MEASURE: A proposed assessment framework for developing ... · of the patient and the chronic wound should begin with a general wound classification using categories such as cause

MEASURE: A proposed assessment framework fordeveloping best practice recommendations for woundassessment

DAVID H. KEAST, MSc, MDa; C. KEITH BOWERING, MDb; A. WAYNE EVANS, MDc; GERALD L. MACKEAN, MDd;CATHERINE BURROWS, RN, BScNe; LINCOLN D’SOUZA, RN, BScNf

The effective management of nonhealing wounds is based on a complete patient history, a detailed initialassessment of the wound, and an analysis of probable causative factors. This information is used to individua-lize a management strategy to the underlying pathophysiology preventing healing and to implement appro-priate wound interventions. Regular reassessment of progress toward healing and appropriate modification ofthe intervention are also necessary. Accurate and clinically relevant wound assessment is an important clinicaltool, but this process remains a substantial challenge. Wound assessment terminology is nonuniform, manyquestions surrounding wound assessment remain unanswered, agreement has yet to be reached on the keywound parameters to measure in clinical practice, and the accuracy and reliability of available woundassessment techniques vary. This article, which resulted from a meeting of wound healing experts in June2003, reviews clinically useful wound measurement approaches, provides an overview of the principles andpractice of chronic wound assessment geared to a clinical audience, and introduces a simple mnemonic,MEASURE. MEASURE encapsulates key wound parameters that should be addressed in the assessment andmanagement 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 edge andsurrounding skin). This article also provides some preliminary recommendations targeted to developing bestpractice guidelines for wound assessment. (WOUND REP REG 2004;12:S1–S17)

A strong rationale exists for the routine assessment ofchronic wounds. Wound assessment is critical to estab-lish a diagnosis, to monitor the effect of treatment, to

identify the presence of infection, and to predict theoutcome of treatment with accuracy.

The principle of routine wound assessment is clo-sely allied with the concept of wound bed preparation,which stresses global assessment, including identifyingand addressing the underlying cause of the lack ofhealing and understanding and dealing with patient-centered concerns, including negotiation of careplans, before evaluating the wound itself (Figure 1).1

Critical local components of wound bed preparationinclude debridement of nonviable or deficient tissue;treatment of infection or inflammation; selection ofmoisture-balancing dressings, and reassessment of the

ICC Intraclass correlation coefficient

PSST Pressure sore status tool

PWAT Photographic wound assessment tool

SPG Stereophotogrammetry

VeV Verge Videometer

From the Department of Family Medicinea, University ofWestern Ontario, London, Ontario; Departmentof Medicineb, University of Alberta, Edmonton,Alberta; Department of Anesthesiac, Universityof Toronto, Toronto, Ontario; Department ofSurgeryd, Dalhousie University, Halifax, NovaScotia; Queen Elizabeth II Health SciencesCentree, Halifax, Nova Scotia; and Departmentof Surgeryf, McGill University Hospital Center,Montreal, Quebec, Canada.

Reprint requests: Dr. David H. Keast, 201-750 BaselineRoad, East London, Ontario, N6C 2R5 Canada.Fax: (519) 433-6087; Email: [email protected].

Copyright # 2004 by the Wound Healing Society.ISSN: 1067-1927 $15.00 + 0.

S1

reason for lack of healing if the epidermal margin is notadvancing or is undermined. These components aresummarized using the acronym TIME: Tissue, Infec-tion, Moisture, and Edge of wound.

A variety of etiologic, systemic, and local factorsmay be involved in the pathogenesis of a nonhealingwound, and these factors must be identified andaddressed before healing can take place. For this rea-son, a global assessment should be undertaken whenassessing nonhealing wounds, including a comprehen-sive patient history and analysis of probable underlyingcauses. In addition, a plan must be developed for mana-ging each contributing factor potentially preventingwound healing, including poor nutritional status, sys-temic medications such as corticosteroids, inadequatetissue perfusion, and unrelieved wound pressure. Thisglobal approach to the patient and the problem is vitalto comprehensive wound assessment and effectivemanagement. Local wound assessment, the focus ofthis article, is a critical part of this overall strategy.

Accurate and comprehensive wound assessmentdepends on meticulous and consistent clinical observa-tion and on the use of quantitativemeasurement methodswhere possible.2 Regular reassessments, currently theonly way of determining treatment effectiveness, quan-tify and document progress and guide further treatmentdecisions.

A thorough initial wound assessment providesbaseline data about the status of the wound and valu-able information that can assist in identifying short-

and long-term goals of care and determining appropri-ate interventions at each stage. The initial assessmentof the patient and the chronic wound should begin witha general wound classification using categories such ascause (surgical or nonsurgical) and depth (superficial,partial thickness, full thickness).2 Additional clinicalclassification approaches include variables that mayaffect healing in patients with specific types of ulcers.For example, initial classification of venous ulcers mayinclude clinical signs, etiology, distribution, and patho-physiology. Similarly, classification of diabetic footulcers combines wound characteristics, ischemia,infection, and ischemia plus infection.

The literature on wound care has not simplifiedwound assessment, which remains a substantial chal-lenge in clinical practice. Terminology describingwound assessment is not standardized, nor has consen-sus been reached on the most appropriate wound healingparameters to monitor. As several classification anddescriptive methods for chronic wounds exist, it is essen-tial that all members of the wound management team usethe same approach.3 In addition, studies of the validityand reliability of wound assessment tend to be con-ducted from a research rather than a clinical perspective.However, in spite of these issues, wound managementexperts do agree that, in clinical practice, regular woundassessment using the same technique, whatever its defi-ciencies, is substantially better than no assessment.

