Wound Measurement and Documentation

A wound is a break in the skin or deeper tissue. Common causes include pressure and shear, trauma, surgery, moisture, poor arterial or venous circulation, and neuropathy. Healing moves through overlapping phases: hemostasis, inflammation, proliferation, and maturation or remodelling. During proliferation, granulation tissue fills the wound from the base and epithelial cells move across it from the edges. A healing wound should therefore get shallower as well as smaller. Measurement is how the team finds out whether that is happening. Depth of tissue loss is described in three levels. Superficial-thickness loss involves only the epidermis, as in an abrasion or blister. Partial-thickness loss involves the epidermis and dermis and looks like a shallow crater. Full-thickness loss extends into subcutaneous tissue or deeper structures such as muscle, tendon, or bone, and may tunnel into surrounding tissue. Pressure injuries, diabetic foot ulcers, surgical wounds, burns, and skin tears each have their own staging or classification system, which the RPN applies as the organization directs. The goal of care shapes how measurements are read. A healable wound has a treatable cause, enough blood...