Measuring wounds to improve outcomes.
ABSTRACT Wound measurement is the only evidence-based predictor of healing.
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ABSTRACT: To investigate the patient and healing characteristics related to full-thickness pressure ulcers, 119 consecutive patients admitted with ulcers in three acute care, four longterm care, and one rehabilitation agency were studied. Of the 119 patients with 153 pressure ulcers, only 48 (40%) had full-thickness ulcers. Compared to patients with partial-thickness ulcers, patients with full-thickness ulcers were more likely to have multiple ulcers, occasional incontinence of urine and feces, a compromised overall skin condition, and a less than optimal nutritional status at baseline. Full-thickness ulcers treated with a hydrocolloid dressing (DuoDERM Hydroactive) did not develop adverse reactions; clinicians perceived the dressing to be efficacious. Ulcers that healed during the study decreased 47% in area in two weeks. This distinguished ulcers that healed from those that did not heal. The findings suggest that ulcers that do not decrease in size within two weeks should be reevaluated for additional or alternate treatments.Decubitus 02/1993; 6(1):16-21.
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ABSTRACT: Venous leg ulcers, which may take months to heal, account for 40-70% of all lower extremity chronic wounds. New treatment options for venous leg ulcers have recently been proposed, and therefore deciding which patients are candidates for these novel-and often expensive-treatments is an important task. Moreover, researchers conducting clinical trials often wish to enroll patients who are unlikely to heal in order to minimize sample sizes needed and research costs. Our purpose was to assess the use of percentage change in venous leg ulcer area over the first few weeks of treatment as a prognostic indicator of healing or non-healing at 24 weeks. We conducted a cohort study based on an existing data set from a multicentre randomized clinical trial that enrolled 104 patients. Wounds were measured using digital planimetry for 4 consecutive weeks following the inception of good wound care. Utilizing the Wilcoxon rank sum (Mann-Whitney) test, we found that percentage change in area over time distinguished between those who healed and those who failed to heal after 24 weeks of good wound care (P < 0.05). The rate of healing, or area healed per week, did not differentiate between those who healed at 24 weeks and those who did not, as all patients had similar rates of healing over the first 4 weeks of treatment. Percentage change in area from baseline to week 4 provided the best combination of positive and negative predictive values (68.2%, 74.7%) and the largest area under the receiver operating characteristic curve (0.75). Thus, percentage change in area over the first 4 weeks of treatment represents a practical and predictive measure of complete wound healing by 24 weeks.British Journal of Dermatology 05/2000; 142(5):960-4. · 4.10 Impact Factor
- Longitudinal study of stage III and stage IV pressure ulcer area and perimeter as healing parameters to predict wound closure. Ostomy Wound Manage 57 50-62..
AJN ▼ August 2013 ▼ Vol. 113, No. 8
awry or we’re suddenly faced with a long-standing,
Wounds must be assessed and monitored to de-
tect important changes, quantify progress, and guide
treatment decisions. Assessment covers a variety of
variables, such as the amounts of exudate, necrotic
tissue, fibrin slough, and granulation tissue; the pres-
ence of undermining, tunneling, and epithelium; and
the size of the wound.
ound healing is a complex process, and
it’s often thought of as a steady one with
a typical course—until something goes
PREDICTING WOUND OUTCOMES
Improvement in any of these variables is encour-
aging and important to document and consider
when making decisions about the type of wound-
treatment product to choose (which dressing, for
instance).1 But merely assessing and documenting
these wound variables and tweaking protocols of
care over many weeks (or months), hoping a pres-
sure ulcer, venous ulcer, or foot ulcer is going to
heal doesn’t suffice. Only one of these variables—
wound size, as measured over time—provides
quantifiable data that can be used to help predict
wound outcome. The healing trajectory, evidenced
by changes in wound size, of every type of chronic
wound can help in the prediction of whether or not
that wound is going to heal within a reasonable pe-
riod of time.
Results of studies involving full-thickness (stage III
or IV) pressure ulcers,2, 3 venous ulcers,3, 4 and foot ul-
cers5, 6 in patients with diabetes have all shown that
the percentage of a reduction in wound size after two
to four weeks of care is a statistically significant, and
often independent, predictor of healing.
Perhaps most surprising is that the trends in wound
reduction documented in all of these studies were the
same regardless of wound type, study design, or mea-
surement methods used, despite the challenges of mea-
suring wounds accurately in daily practice and the
minor variations in the actual percentage of wound
reduction clinicians observed during the first weeks of
care. The Centers for Medicare and Medicaid Services
State Operations Manual on long-term care states that
pressure ulcer improvement must be documented dur-
ing the first two to four weeks of care for healing to be
considered to be taking place.7 And content-validated
pressure ulcer and wound care guidelines now include
the recommendation that all patient and wound care
Measuring Wounds to Improve
Wound measurement is the only evidence-based predictor
The percentage of a reduction in
wound size after two to four
weeks of care is a significant,
and often independent,
predictor of healing.