Documentation is an integral part of wound assess-ment, to meet accepted standards of care, to assess

Chronic wounds

Treat the cause Local wound carePatient centred

concerns

Tissue debridementInflammation/

infectionMoisture balance

Edge of wound

• Growth factors• Other biologicals• Skin substitutes• Skin grafts• Adjunctive therapy

• Surgical• Autolytical• Mechanical• Enzymatics• Biological

• Absorbent• Calcium• Alginates• Hydrogels• Hydrocolloids • Film

FIGURE 1. Wound bed preparation.

WOUND REPAIR AND REGENERATIONS2 KEAST ET AL. MAY–JUNE 2004

wound progress toward the treatment goal, and to facil-itate communication between members of the woundmanagement team.3 The requirement to document thestatus of all wound parameters at each assessmentunderlines the importance of using objective and accu-rate wound assessment techniques and standard termin-ology and of applying a consistent approach duringeach assessment. Accurate wound measurement iscentral to the assessment process.

WOUND MEASUREMENT TECHNIQUESWounds should be measured at each assessment.A variety of parameters can be measured, includinglength, width, depth, and circumference.1 Wound areaand volume can be calculated from these measureddimensions, and area and volume can also be estimatedusing several techniques. During the past decade,research evaluating wound measurement techniqueshas increased considerably, supporting the evolutionof this important aspect of wound assessment from aclinical art into a science.

Clinical importance of wound measurementThe clinical value of measuring wounds has been wellestablished by numerous studies. Sheehan et al. con-ducted a prospective multicenter trial of 203 diabeticpatients with foot ulcers to assess how well the healingrate during the initial 4 weeks predicted total healingwithin 12 weeks.4 The authors found that higher 4-weekhealing rates were significantly correlated with healingat 12 weeks and concluded that assessing healing at 4weeks is an important clinical indicator for early iden-tification of individuals who are unlikely to heal withstandard therapy.

Zimny et al. conducted a prospective study toassess wound size reduction and healing time over atleast 10 weeks and to establish equations predictinghealing time for neuropathic, neuroischemic, andischemic diabetic foot ulcers.5 The authors found thathealing rate is determined more by ulcer etiology thanby size, although initial area was significantly corre-lated with time to healing for neuropathic and neurois-chemic ulcers. The authors concluded that in patientswith neuropathic and neuroischemic ulcers, if initialwound size is known, healing can be predicted usingthe estimated daily wound radius reduction.

Gorin et al. postulated that measuring percentagechange in area overestimates healing in small com-pared with large wounds, whereas measuring changein area overestimates healing in large compared withsmall wounds.6 Methods influenced by initial woundsize do not allow accurate comparison of healingrates in clinical trials. The authors therefore evaluatedthe calculation of average linear healing of the wound

edge toward the center as a means of comparingwound healing across clinical trials. They found thatdaily linear healing rate was uninfluenced by geometricvariables and concluded that this measure is a validway of comparing healing in wounds of differentdimensions in clinical trials.

The prolonged healing time and high prevalence ofvenous ulcers among chronic wounds make it desirableto predict the likelihood of nonhealing early after insti-tuting a specific therapeutic regimen. Kantor andMargolis compared the use of percentage change invenous leg ulcer area and weekly area healed as prognos-tic indicators of 24-week healing.7 The authors found thatthe percentage change in area from baseline to 4 weekspredicted healing or nonhealing at 24 weeks (p < 0.05) andwas unaffected by initial wound size or duration. Weeklyarea healed was not predictive of healing.

Researchers continue to debate which wound heal-ing parameters accurately predict wound healing. Never-theless, the existence of this debate does not affect thekey clinical message for wound care practitioners: amethod of measuring wounds should be selected andconsistently applied, and results should be meticulouslydocumented to assess the progress of healing.

Tallman et al. compared the ability of baseline-adjusted healing rate (comparing weekly with baselineulcer size) and mean-adjusted healing rate (measuringmean healing between all visits) to predict wound heal-ing.8 The authors found that the baseline-adjusted healingrate decreased the ability to predict healing, whereas themean-adjusted healing rate predicted complete healing asearly as 3 weeks after initiating therapy (p < 0.001).

Evaluation of wound measurement techniquesA variety of methods are available to measure woundarea, including the ruler method; acetate tracing plusmanual square counting or mechanical planimetry; digi-tal photography with computerized planimetry using theVerge Videometer (VeV); stereophotogrammetry (SPG),and acetate tracing plus a digitizing tablet.9,10 The accu-racy and reliability of several wound measurement tech-niques have been evaluated in clinical practice, in thelaboratory using models, and in animal studies.

Ruler-based techniques to calculate area are simplebut inconsistent and are not very reliable for irregularor large wounds.10 The accuracy of wound area calcu-lations can be increased by using the average of threelength and width measurements. These techniques alsocarry the risk of wound contamination. Tracing thewound edges onto a transparency and using a metricgrid to count the number of square centimeters makingup the wound is a commonly used but time-consumingmethod. In addition, inaccuracy can arise from estimat-ing partial squares.9 Substituting an electronic or com-puterized planimetry device for manual counting is alsoa practical and popular way of measuring wound area.

WOUND REPAIR AND REGENERATIONVOL. 12, NO. 3 KEAST ET AL. S3

This method has been shown to have excellent inter-rater and intra-rater reliability, although reliabilitydecreases for small wounds. It is also inexpensive andconvenient and requires minimal training.

