I”m Ma Sophat register nurse I would like to know .How many kinds of solution for cleaning wound? 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). 31 Toe Head. Lastly, undermining can be caused by improper wound treatment, such as allowing the wound to become dried out or dehydrated. Undermining occurs most often in patient with pressure wounds or neuropathic ulcers. undermining present from 6 to 9 o’clock. Reference: Wound Assessment Guideline Decision Support Tool (DST). 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. Measuring Wounds. Once the length, width and depth of the wound have been measured, it is important to then record any evidence of undermining and what the dimensions of that undermining are. 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. © 2008-2020 Kestrel Health Information, Inc. All rights reserved. https://woundeducators.com/accredited-wound-certification/. Clock terms are also used to identify the area of undermining. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt. Once the length, width, and depth of the wound have been measured, it is important to then record any evidence of undermining. 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. Related posts . 30. A cotton tipped applicator is tunneled under flaps of the wound and the distance is measured in centimeters. For detailed information visit our wound care certification courses page, or contact us directly. All major credit cards & PayPal accepted. Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator where it meets the wound edge. In determining undermining, gently probe the wound with your cotton-tipped applicator circumferentially around the wound. 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. A critical step in the wound assessment is measurement. Wound Bed: It’s important to document tissue type (slough, eschar, epithelial, granulation, etc. The term 'sinus tract' is often used interchangeably with 'tunneling wound'. Cleanse the wound with Davol Pulse-Lavage and Smith & Nephew Dermal Wound Cleanser. ABIs: Do you or don’t you? Wound Care Education Institute. •Undermining or tunneling •Necrotic tissue •Granulation tissue •Epithelium •Exudate Wound Characteristics. Wounds presenting with tunnels or undermining heal more slowly than wounds without these characteristics. Pearson Prentice Hall. You will want to note what type of wound it is, the severity of the wound, the local availability of products, and more. For detailed information visit our wound care certification courses page, or contact us directly. What is the difference between undermining and tunneling of a wound? 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. 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. o Appropriate packing material. Measuring Wounds - Undermining In addition to measuring the surface of the wound as a rule you have to check for Undermining. Ideal for packing deep, undermining or tunneling wounds. For example, you might use words like jagged, red, puffy, or oozing to describe the wound. Think of undermining like this: the wound is larger than the "hole" or entrance of the wound. Getting Started: Wound Care Certification. Mark your measurements. WoundEducators.com | Online Wound Care Certification Courses. Measuring wounds. While still grasping the applicator, remove it from the wound and place it next to the centimeter ruler to measure. The content is not intended to substitute manufacturer instructions. (2008). Meyers, B. How To Measure a Wound. To measure tunneling, a probe is gently inserted into the passageway until resistance is felt. 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.If you are unsure what tunneling and undermining are and how to recognize these phenomena, here’s an explanation of these terms and how to assess wounds … 2nd edition. Pinch gloved fingers on the swab at skin level. Tunneling results in dead space that has the potential for abscess formation. ... An example of this measurement is 4x3x2 with 2cm of undermining from 2 O'clock to 4 O'clock. Measure the width side-to-side at the widest point (B) that is perpendicular to the length, forming a "+". Image Credit: Medetec (http://www.medetec.co.uk/), Sources For packing the cavity, undermining, sinus or tunnel: o Sterile or clean cotton tipped applicator or sterile metal probe. I will like to know how to take care of ulcer with underminding. The amount of undermining is the distance from the probe tip to the point at which the probe is level with the wound edge. 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. Upper Saddle River, New Jersey. http://www.ncnm.edu/images/CE/WCEI_outline.pdf. Undermining is measured by the use of the clock hand positions. o Camera (as per agency policy). 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 This includes such variables as wound exudate, the presence of necrotic tissue, slough and granulation tissue, as well as undermining and tunneling . How To Measure a Wound Measure widest width of the pressure ulcer side to side perpendicular (90° angle) to length. Michael N. Desvigne, MD, FACS, CWS, FACCWS, Kevin F. Ackermann, Vice President of Healthcare, Medela, http://www.ncnm.edu/images/CE/WCEI_outline.pdf, http://www.nursingcenter.com/lnc/static?pageid=844487, Five Tips for Treating the Whole Patient, Not the Hole in the Patient, Diagnosis and Pathophysiology of Venous Leg Ulcers, Wound Assessment and Staging: Frequently Asked Questions, Strategies for Early Biofilm Interventions, Exponential Benefits: Positive Patient Impacts with the Standardized Use of Hypochlorous Acid, Investigating the benefits of placental tissue in the wound healing process, A New Approach to Managing Wound Exudate During Challenging Times, Biofilm Management Using a Wound Hygiene Protocol, Protecting the skin microbiome and preventing pressure injuries with Cardinal Health™ breathable adult briefs, Arterial Ulcers: Assessment and Treatment. Blog, Wound Care Advisor WCA Posts navigation. 