Here, a sacral pressure ulcer is measured using both the greatest length
and width of the wound and the “clock method.” Photo by Garry
Watson / Science Source.
AJN ▼ August 2013 ▼ Vol. 113, No. 8
By Lia van Rijswijk, MSN, RN, CWCN
protocols be reevaluated if a wound doesn’t exhibit a
reduction in size (usually 20% to 50%) within that
time frame.1, 7, 8
Measuring wounds. Because wound measurement
in most health care settings is routine, implement-
ing these evidence-based recommendations—and
improving patient outcomes—is relatively easy.
Few wound-measurement methods provide an
accurate number. All two-dimensional measure-
ment techniques provide only an estimate of the
actual wound area. But because it is the change—
not the actual area—that’s important in clinical
practice, it’s essential to measure a wound consis-
tently. Therefore, when deciding which measure-
ment technique to use, it’s better to choose one
that will be used consistently than one that may
provide the most accurate dimensions. For exam-
ple, multiplying the greatest overall wound length
by the greatest length perpendicular to it is more
accurate than using the “clock method” (the length
along the 12:00-to-6:00 [head-to-toe] plane multi-
plied by the length along the 9:00-to-3:00 [side-to-
side] plane),9 but the clock method may be used
more consistently and would therefore be a better
In most facilities, disposable rulers with millime-
ter and centimeter markings are readily available for
wound measurement. Transparent measuring guides
with a measurement grid and disposable backings
(to keep them sterile) can also be used. Regardless of
which is adopted, the method used should always be
documented, as should the patient’s position at the
time of measurement.
Once the wound area has been calculated, that
value can be used to calculate the change in wound
size and, consequently, objectively evaluate progress.
Because the initial size of the wound also affects the
time to healing (large wounds take more time to heal
than small ones do), current recommendations are to
use the percentage change, calculated as follows:
baseline wound area − current wound area × 100.
baseline wound area
The measurements are performed weekly, and
progress in the wound’s healing (or the lack thereof)
will emerge after two to four weeks. A wound that’s
on the road to healing will show signs of the later
stages of healing (contraction and epithelialization). If
the goal of care is healing and the numbers are low
(50% or less), the care team should reevaluate all pa-
tient and wound variables that may be responsible
for the lack of progress. By heeding this early sign
of nonhealing, clinicians can avoid many weeks (or
months) of ineffective care. ▼
Lia van Rijswijk is an instructor at Holy Family University
School of Nursing and Allied Health Professions in Philadel-
phia, the clinical editor of Ostomy Wound Management, and
the coordinator of Wound Wise: firstname.lastname@example.org.
The author has disclosed no potential conflicts of interest, fi-
nancial or otherwise.
1. ConvaTec. SOLUTIONS(R) wound care algorithm. Rock-
ville, MD: National Guideline Clearinghouse, Agency for
Healthcare Research and Quality; 2008. http://guideline.gov/
2. Edsberg LE, et al. Longitudinal study of stage III and stage
IV pressure ulcer area and perimeter as healing parame-
ters to predict wound closure. Ostomy Wound Manage
3. van Rijswijk L. Full-thickness pressure ulcers: patient and
wound healing characteristics. Decubitus 1993;6(1):16-21.
4. Kantor J, Margolis DJ. A multicentre study of percentage
change in venous leg ulcer area as a prognostic index of
healing at 24 weeks. Br J Dermatol 2000;142(5):960-4.
5. Lavery LA, et al. Prediction of healing for postoperative dia-
betic foot wounds based on early wound area progression.
Diabetes Care 2008;31(1):26-9.
6. Sheehan P, et al. Percent change in wound area of diabetic
foot ulcers over a 4-week period is a robust predictor of
complete healing in a 12-week prospective trial. Diabetes
7. Centers for Medicare and Medicaid Services. Revisions to
Appendix P—survey protocol for long term care facilities—
and Appendix PP—guidance to surveyors for long term care
facilities. Baltimore, MD; 2006 Dec 15. CMS manual sys-
tem: pub 100-07 state operations provider certification;
8. Association for the Advancement of Wound Care (AAWC).
Association for the Advancement of Wound Care guideline
of pressure ulcer guidelines. Rockville, MD: Naitonal Guide-
line Clearinghouse, Agency for Healthcare Research and
Quality; 2010. http://www.guidelines.gov/content.aspx?id=
9. Bryant JL, et al. Reliability of wound measuring techniques
in an outpatient wound center. Ostomy Wound Manage
Because it is the change—not the actual area—that’s
important in clinical practice, it’s essential to
measure a wound consistently.