Digital photography with computerized planimetryis also reliable and accurate, but the potential forinaccuracy as a result of parallax exists. The VeV systemconsists of a video or digital camera to produce colorphotographs of the wound and a computer and softwaresystem using an accurate perimeter-based algorithmto determine wound measurements and perform acolor analysis (Figure 2).11 The VeV assists in woundmonitoring and improves measurement consistency byproviding objective and accurate data to track outcomes,analyze treatment, and document healing. This noncon-tact method eliminates the risk of wound contamin-ation, damage to the wound bed, and the possibility ofprocedure-related pain.

SPG is a reliable and precise computer-assistedtechnique using two digital cameras to create athree-dimensional wound image that allows area andvolume determinations to be performed.9 SPG istime consuming and expensive, and it requires special

training, making it impractical for routine use inclinical practice.

Langemo et al. assessed the accuracy of fourwound measurement techniques using plaster mod-els.12 The authors compared ruler-based length andwidth, planimetry, SPG length and width, and SPGarea using a sample of 66 raters. The authors foundthat the most accurate technique, based on standarderror and multiple raters, was SPG area, followed inorder by ruler length and width, SPG length and widthand, lastly, planimetry. The authors also concluded thatSPG area was the only technique reliable enough forclinical or research purposes.

Lucas et al. evaluated the use of a combined techni-que to measure wound area using full-scale photographyplus transparency tracings to assess pressure ulcers.13

The authors used two independent observers to assess30 wounds from 26 subjects over 2 weeks and found thatall measurement comparisons were highly reliable, withan intraclass correlation coefficient (ICC) of 0.99. Theauthors concluded that the combined technique is asimple, practical, inexpensive, and accurate way of moni-toring healing in pressure ulcers in clinical practice.

FIGURE 2. Verge Videometer (VeV) system: the target in the picture has a known area, which the computer uses to correct forparallax. The yellow line represents the digital tracing of the wound margin.


Thawer et al. performed a study evaluating theVeV, and comparing it with acetate tracings andmechanical planimetry in measuring 45 chronichuman wounds and 38 small surgical animal wounds.9

The authors found excellent intra-rater and inter-raterreliability for single measurements of human and ani-mal wounds, but greater precision with the computer-ized technique. Reliability increased when threemeasurements were taken and the results averaged.Precision also increased when the average of threemeasurements was used, except for the computerizedtechnique with animal wounds. Excellent concurrentvalidity between the two techniques for humanwounds, but poor concurrent validity for the smallanimal wounds, was seen. The authors concluded thatthe computerized technique is as reliable and precise asthe manual one for measuring chronic human wounds.

Keast and Cranney conducted a retrospective ana-lysis of a large wound database using the VeV.14 Theycompared the relation between calculated rectangulararea (length ·width), calculated elliptical area(length ·width · �/4) and true wound area using infor-mation from 12,181 observations of 2131 patients with2768 wounds. True area was obtained from VeVmeasurements in the database. Rectangular area andelliptical area were calculated from length and widthmeasurements (Figure 3). Wounds of all etiologies,such as pressure, venous, and diabetic ulcers, wereincluded in the analysis. The absolute and percentagedifferences between rectangular area and true area andbetween elliptical area and true area were calculated.

The calculated rectangular area overestimated truearea by 44 percent (p < 0.001) and the calculated ellip-tical area overestimated true area by 13 percent(p < 0.001) (Table 1). Bland-Altman plots showed theseresults (Figures 4 and 5). With these plots, the horizon-

tal lines represent � 2 standard deviations, and calcu-lated area represents true area if most points fallbetween the lines.

Consistent with previous studies, the data alsoshow that agreement between calculated rectangulararea and true area becomes progressively worse asulcer size increases, even for smaller ulcers. This retros-pective analysis clearly shows that calculated ellipt-ical area provides a better approximation of true areabut still overestimates true size considerably. It there-fore seems reasonable to use an ellipse, rather than arectangle, as a model for calculating wound area. It isimportant to remember, however, that calculatingwound area from length and width measurements pro-vides only an approximation of wound size. As a result,in situations where serial wound area measurementsare being used prognostically, or where accuracy isimportant for other reasons, a more accurate methodof determining wound area may be appropriate.

Measurement of wound volume can be useful insome clinical situations, for example, to assess theprogress of granulation in deep wounds.15 In this situ-ation, area measurements miss early healing, as suchwounds initially heal from the base.

Schubert and Zander compared the reliability ofpressure ulcer size measurements using volume, area,perimeter, and depth.16 The authors found that volumeand area were more reliable than perimeter and depth,and that area measurement was most suitable for rela-tively broad and irregularly shaped ulcers, whereasvolume measurement was most appropriate for deepulcers.

Langemo et al. compared the inter-rater and intra-rater accuracy of wound volume measurements per-formed using either a Kundin device or an SPG techni-que and found the less biased and more accuratetechnique to be SPG.17

Plassmann et al. compared three methods of meas-uring wound volume: filling the defect with saline, mak-ing an impression with alginate, and using imageprocessing based on a structured light technique.15

The structured light technique creates a three-dimensionalimage of the wound and calculates volume using operator-provided wound data. The authors found the salinemethod to be least precise and the computer imagingmethod to be most precise and reliable.

