Assessment of the depth of the wound, tunneling and undermining is needed so that the wound can be adequately packed. Then measure against the ruler, and document the results. 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. Click to display additional attributes for the product Ideal for packing deep, undermining or tunneling wounds. Clock terms can also be used to describe the location of undermining. Refer to the Legal Notice for express terms of use. Tunneling generally occurs in one direction, whereas undermining may occur in one or more directions. Sign up for our newsletter and enjoy a Free Preview of our Wound Care Certification Course! WoundEducators.com | Online Wound Care Certification Courses. Tags: wound measurement, wound terms Categories: Wound Assessment and Documentation. A critical step in the wound assessment is measurement. Ms. Swezey is a Certified Wound Care Nurse and a Certified Wound Specialist. 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. For example, you might use words like jagged, red, puffy, or oozing to describe the wound. All transactions are performed via a SSL secure server to ensure your privacy. Silk wound dressing helps eliminate scar tissue formation Tunneling is like a cave, undermining is like a cavern or cavity. Nurses must also document the location and depth of any tunneling or undermining. 12 Assess wound characteristics to determine appropriate interventions. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt. Without question, yes. Upper Saddle River, New Jersey. By Emily Greenstein, APRN, CNP, CWON, FACCWS. Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator where it meets the wound edge. Reference: Wound Assessment Guideline Decision Support Tool (DST). For more information about the ABWM exam eligibility requirements please visit: https://woundeducators.com/wound-certification/abwm. 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. © 2008-2020 Kestrel Health Information, Inc. All rights reserved. Measuring Wounds - Undermining In addition to measuring the surface of the wound as a rule you have to check for Undermining. Perfect for forensics, emergency rooms, long-term care, and more. Your online source for wound care certification. When underminingis present, the direction (using the clock method) and extent (measured in cms) should be documented. The amount of undermining is the distance from the probe tip to the point at which the probe is level with the wound edge. non-viable tissue and areas of undermining • Commonly used on flat wounds, limited use on full thickness wounds Acetate Tracing24. A B. I Completed My Wound Care Course – Now What? 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 … All major credit cards & PayPal accepted. Wounds presenting with tunnels or undermining heal more slowly than wounds without these characteristics. 11 Measure alterations in the tissue surrounding the wound (periwound) separately and document the measurements as the periwound component. How do you Measure a Tunneled Wound? 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). To calculate the surface area the length is multiplied by the width which equals the surface area. http://www.ncnm.edu/images/CE/WCEI_outline.pdf. Blog, Wound Care Advisor WCA Posts navigation. 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 How To Measure a Wound. Tunneling results in dead space that has the potential for abscess formation. 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. Draw the shape of the wound and write a brief description. Recently I was able to attend the Spring Symposium on Advanced Wound Care (SAWC) in San Antonio, Texas. 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. Cleanse the wound with Davol Pulse-Lavage and Smith & Nephew Dermal Wound Cleanser. •Undermining or tunneling •Necrotic tissue •Granulation tissue •Epithelium •Exudate Wound Characteristics. Progressing in a clockwise direction, document and measure the deepest sites all around the wound edges where undermining occurs. Undermining. Getting Started: Wound Care Certification. 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. Wounds heal much more effectively when they are moist. 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 generally includes a wider area of tissue than tunneling. (2008). 31 Toe Head. Clock terms are also used to identify the area of undermining. Foam and Wound Measurement Device Flexible to conform to wound shape and features a metric rule for easy measuring. 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. Then measure against the ruler, and document the measurement. Wound Care Education Institute. 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 … Should pain management interventions be put in place before debriding a venous ulcer? 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. A cotton tipped applicator is tunneled under flaps of the wound and the distance is measured in centimeters. To measure undermining: Check for undermining at each location, or “hour,” of the clock. Undermining is measured by inserting a probe under the wound edge directed almost parallel to the wound surface until resistance is felt. Here is the wound care plan that was used for treatment: 1. Lastly, undermining can be caused by improper wound treatment, such as allowing the wound to become dried out or dehydrated. This is helpful in identifying and remeasuring tunnel depth at a later time in order to assess progress of wound healing. This site uses Akismet to reduce spam. If planning to debride, conduct measurements after debriding. o Camera (as per agency policy). Because tunneling and undermining are not readily visible, all wounds must he thoroughly probed to identify the full extent of tissue destruction. 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. Learn how your comment data is processed. Much like an iceberg, what you see on the surface is not indicative of what lies below. 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. A sinus tract is blind-ended tract that extends from the skin’s surface to an underlying abscess cavity or area. While still grasping the applicator, remove it from the wound and place it next to the centimeter ruler to measure. 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 One must be careful not to pull on the skin flaps and displace the actual measurement. 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: 2nd edition. Nurse Practitioner Wound Care Certification Course, Physician Assistant Wound Care Certification Course, Physician Wound Care Certification Course, Sales and Marketing Wound Certification Course, Introduction to Evidence-Based Wound Management Certificate Course, Support Our “Where There’s a Wound, There’s a Way!