be used to describe the location of undermining. Undermining To measure undermining, insert a saline-moistened cotton-tip applicator into the undermined area and grasp the applicator where it meets the wound’s edge. Join our “Where There’s a Wound, There’s a Way!™” fundraising campaign  Learn more, Copyright © 2009-2018 | WoundEducators.com | All Rights Reserved Wound Care Certification Courses Risk Free Guarantee | Terms and Policies | Sitemap. This site uses Akismet to reduce spam. Hi Catherine, As an RN dedicated to treating wounds, I highly recommend wound care certification. The measurement of a wound, and the plotting of its size over time, is the only estimate that can be used to accurately predict wound healing. Should pain management interventions be put in place before debriding a venous ulcer? The following presentation provides a brief overview of our program: https://woundeducators.com/course-preview/, We also recommend reading the following article: The Importance of Formal Accredited Certification in Wound Care: There are many different wound cleansing solutions, and the best choice will be determined by several factors. To measure tunneling, a probe is gently inserted into the passageway until resistance is felt. A B. Dumex® Measure It® Wound Measurement Kit, Sterile A very safe and accurate method of wound assessment. Blog, Wound Care Advisor WCA Posts navigation. Tunneling and undermining are not always easily visualized, therefore all wounds should be thoroughly probed in order to determine the full extent of tissue damage. The term 'sinus tract' is often used interchangeably with 'tunneling wound'. Then measure against the ruler, and document the measurement. One must be careful not to pull on the skin flaps and displace the actual measurement. The biggest difference between sinus tracts or tunneling and undermining is that tunneling and sinus tracts are unidirectional, whereas undermining may occur in more than one direction. The WoundEducators.com online interactive educational programs are convenient and will prepare you for the nationally accredited wound care certification exam provided by the American Board of Wound Management (ABWM). Progressing in a clockwise direction, document and measure the deepest sites all around the wound edges where undermining occurs. Not only does it provide objective data to confirm wound progress, but it can also serve to alert clinicians about wound deterioration.1 Wound description and documentation also enhances communication among healthcare providers, patients, and care settings.1,2 Assessment of wounds is important because several clinical characteristics, such as new o… All transactions are performed via a SSL secure server to ensure your privacy. Gently measure deepest portion of the wound using a sterile cotton-tipped applicator or measurement device “straight in” (Figure 5) The depth is measured when the applicator shaft emerges at skin level. Tunneling results in dead space that has the potential for abscess formation. A packing count of all dressings used to fill the wound space is to be done for any wound where the depth or the wound bed, undermining or sinus tract is 1 cm or greater. Tunneling is like a cave, undermining is like a cavern or cavity. Mark your measurements. Image Credit: Medetec (http://www.medetec.co.uk/), Sources The distance from the tip of the probe to the point at which the probe is level with the wound edge represents the depth of the tunnel. Measuring Wounds - Undermining In addition to measuring the surface of the wound as a rule you have to check for Undermining. The most common type of chronic lower extremity wound is the venous ulcer, affecting 1% to 3% of the U.S. population. Undermining is a wider area of wounding that lies beneath the wound opening. Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist. Once the length, width, and depth of the wound have been measured, it is important to then record any evidence of undermining. For detailed information visit our wound care certification courses page, or contact us directly. Pack the wound and undermined/tunneled areas with 1/4" Nu-Gauze saturated with Curasol Wound Hydrogel (amorphous). Measuring wounds. 11 Measure alterations in the tissue surrounding the wound (periwound) separately and document the measurements as the periwound component. While still grasping the applicator, remove it from the wound and place it next to the centimeter ruler to measure. 30. 2nd edition. If planning to debride, conduct measurements after debriding. By Emily Greenstein, APRN, CNP, CWON, FACCWS. The distance from the probe tip to the point at which the probe is level with the wound edge represents the amount of undermining present. I attended many different lectures, presented, and sat on a few expert panels. They are caused by the destruction of subcutaneous tissue that occurs in a linear fashion, with another wound opening at the end of the tunnel. Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. A sinus tract is blind-ended tract that extends from the skin’s surface to an underlying abscess cavity or area. Upper Saddle River, New Jersey. Chronic venous ulcers significantly impact quality of life and are a financial burden for both the patient and the health care... By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWCN-AP, CWS, RNFA. Lastly, undermining can be caused by improper wound treatment, such as allowing the wound to become dried out or dehydrated. Ideal for packing deep, undermining or tunneling wounds. o Sterile scissors. Site of the wound MEASURE encapsulates key wound parameters that should be addressed in the assessment and management of chronic wounds: Measure (length, width, depth, and area), Exudate (quantity and quality), Appearance (wound bed, including tissue type and amount), Suffering (pain type and level), Undermining (presence or absence), Reevaluate (monitoring of all parameters regularly), and Edge (condition of … In determining undermining, gently probe the wound with your cotton-tipped applicator circumferentially around the wound. How are you differentiating the “big three”? Obviously, wounds with tunneling and/or undermining will take a longer period of time to heal due to the fact that these defects must be filled in. Wounds heal much more effectively when they are moist. Wounds presenting with tunnels or undermining heal more slowly than wounds without these characteristics. Here is the wound care plan that was used for treatment: 1. Wound Bed: It’s important to document tissue type (slough, eschar, epithelial, granulation, etc. Undermining occurs most often in patient with pressure wounds or neuropathic ulcers. Your online source for wound care certification. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt. I will like to know how to take care of ulcer with underminding. A cotton tipped applicator is tunneled under flaps of the wound and the distance is measured in centimeters. Click to display additional attributes for the product Much like an iceberg, what you see on the surface is not indicative of what lies below. I”m Ma Sophat register nurse I would like to know .How many kinds of solution for cleaning wound? Write a brief description of the wound’s appearance to go along with the drawing. How To Measure a Wound. Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening. ABIs: Do you or don’t you? Clock terms are also used to identify the area of undermining. Pinch gloved fingers on the swab at skin level. 12 Assess wound characteristics to determine appropriate interventions. 17 d ram ... •The precision of wound measurement and the method of calculating the rate of change can influence clinical decisions Using Wound Measurements to The content is not intended to substitute manufacturer instructions. http://www.ncnm.edu/images/CE/WCEI_outline.pdf. For example: 2 cm. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or product usage. Tunneling is caused by destruction of the fascial planes which results in a narrow passageway. To calculate the surface area the length is multiplied by the width which equals the surface area. ... An example of this measurement is 4x3x2 with 2cm of undermining from 2 O'clock to 4 O'clock. All major credit cards & PayPal accepted. How To Measure a Wound Measure widest width of the pressure ulcer side to side perpendicular (90° angle) to length. I’m a Register Nurse dedicate to wound treatment. As part of a thorough wound assessment, in addition to noting location and measuring size, the entire wound bed should be probed for the presence of tunneling and/or undermining. Measurement of the wound can be done in several ways: • Ruler • Acetate/Grid • Visitrak (planimetry) • Digital photo and wound tracing software (digital planimetry) • Specialised photographic device Prior to measuring the wound, clean the wound. Look closely at the wound and its edges, and then draw the wound’s shape. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies. 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