New technology for wound measurementThe VisitrakTM (Smith & Nephew) is a novel bedsidewound measurement system currently undergoing clin-ical evaluation (Figure 6). The system consists of atransparent tracing grid, a depth indicator, and a digitaltablet. The tracing grid consists of a three-layer trans-parent film. The film is sterile, comfortable, and easy todraw on, and the multilayer structure minimizes therisk of contamination. The top film layer, which is

FIGURE 3. Wound area approximations using rectangular andelliptical models. From Keast et al. 200314 with permission.


used to record wound measurements, is clean and canbe stored in patient records. The depth indicator is asterile, single-use, foam-tipped probe. The battery-operated digital tablet is a portable lightweight toolthat can be disinfected. It accurately (to 0.1 cm2) andreproducibly measures area, length, and width. Measure-ments are recorded using a special stylus. The VisitrakTM

system rapidly calculates percentage reduction in woundarea from previous measurements, measures woundslarger than one film, and subtracts traced areas ofepithelialization from overall wound size. In addition,the clinician can select additional wound factors totrack, such as undermining, epithelialization, or thepercentage of different tissue types, including nonviabletissue.

The VisitrakTM has undergone internal reliabilitytesting by the developer, Smith & Nephew. Testinginvolved 25 volunteers who made 10 traces of each offive different wound templates, using four different timelimits (short, medium, long, and natural time). True areawas determined by a computerized technique. Areaaccuracy equaled or exceeded 98.3 percent for all testsand was highest for the shortest time (98.7%).

MEASURE: A PROPOSED FRAMEWORK FORWOUND ASSESSMENTA clinically oriented overview of the principles andpractice of chronic wound assessment accompaniesthe discussion of the simple mnemonic, MEASURE and

the underlying concept.10 MEASURE encapsulates thefollowing basic wound parameters, which should beaddressed in the routine assessment and managementof chronic wounds: Measure (length, width, depth, andarea), Exudate (quantity and quality), Appearance(wound bed, including tissue type and amount), Suffer-ing (pain type and level), Undermining (presence orabsence), Reevaluate (monitoring of all parameters reg-ularly), and Edge (condition of edge and surroundingskin). Preliminary recommendations to encourage stan-dardization of terminology and definitions and consist-ency in the approach to clinical wound assessmentusing the MEASURE framework are proposed. MEA-SURE can also be used as the basis for developing aconsistent approach to documenting wound status ateach assessment and for creating institution-specificassessment flow sheets (Table 2).10

M – MeasureAs a wound heals, growth of granulation tissuedecreases wound depth and volume, and proliferationand migration of new epithelium decrease woundarea.18 Measures of wound size are therefore importantindicators of healing. Dimensional wound parametersthat can be measured, estimated, or calculated includelength, width, depth, circumference, area, and volume.

Numerous tools and techniques have been devel-oped to measure wounds, including the ruler method tomeasure length and width and calculate rectangular orelliptical area; acetate wound tracings from which area

Table 1. Rectangular and elliptical wound area compared with true area

Relation between calculated and true area Rectangular area Elliptical area

Total observations 12,181 12,181Calculated area > true area 12,102 10,916Calculated area¼ true area 4 280Calculated area < true area 75 985Mean percent difference 44% (p < 0.001) 13% (p < 0.001)

Adapted from Keast et al. 2003.14

Est. - True1401301201101009080706050403020100

0

–10

100

Rectangular Area (Ulcers < 200cm2)

Mean of Estimated and True

200 300

FIGURE 4. Wound area approximation using rectangular area(ulcers < 200 cm2). From Keast et al. 200314 with permission.

Est. - True Elliptical Area

Mean of Estimated and True

400

300

200

100

0

0 100 200 300 400 500 600 700 800 900 1000–100

FIGURE 5. Wound area approximations using elliptical area.From Keast et al. 200314 with permission.


can be estimated using a manual square count, mechan-ical or computerized planimetry, or a digitizing tablet;digital photography with or without computerized pla-nimetry; and volumetric calculations, measures, or

modeling techniques.10,19 These methods have varyingdegrees of reliability, validity, clinical practicality, andresponsiveness to changing wound status.

Area measurement is a crucial part of woundassessment and an important tool in articulating thegoals of care, developing a care plan, and predictinghealing time.2 Initial wound area affects healing time,and regular reevaluation of wound size can quantifyhealing or identify a lack of healing. The percentagedecrease in wound area during the first 2–4 weeks oftreatment has been found to be predictive of healing at12–24 weeks.14 As a result, accurate measurements ofwound area are vital to the clinician in making treat-ment decisions.

A literature review conducted by Flanagan criti-cally evaluated the effectiveness of wound measure-ment techniques with the dual objective of providingan evidence-based rationale for accurate wound mea-surement and of identifying measurement parameterscorrelated with healing.18 Most wound measurementmethods used in clinical trials to evaluate healingassess the change either in wound area or in wounddepth. The accuracy of these techniques relies both onthe inherent precision of the technique and on theclinician’s ability to see the new epithelium at the mar-gin of the wound.2 Area calculations based on thecommonly used ruler-based wound size measurementshave been found to be reliable.14 However, as thesetechniques commonly overestimate wound size, deter-mining the best way to measure irregular wounds canbe difficult, and measurements are less reliable forlarger wounds. For example, researchers have notedthat the accuracy of area calculations based on greatestlength and width measurements varies with how clo-sely the wound conforms to a regular geometric shape.2

In addition, the accuracy of this approach decreaseswith increasing wound size. Finally, research indicatesthat measuring the greatest length and the greatestwidth, perpendicular to the greatest length, is morevalid and reliable than other ruler-based methods.