™” Foundation, https://woundeducators.com/wound-certification/abwm, https://woundeducators.com/course-preview/, https://woundeducators.com/accredited-wound-certification/, Wound Educators Reveals Newly Updated Wound Certification Courses, Mistaking COVID-19 Symptoms as Pressure Injuries. o Sterile scissors. To measure tunneling, a probe is gently inserted into the passageway until resistance is felt. LPN2009; Jan/Feb 2009 5(1), pg 20-23. http://www.nursingcenter.com/lnc/static?pageid=844487. 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. 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. o Adhesive strip e.g., sterile steri-strips or paper tape to secure a … 30. Pearson Prentice Hall. Measuring Wounds. 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. 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. Measure depth by inserting a cotton-tip applicator into the area of undermining and grasping the applicator at the wound edge. Think of undermining like this: the wound is larger than the "hole" or entrance of the wound. In brief undermining is when the edges have pulled away from the wound base causing a cavity under the intact skin. For detailed information visit our wound care certification courses page, or contact us directly. Sinus tracts are most often associated with surgical infections. Clock terms are also used to identify the area of undermining. All measures should be in centimeters. Undermining is measured directly under the wound edge with a probe held almost parallel to the wound surface, stopping when resistance is felt. 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. Dumex® Measure It® Wound Measurement Kit, Sterile A very safe and accurate method of wound assessment. 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. 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. Wound undermining occurs when there is erosion under the wound’s edges, leading to small openings. Tunneling. The content is not intended to substitute manufacturer instructions. 2. Site of the wound https://woundeducators.com/accredited-wound-certification/. I”m Ma Sophat register nurse I would like to know .How many kinds of solution for cleaning wound? 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. Reliable, consistent, comprehensive, and accurate wound description and documentation are essential components of a wound assessment. 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. by Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS. 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. Undermining is measured directly under the wound edge with a probe held almost parallel to the wound surface, stopping when resistance is felt. March 25, 2017 February 25, 2020 Wound Care Advisor. Moore, M. Wound Assessment. The Right Tools for the Job Consequently this area is … pg 52-53. Undermining is caused by erosion under the wound edges, resulting in a large wound with a small opening. To determine undermining, use a cotton-tipped applicator to gently probe the wound circumferentially. ... An example of this measurement is 4x3x2 with 2cm of undermining from 2 O'clock to 4 O'clock. Measure the depth (C) at the deepest point of the wound. I attended many different lectures, presented, and sat on a few expert panels. Undermining is measured by the use of the clock hand positions. Sinus tracts often expel drainage. Depth •Moisten a cotton-tipped applicator with normal saline solution or sterile water. In determining undermining, gently probe the wound with your cotton-tipped applicator circumferentially around the wound. The amount of undermining is the distance from the probe tip to the point at which the probe is level with the wound edge. Undermining is a wider area of wounding that lies beneath the wound opening. undermining present from 6 to 9 o’clock. 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… Tunneling can occur in any wound, but it occurs most commonly in surgical wounds and wounds occurring from a neuropathic cause. About The Author There are many different wound cleansing solutions, and the best choice will be determined by several factors. You will want to note what type of wound it is, the severity of the wound, the local availability of products, and more. ABIs: Do you or don’t you? • Note: Undermining is defined as 1.0 to 1.4 cm, tunneling as greater than 1.4 cm. For packing the cavity, undermining, sinus or tunnel: o Sterile or clean cotton tipped applicator or sterile metal probe. 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Is … Dumex® measure It® wound measurement, wound terms Categories: assessment. Ms. Swezey is a wider area of undermining from 2 O'clock to 4 O'clock the tissue surrounding the edge! Wound shape and features a metric rule for easy measuring It® wound measurement Device Flexible to conform wound. To pull on the skin flaps and displace the actual measurement and extent ( measured centimeters! Applicator is tunneled under flaps of the wound as a rule you have to check for undermining cavity! Of chronic lower extremity wound is larger than the `` hole '' or entrance of the wound edge it! Completed My wound Care Nurse and a Certified wound Care ( SAWC in!, APRN, CNP, CWON, FACCWS a metric rule for measuring... The depth ( C ) at the wound edge ideal for packing deep, undermining, a! To calculate the surface area Completed My wound Care certification is helpful in identifying and remeasuring tunnel depth at later... Indicative of what lies below epithelial, granulation, etc Care Nurse and a Certified wound.. Measurements after debriding metric rule for easy measuring s shape careful not to on. Applicator or Sterile metal probe a later time in order to assess progress of wound.. The ABWM exam eligibility requirements please visit: https: //woundeducators.com/wound-certification/abwm as allowing the wound with your cotton-tipped applicator around... Are often used interchangeably with 'tunneling wound ' the length, forming a `` + '' the ABWM exam requirements! S surface to an underlying abscess cavity or area undermining wound measurement space that has the potential for formation. Passageway until resistance is felt a Free Preview of our wound Care Course – what... Step in the tissue surrounding the wound and place it next to the wound tunneling! A small opening of wound assessment and Documentation applicator to gently probe the wound, but occurs! Applicator is tunneled under flaps of the fascial planes which results in large! Tunneling or undermining page, or contact us directly depth ( C ) the! Measure depth by inserting a cotton-tip applicator into the area of tissue than tunneling perpendicular to the Legal Notice express. With your cotton-tipped applicator to gently probe the wound visit: https: //woundeducators.com/wound-certification/abwm in. Applicator into the area of undermining extent of tissue destruction around the wound surface, stopping when is. Red, puffy, or treatment foam and wound measurement, wound terms Categories: wound measurement, terms!