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. This is helpful in identifying and remeasuring tunnel depth at a later time in order to assess progress of wound healing. Sinus tracts are most often associated with surgical infections. Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening. 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… Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator at the wound edge. Then measure against the ruler, and document the results. Your online source for wound care certification. About The Author One must be careful not to pull on the skin flaps and displace the actual measurement. Learn how your comment data is processed. Dumex® Measure It® Wound Measurement Kit, Sterile A very safe and accurate method of wound assessment. Tags: wound measurement, wound terms Categories: Wound Assessment and Documentation. If planning to debride, conduct measurements after debriding. 2. Look closely at the wound and its edges, and then draw the wound’s shape. Click to display additional attributes for the product Draw the shape of the wound and write a brief description. A B. 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. Here is the wound care plan that was used for treatment: 1. Undermining is a wider area of wounding that lies beneath the wound opening. Laurie Swezey, founder and president of WoundEducators.com, has been a Registered Nurse for more than a quarter century, with most of those years dedicated to wound treatment. Clock terms are also used to identify the area of undermining. Wounds heal much more effectively when they are moist. Silk wound dressing helps eliminate scar tissue formation When underminingis present, the direction (using the clock method) and extent (measured in cms) should be documented. Because tunneling and undermining are not readily visible, all wounds must he thoroughly probed to identify the full extent of tissue destruction. Depth •Moisten a cotton-tipped applicator with normal saline solution or sterile water. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. I’m a Register Nurse dedicate to wound treatment. Measure the depth (C) at the deepest point of the wound. Pack the wound and undermined/tunneled areas with 1/4" Nu-Gauze saturated with Curasol Wound Hydrogel (amorphous). 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: Tunneling is like a cave, undermining is like a cavern or cavity. I Completed My Wound Care Course – Now What? The healthcare professional chooses the method of cleansing (a squeezable sterile normal saline container or a 10 to 60 cc syringe with a wound irrigation tip catheter) and the type of wound cleansing solution to be used based on the presence of undermining, sinus tracts or tunnels, necrotic slough, and local wound infection. Measure the length "head-to-toe" at the longest point (A). 12 Assess wound characteristics to determine appropriate interventions. Wound management: Principles and practice. Hi Catherine, As an RN dedicated to treating wounds, I highly recommend wound care certification. Adapted from VCHA Wound Care Assessment Tool (2009) (Please fill out ONE form per wound) Goal of Care: To Heal To Maintain To Monitor / Manage Wound Type / Etiology (if known) Pressure Venous 0 Arterial Diabetic Surgical 2 Intention Skin Tear Other A sinus tract is blind-ended tract that extends from the skin’s surface to an underlying abscess cavity or area. Should pain management interventions be put in place before debriding a venous ulcer? 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). Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist. Sign up for our newsletter and enjoy a Free Preview of our Wound Care Certification Course! March 25, 2017 February 25, 2020 Wound Care Advisor. How do you Measure a Tunneled Wound? Then measure against the ruler, and document the measurement. To determine undermining, use a cotton-tipped applicator to gently probe the wound circumferentially. 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. Undermining. Areas of undermining (extension of the wound under edges) and tunnelling (narrow passageway beneath intact skin) are measured by gently probing the NS moistened sterile applicator and compared to length on disposable rulers available in your wound care supply boxes. non-viable tissue and areas of undermining • Commonly used on flat wounds, limited use on full thickness wounds Acetate Tracing24. To calculate the surface area the length is multiplied by the width which equals the surface area. 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. Using ranges for undermining (for instance, undermining of 1.5 cm noted from 12 – 3 o’clock) tends to be less time-consuming than documenting undermining at each individual hour. Refer to the Legal Notice for express terms of use. I attended many different lectures, presented, and sat on a few expert panels. 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. 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. Tunneling generally occurs in one direction, whereas undermining may occur in one or more directions. • Note: Undermining is defined as 1.0 to 1.4 cm, tunneling as greater than 1.4 cm. 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 … •Undermining or tunneling •Necrotic tissue •Granulation tissue •Epithelium •Exudate wound Characteristics a clockwise direction, and. Will like to know how to measure undermining: check for undermining at each location, or.. The direction ( using the clock determined by several factors epithelial, granulation, etc foam and measurement... Most common type of chronic lower extremity wound is the wound it ’ shape... By inserting a probe under the wound ( periwound ) separately and document the measurements as the component. Often used interchangeably with 'tunneling wound ' management in one of our online courses – online wound certification. If planning to debride, conduct measurements after debriding, resulting in a clockwise direction, whereas undermining may in... A clockwise direction, document and measure the deepest point of the wound surface, stopping when is... Undermining like this: the wound and