Wound depth is an important measure for deepwounds, as it is correlated with the degree of tissuedamage. A variety of staging systems, such as the pres-sure ulcer staging system, based on the work of Shea,the International Association of Enterostomal Therapyand the National Pressure Ulcer Advisory Panel, andthe University of Texas diabetic wound classificationsystem can be used to categorize wound depth.2 Theuse of staging systems in wound assessment is valu-able, as these systems standardize terminology. How-ever, they rely on clinical depth measurement, whichmay be complicated by several factors.

No technique to measure wound depth is accurateif the wound bed contains debris, particulate matter, orbits of dressing. Therefore, the first step in measuringwound depth is cleansing. Similarly, if eschar covers a

(a)

(b)

(c)

FIGURE 6. VisitrakTM system. (a) The VisitrakTM system consists ofa multilayer acetate tracing, a sterile depth probe, and adigitizing tablet. (b) The wound is traced onto the acetatesheet and the backing layer removed and discarded. (c) Thewound outline is traced onto the digitizing tablet and thewound area is calculated.


wound, depth measurement cannot be performed untilthe wound has been debrided. Accurate measurementof the depth of a wound with sinus tracts or tunnels isnot possible. In this situation, however, recording theamount of wound product needed to fill the defectprovides an indication of the depth of the tunnel. Thedepth of wounds that contain areas of partial-thicknessand full-thickness damage must be estimated, but thegreatest depth is usually recorded as the wound depth.Wound depth is typically measured by inserting a ster-ile swab into the deepest part of the wound, placing agloved forefinger at the level of the surrounding skin,and measuring the length of swab within the woundagainst a ruler or other calibrated guide.

Volumetric wound measurements have severalinherent practical problems including the following:the subjective nature of defining wound boundaries;the impact of positioning or movement on reproduci-bility of measurements; wound volume changes result-ing solely from positioning differences and the impactof the normal curvature of the body on the accuracy ofoptical measuring techniques. In addition, a residualdefect may remain in spite of complete healing ofwounds in anatomical areas with thick subcutaneoustissues, such as the abdomen.15

In summary, research indicates that measuringwound area provides clinically useful and valid informa-tion about wound healing, whereas the clinical benefit ofmeasuring wound volume has not yet been definitelyestablished. Evidence for the accuracy and validity ofdifferent wound measurement techniques is reviewed inthe section on wound measurement techniques.

RecommendationsArea – Repeated assessment of wound area can effect-ively both monitor and predict healing. Tracing thewound margin onto acetate and calculating area usingmechanical planimetry is currently an accepted standardfor measuring wound area. Calculating wound area from

length and width measurements may be acceptable forsome clinical settings, and accuracy may be improved byhaving a single individual perform the measurementsand by taking the average of three measurements. Avalidated and reliable wound surface area measurementtechnique should be used in clinical research.

Depth – Simple depth measures may be useful inthe assessment of full-thickness wounds to monitorhealing. Depth should be measured in a standard way,preferably using a sterile swab inserted into the dee-pest part of the wound.

Volume – No simple, valid, and reliable techniquefor measuring wound volume is available to clinicianstoday. As a result, the routine measurement of woundvolume cannot be recommended.

New technologies and techniques – New measure-ment techniques and technologies should be validatedagainst accepted standards, such as the use of acetatetracings and mechanical planimetry for the measurementof area, before being recommended for routine clinical use.

E – ExudateExperience with acute wounds has shown that acutewound fluid contributes to the healing process, as itcontains growth factors, which stimulate tissue regen-eration and promote cellular migration; proteases,which degrade necrotic tissue; and inhibitors of bacter-ial growth.20,21 The composition of wound fluid mayvary between individuals and at different stages ofhealing, although the amount of exudate graduallydecreases as healing progresses.21 In fact, recent dataconfirm that the quantity of wound exudate is a reliableand sensitive indicator of healing.22

The situation with chronic wound exudate is morecomplex. Chronic wound exudate differs biochemicallyfrom acute wound exudate.20 Studies have shown thatchronic wound fluid contains a variety of factors thatinhibit or prevent cellular proliferation; decreasedlevels of growth factors compared with acute wound

Table 2. Documentation of wound assessment using MEASURE

Parameter Clinical observation Indicator

Measure Wound size: length, width, area, depth, volume Decrease or increase in wound surface area and/or depthExudate Quality and quantity Decreased or increased purulence*

Decreased or increased quantityAppearance Wound bed appearance Decreased or increased percentage granulation tissue(wound bed) Tissue type and amount Decreased or increased percentage necrotic tissue

Friability of granulation tissue*Presence or absence of deep tissue structures (tendon, bone, joint)

Suffering Patient pain level using validated pain scale Improving or worsening wound-related painUndermining Presence or absence Decreased or increased amountReevaluate All parameters monitored regularly (1–4 weeks) Planned monitoring and reassessment frequencyEdge Condition of wound edge and surrounding skin Presence or absence of attached edge with advancing border of epithelium

Presence or absence of erythema and/or indurationPresence or absence of maceration

*May indicate infection.



fluid; high levels of proteinases, which produce chronictissue turnover, preventing epithelialization; and highinflammatory cytokine levels and low glucose levels,both of which are associated with nonhealing wounds.

In chronic wounds, the amount of exudate may bemaintained or may increase for a variety of reasons.21

Wounds in patients with chronic venous insufficiencyor lymphedema may be associated with a large amountof exudate.22 Individuals with decreased serum proteinlevels, either as a result of excessive protein loss ordecreased production, have increased capillary fluidleakage, producing a greater volume of wound fluid.23

A high exudate volume may indicate local infection orosteomyelitis, and a sudden increase in exudate maysignal an increased bacterial burden in the wound bed,even in the absence of typical signs of infection.Bacteria, necrotic tissue, and foreign materials in thewound all increase exudate production.

