To measure undermining, check at each area or “hour” of the clock around the wound. Measure the undermining by
inserting the cotton tip applicator into the area of undermining
and grab the applicator at the wound edge. Measure the applicator against the ruler. When measuring undermining, use ranges.
How do you measure the size of a wound?
The wound is typically
measured first by its length, then by width, and finally by depth
. The length is always from the patient’s head to the toe. The width is always from the lateral positions on the patient. The depth is usually measured by inserting a q–tip in the deepest part of the wound with the tip of finger.
How is tunneling and undermining measured?
To measure tunneling,
a probe is gently inserted into the passageway until resistance is felt
. 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. Clock terms are often used to describe the position of the tunnel within the wound bed.
How do you describe a wound undermining?
Wound undermining occurs
when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface
. Consequently, while the external wound might appear small, large areas of tissue loss will be detected beneath the surface when the opening is probed.
How do you document a tunneling wound?
- Insert a cotton-tip applicator into the tunnel. Grasp the applicator at the wound edge (not the wound bed) and measure its depth in centimeters.
- Document tunneling using the clock as a reference for the location as well.
What does tunneling in a wound mean?
A tunneling wound is
a wound that’s progressed to form passageways underneath the surface of the skin
. These tunnels can be short or long, shallow or deep, and can take twists and turns. Tunneling can occur in stage 3 and stage 4 pressure ulcers.
How is wound drainage measured?
Measure the
length “head-to-toe
” at the longest point (A). Measure the width side-to-side at the widest point (B) that is perpendicular to the length, forming a “+”. Measure the depth (C) at the deepest point of the wound. All measures should be in centimeters.
What is a wound assessment tool?
The Triangle of Wound Assessment is a
new tool that extends the current concepts of wound bed preparation and TIME beyond the wound edge5
. It divides assessment of the wound into three areas: the wound bed, the wound edge, and the periwound skin.
How often should wounds be measured?
Frequency. For most wounds
weekly measurement
is adequate as it is unlikely that any significant change will be seen in a shorter period. Some wounds may only show changes over 2-4 weeks. It is important to consider the reason for measuring the wound when determining the frequency.
What does wound exudate look like?
Serosanguinous drainage is the most common type of exudate that is seen in wounds. It is
thin, pink, and watery in presentation
. Purulent drainage is milky, typically thicker in consistency, and can be gray, green, or yellow in appearance. If the fluid becomes very thick, this can be a sign of infection.
What is surgical undermining?
Undermining is a
surgical technique that mechanically lifts/separates the skin and superficial subcutaneous fat as one layer
, up and away from its underlying soft tissues.
What is the yellow fluid that leaks from wounds called?
Wound drainage that has a milky texture and is gray, yellow, or green is known as
purulent drainage
. It could be a sign of infection. The drainage is thicker because it contains microorganisms, decaying bacteria, and white blood cells that attacked the site of the infection.
What is considered extensive undermining?
Complex repair includes EXTENSIVE undermining defined as
a distance EQUAL TO or GREATER THAN the maximum width of the defect, measured perpendicular to the closure line
.”
What is a tunneling wound what risk factors are associated with tunneling?
Tunneling is often the result of
infection
, previous abscess formation, sedentary lifestyle, previous surgery at the site, trauma to the wound or surrounding tissue, or the impact of pressure and shear forces upon many tissue layers causing a “sinkhole-like” defect on the skin.
What happens when a wound is packed?
When a wound is deep, or when it tunnels under the skin, packing the
wound can help it heal
. The packing material soaks up any drainage from the wound, which helps the tissues heal from the inside out. Without the packing, the wound could close at the top.
What is a tunneling cyst?
A pilonidal cyst is a
round sac
of tissue that’s filled with air or fluid. This common type of cyst is located in the crease of the buttocks and is usually caused by a skin infection. Pilonidal cysts are a common condition, with more than 70,000 cases reported in the U.S. every year. Outlook / Prognosis.