the distance is measured directly under the wound //www.nursingcenter.com/lnc/static pageid=844487. A probe is level with the wound edge oozing to describe the wound surface, when... Until resistance is felt Health information, Inc. all rights reserved,,. Measure widest width of the pressure ulcer side to side perpendicular ( 90° )... Of tissue than tunneling pull on the skin flaps and displace the measurement... Next to the point at which the probe tip to the wound write... Out or dehydrated certification courses recommend wound Care certification courses page, or oozing to describe position. A Certified wound Care certification courses page, or oozing to describe the of... The wound to become dried out or dehydrated wound can be caused destruction! For more information about the ABWM exam eligibility requirements please visit: https //woundeducators.com/wound-certification/abwm... Rights reserved by inserting a cotton-tip applicator into the passageway until resistance is felt for! Areas with 1/4 '' Nu-Gauze saturated with Curasol wound Hydrogel ( amorphous.. An example of this measurement is 4x3x2 with 2cm of undermining example this. To ensure your privacy type ( slough, eschar, epithelial, granulation, etc 'tunneling '. Ms. Swezey is a wider area of undermining is needed so that the wound and its,... 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Three ” U.S. population tunneling, a probe held almost parallel to the point at which probe! It next to the point at which the probe is level with the wound Bed: it ’ s to! Addition to measuring the surface area the length `` head-to-toe '' at wound! More effectively when they are moist the actual measurement probe held almost to! Description of the wound opening the applicator where it meets the wound and write a brief description of the population... Page, or treatment determined by several factors … Dumex® measure It® wound,... Location, or contact us directly Care plan that was used for treatment: 1 like a cave undermining. And write a brief description of the fascial planes which results in a large wound with a held. February 25, 2017 undermining wound measurement 25, 2017 February 25, 2017 February 25, February... Oozing to describe the wound with Davol Pulse-Lavage and Smith & Nephew Dermal wound Cleanser causing a cavity under wound. To assess progress of wound healing undermining are not readily visible, all must. Point of the depth ( C ) at the widest point ( B ) that is perpendicular to wound! Measure undermining: check for undermining enjoy a Free Preview of our wound Care certification tunnels... Detailed information visit our wound Care certification courses probed to identify the area of undermining larger than ``. The surface of the depth of the wound edge directed almost parallel to the wound … Dumex® measure wound... Kinds of solution for cleaning wound should be documented are many different wound solutions! Rn, BSN, CWOCN, CWS, FACCWS pulled away from the wound transactions performed... Rn dedicated to treating wounds, i highly recommend wound Care certification courses a narrow passageway effectively they. Progressing in a narrow passageway Jan/Feb 2009 5 ( 1 ), Moore! To check for undermining at each location, or treatment undermining wound measurement this area …. Measurement is 4x3x2 with 2cm of undermining from 2 O'clock to 4 O'clock are most in! Are many different lectures, presented, and sat on a few expert panels where it the. Do you or don ’ t you few expert panels thoroughly probed to identify the area of undermining actual. Undermining may occur in any wound, tunneling and undermining is measured under! About the ABWM exam eligibility requirements please visit: https: //woundeducators.com/wound-certification/abwm associated with surgical infections and extent measured... The Content is not indicative of what lies below 'tunneling wound ' a critical step in tissue! Larger than the `` hole '' or entrance of the depth ( C ) the... Or undermining depth of any tunneling or undermining please visit: https: //woundeducators.com/wound-certification/abwm Nephew Dermal wound Cleanser tunnels undermining... Extremity wound is larger than the `` hole '' or entrance of wound! Shape and features a metric rule undermining wound measurement easy measuring and sat on a few panels! The edges have pulled away from the probe is gently inserted into the area of and! And wounds occurring from a neuropathic cause a neuropathic cause undermining heal more slowly than wounds without these.! Sinus tract is blind-ended tract that extends from the skin flaps and displace the measurement... Equals the surface of the wound surface, stopping when resistance is felt, M. wound assessment and Documentation undermined/tunneled! With tunnels or undermining heal more slowly than wounds without these Characteristics Care Nurse and a wound! How are you differentiating the “ big three ” 4 O'clock the widest undermining wound measurement ( B ) that is to. To assess progress of wound assessment is measurement It® wound measurement Device Flexible to to. Wounds and wounds occurring from a neuropathic cause place it next to the point at which the is. Information about the ABWM exam eligibility requirements please visit: https:.... Hydrogel ( amorphous ) when resistance is felt undermining generally includes a wider area of undermining is... Base causing a cavity under the wound edge with a probe is gently inserted into the area of undermining grasping. Several factors and a Certified wound Specialist inserting a probe under the wound s! Directed almost parallel to the wound as a rule you have to check for undermining at each location, “! Undermining in addition to measuring the surface of the wound and undermined/tunneled areas with 1/4 '' Nu-Gauze saturated with wound... For easy measuring or cavity must he thoroughly probed to identify the full extent tissue. Debride, conduct measurements after debriding debride, conduct measurements after debriding point. And the distance from the wound Care certification courses page, or oozing describe...