Assessing wound exudate, also known as woundfluid or wound drainage, is an essential component ofcomprehensive wound assessment. Serial documenta-tion of the quantity and quality of wound exudateassists in monitoring wound response to treatmentand in diagnosing infection.

The characteristics of wound exudate that can beassessed are quantity, quality and odor. Assessing thesecharacteristics is inherently subjective and primarilyqualitative. Descriptive terms used for exudate volumeinclude absent, scant, small, moderate, heavy, high andcopious. Perceptions of the meaning of these termsvary considerably and, although standardized defini-tions have been proposed, no consensus has beenreached.21 Even experienced wound care clinicianshave difficulty in estimating exudate amount and inagreeing on the amount.24 Evaluating the state of thedressing when it is changed may provide a rough guideto exudate quantity. However, it is important to docu-ment the dressing type, degree of saturation, and fre-quency of dressing change required as a result ofdrainage. One measurement system bases the descrip-tion of exudate quantity on 10-cm gauze squares and onthe frequency of dressing changes required as a resultof exudate production.23 Although such a system intro-duces an element of objectivity into assessing exudatevolume, its application is limited to the use of 10-cmgauze squares. Adaptation of the volume estimatesused to other dressing types with different absorptivecapabilities would be necessary.

The MEASURE approach suggests using a simplenumerical scoring system, first proposed by Falanga,for quantifying the amount of exudate, using none (0),small (1), moderate (2), and large (3) and providesdefinitions for each category (Table 3).25

In addition to quantity, other important wound exu-date characteristics are quality and odor.2 As termsdescribing exudate quality may be confusing if not

clearly defined, the MEASURE system recommendsdescribing exudate quality using the following definitions(Table 4).10,23 Serous refers to exudate that is clear, con-tains no debris, blood or pus, and is generally odorless.Serosanguineous fluid is pink to light red in color, possi-bly with a yellow tone, and thin and watery. Sanguineousfluid is bright red and bloody. Serous and serosangui-neous exudate reflect the normal inflammatory and pro-liferative phases of healing, whereas sanguineousdrainage signifies disrupted blood vessels. Seropurulentdrainage is cloudy and yellow to tan in color, and puru-lent exudate is yellow, tan, or green. These types ofexudate may be accompanied by a foul odor.10 Purulentdrainage is typically thick and may be translucent oropaque.10,22 Conversion of exudate to seropurulent andthen to purulent drainage suggests bacterial proliferationor progression to wound infection.

However, the presence of purulent exudate does notnecessarily indicate infection. The diagnosis of infectionin chronic wounds is not straightforward. A large studyfound that increased wound pain and wound breakdownwere the most valid signs and symptoms of infection inchronic wounds, with a specificity of 100 percent.26 Thesame study found that friable granulation tissue and foulodor were more reliable signs and symptoms of infec-tion than purulent exudate. However, infection may alsobe present without significant odor being evident. Accu-rate diagnosis of wound infection in nonhealing woundsis challenging and relies on careful clinical observation,assessment of an individual’s risk of infection, andappropriate investigations, including quantitative orsemiquantitative culture.2

Assessing wound odor is an important part ofwound assessment, although descriptions are neces-sarily subjective and standard terminology has notbeen adopted.2 A change in the amount and type ofodor may indicate a change in wound status. However,it is important to remember that all occluded woundshave an odor, and that the type of dressing used mayaffect wound odor.22 Hydrocolloids, for example, may

Table 3. Exudate volume quantification

Numerical

score Description Definition

0 None No exudate1 Small (scant) Exudate fully controlled

Nonabsorptive dressingmay be used

Wear time up to 7 days2 Moderate Exudate controlled

Absorptive dressingsmay be required

Wear time 2–3 days3 Large (copious) Exudate uncontrolled

Absorptive dressings requiredDressing may be

overwhelmed in < 1 day

Adapted from Falanga 2000.25


emit a foul odor upon removal. Necrotic tissue in awound contaminated with anaerobes may produceexudate with a particularly foul odor.2 Finally, specificorganisms may have a characteristic odor. If Pseudo-

monas aeruginosa is present in a wound, the exudatemay be a characteristic lime-green color and have asweet odor.22 One proposed scale for assessing odorwith the dressing in place uses the following scale: noodor at close range, faint odor at close range, moderateodor in room, and strong odor in room.2

RecommendationConsistent and clear terminology, definitions, qualita-tive descriptions, and quantitative measures of woundexudate, such as those proposed by Falanga anddescribed in Tables 4 and 5 should be used in woundassessment in clinical practice and in research.

A – AppearanceDirect observation of the wound bed is fast and simpleto perform, but it provides critical information aboutthe etiology of the wound, contributes to accurate diag-nosis, and helps to identify treatment goals and anappropriate plan of care.3,19 Reevaluation helps todetermine treatment progress.

Assessing the clinical appearance of the wound beddepends on thorough observation and involves describ-ing its color and texture and noting any deeper tissuestructures that are palpable or visible. Considerable var-iation exists in wound bed color, but black, yellow, red,pink, and white are most commonly used to describe thewound bed (Table 5 and Figure 7).3 This selection isoften simplified to black, yellow, and red.2 Little dataexist concerning the reliability of this system, but onestudy of six observers found good inter-rater agreement.

A black or dark brown wound can be seen whendehydrated necrotic tissue has compacted in the wound,most often in arterial ulcers with local ischemia. Thisnecrotic tissue, or eschar, represents full-thickness tis-sue destruction, and it may cover the wound bed com-pletely or patchily. Eschar retards healing and should beremoved from healable ulcers. However, in lower extre-mity ulcers associated with compromised circulation,stable eschar should not be removed.

A yellow wound bed generally points to eitherfibrous tissue or slough. Fibrous tissue, which is com-posed of fibrin, is firm in texture. It appears in thewound bed before granulation tissue develops. Sloughis composed of cellular debris and may adhere tightlyto the wound bed or be loose and stringy.3,27 If largenumbers of white blood cells are present, slough maybe a creamy yellow color, and if necrotic fascia ispresent, slough may appear yellow to gray-green.3,10

Desloughing a wound must be performed cautiously ifslough is adherent to fibrous tissue in the wound bed toavoid unnecessary wound trauma and prolongation ofthe inflammatory response.3

A red wound bed indicates the presence of granula-tion tissue, with a bright red, moist appearance indicat-ing healthy granulation tissue and a paler appearancewith spontaneous bleeding possibly indicating ische-mia, infection, or a comorbidity such as anemia.3

Dark red or beefy-looking granulation tissue may alsoindicate infection.

Pink epithelializing wounds represent the finalstages of healing.3 At this stage, pink, white, or translu-cent areas of epithelialization may be seen overlying ahealthy bed of granulation tissue, migrating either fromthe wound margin or from hair follicles within thewound. However, these cells may be obscured by exu-date or slough or confused with macerated skin at thewound edge.

The texture of the wound should also be noted.Black eschar is usually hard and leathery, but it mayalso be soft and wet. Granulating wounds usually havean uneven texture, but significantly raised areas ofgranulation, referred to as hyper-granulation, may indi-cate excess moisture in the wound. Pocketing at thebase of the wound may signify infection. A prospectivestudy evaluated healing in 100 patients with unsuturedpilonidal sinus excisions.28 Of 30 patients participating

Table 4. Exudate quality description

Descriptor Definition

Consistency Color OdorSerous Thin, watery Clear to yellow Usually odorlessSerosanguineous Thin, watery Pink to light red Usually odorlessSanguineous Frank blood Bright redSeropurulent Thin, watery White to cream Possibly foul odorPurulent Thick, translucent to opaque White to cream Possibly foul odor

Adapted from Keast et al.10

Table 5. Wound bed tissue types

Tissue type Description

Granulation Red, firm and pebbled. Friability may indicate infectionFibrin Yellow and firm. Represents collagen in the wound bed.Slough Yellow to gray-green and loose. May represent necrotic

fascia.Eschar Black: soft and wet or hard and dry. Necrotic tissue.



in the study who were not receiving antibiotic therapy,10 had pocketing at the wound base that was found tobe related to infection and that prevented granulation.

If deeper anatomical structures are visible, severetissue destruction is present. Structures that may beseen include tendon, bone, and joint capsule.

(a)

(c)

(e)

(b)

(d)

FIGURE 7. Wound appearance descriptions: (a) Eschar: heel with extensive tissue necrosis or eschar. (b) Slough: loose white-to-yellownecrotic slough in wound bed. (c) Fibrin: firm yellow fibrin representing collagen deposition in healing wound with buds of granulationand an epithelializing border. (d) Granulation: firm, uneven red granulation tissue, with some fibrin in the center of the wound.(e) Epithelialization: Advancing edge of pale pink epithelial tissue, especially prominent in the lower right corner of the wound.


Depending on the severity of the wound, as healingprogresses, wound color usually changes from an initialblack or yellow to red and then to pink. Typically, manyischemic wounds, venous ulcers with associated small-vessel disease, and some pressure ulcers follow thisprogression.19 Epithelialization in these wounds doesnot begin until the black or yellow eschar has eitherdebrided itself or been debrided and healthy granula-tion tissue has developed. Neuropathic ulcers anduncomplicated venous ulcers, however, frequently pre-sent with a red wound bed.

A qualitative color-based evaluation is inadequate toassess wound appearance accurately, as many woundsshow a combination of stages of healing, and hence, ofcolors.2 As a result, investigators have developed a vari-ety of qualitative and quantitative rating scales todescribe more accurately the wound surface and docu-ment treatment effects. A percentage can be estimatedfor each tissue type present in the wound. Validity andreliability studies of this strategy have not been con-ducted, but estimating the tissue type percentages ismore precise than simply noting the dominant woundcolor. Limited research on the reliability of visually esti-mating a percentage range for different tissue typesindicates that this approach, although insufficiently reli-able for research uses, is more precise in assessingprogress than ratings simply indicating whether a tissuetype is present or absent. This approach is highly sub-jective, but standardizing terminology facilitates com-parison between ratings by different observers.18

Qualitative and quantitative approaches can also becombined to produce a wound bed appearance scoringsystem, such as proposed as part of the MEASUREapproach (Table 6).10 Numerous evaluation tools areavailable to document various aspects of pressureulcers, although they are incompletely validated.29

Tools include the pressure sore status tool (PSST),the Pressure Ulcer Scale for Healing (PUSH), the Suss-man Wound Healing Tool (SWHT), the Wound HealingScale (WHS), and the Sessing Scale (SS).

Wound photography can provide valuable add-itional information. Both standard and Polaroid photo-graphy are useful and practical ways of documentingwound status in many clinical settings. Digital photo-graphy, however, may be impractical due to the largefile size and lack of color consistency, especially forreds. Houghton et al. compared the reliability and valid-

ity of a photographic wound assessment tool (PWAT), amodification of the PSST, to that of full bedside assess-ment using the PSST.30 The study evaluated the toolusing chronic pressure ulcers (n¼ 56) and vascular legulcers (n¼ 81). The authors found the PWAT tohave good intra-rater (ICC¼ 0.96) and inter-rater(ICC¼ 0.73) reliability and concurrent validity(r¼ 0.70) compared with PSST. Assessment using thePWAT was found to be sensitive to change in healing,but not in nonhealing, ulcers. Wound photography,although useful for many types of chronic wounds, isnot applicable to wounds extending around a limb or towounds with extensive undermining.

RecommendationsConsistent and clear terminology, definitions, anddescriptions of wound appearance, such as those pro-posed by Keast and described in Table 4, should beused in assessing wound appearance in clinical prac-tice and research.

The wound bed appearance score proposed byFalanga and summarized in Table 5, which has yet tobe validated, may form the basis of a quantitativewound appearance scoring system for clinical practice.Validated wound bed appearance tools should be usedin research studies.

Wound photography may provide a valuablerecord. However, it is not practical for all woundtypes and it may not be feasible in some clinical set-tings. As a result, wound photography cannot berecommended as a standard part of assessing woundappearance.

S – SufferingAssessment of pain is an important component of localwound assessment, both from the perspective ofpatient comfort and as a clinical indicator of woundinfection.10 Pain accompanies many chronic woundsand is a serious concern for many patients, significantlyaffecting quality of life and general well being.31 Aspain is often an intense and distressing subjectiveexperience that can have significant psychologicalramifications and a negative impact on an individual’sfunctional status, it is critical that a patient-centeredapproach be incorporated into pain assessment andmanagement strategies.32

Table 6. Wound bed appearance scoring system

Appearance score Granulation tissue (red) Fibrinous tissue (yellow) Eschar (black)

A 100% � �B 50–99% þ �C < 50% þ �D � � þ

Adapted from Falanga 2000.25


Management of wound pain poses a substantialchallenge in clinical practice, as the assessment ofpain may be difficult in individuals with cognitive orsensory impairments; numerous underlying causes andlocal factors can contribute to wound pain; and diverseinterventions may be required for different clinical pre-sentations.32 Little research on chronic wound pain hasbeen performed, and what little data are available sug-gest that wound pain is both infrequently assessed andinadequately managed.31,32

The initial assessment of wound pain shouldinclude a complete history; an evaluation of the under-lying cause of the pain, often related to the individualwound pathophysiology; local wound factors, fre-quently associated with wound manipulation; determi-nation of the nature, onset, intensity, and duration ofthe pain; identification of factors that worsen or relievethe pain and effect of the pain on activities of dailyliving and functional status.32 Pain should be monitoredfrequently to evaluate response to treatment, and itshould be reassessed regularly as part of the woundreevaluation process.

Numerous practical tools to assist in taking a painhistory have been developed, and a variety of validatedpain assessment instruments are available.31 Visual analogscales, which are simple to use in clinical practice, havebeen shown to be highly reliable. More extensive ques-tionnaires primarily have value in the research setting.

A model of the chronic wound pain experiencedeveloped by Krasner helps to guide the assessmentand management of pain (Table 7).22 This experience isdefined as ‘‘a complex, subjective phenomenon ofextreme discomfort experienced by a person inresponse to skin and/or tissue injury.’’ The modeldivides pain associated with a nonhealing wound intononcyclic acute wound pain, cyclic acute wound painand chronic wound pain. Noncyclic acute wound painis defined as acute pain occurring as a single episode,for example pain associated with sharp debridement.

Cyclic acute wound pain is defined as acute pain recur-ring periodically and associated with repeated interven-tions, for example, daily dressing changes orrepositioning. Chronic wound pain is defined as persist-ent pain occurring in the absence of manipulation.

Pain associated with a chronic wound can bedescribed as either nociceptive or neuropathic. Acutenociceptive pain, an inflammatory response to tissuedamage associated with a specific trigger, is oftendescribed as aching or throbbing.32 In contrast, chronicneuropathic pain, which results from persistent nerveinjury and is not associated with identifiable triggers, isoften described as burning, stinging, or shooting.

Determining and addressing the underlying woundpathophysiology is the first stage in assessing and mana-ging chronic wound pain. In patients with venous ulcers,improving venous return with compression therapy orpentoxifylline may reduce or relieve pain.33–35 In patientswith arterial ulcers, revascularization is often needed,and in those with pressure ulcers and diabetic footulcers, pressure offloading is required. Patients with dia-betic foot ulcers usually also require debridement andnormalization of blood glucose levels.

Local wound factors that may contribute to painare primarily associated with wound care procedures,but they may also be related to wound infection.31

Forceful irrigation, some debridement methods, dry oradherent dressings, exudate accumulation, and concen-trated or harsh wound cleansing agents are all sourcesof wound pain and should be avoided. In addition,surveillance for infection should be carried out andlocal or systemic therapy instituted if warranted.

A combination of pharmacologic and nonpharmaco-logic approaches may be most effective in managingpain associated with chronic wounds, but research hasyet to determine the most effective modalities and com-binations for different types of pain.31,32 Systemicanalgesic therapy must be implemented and titratedcarefully in elderly patients, however, as they are

Table 7. Chronic wound pain experience model

Pain history andassessment

. Underlying pathophysiology

. Local contributing factors

. Nature, onset, intensity, duration of the pain

. Effect on activities of daily living and functional status

. Determination of pain typePain type Noncyclic acute wound pain Cyclic acute wound pain Chronic wound pain

Pharmacologic Local anesthesia Local anesthesia Systemic analgesiainterventions Systemic analgesia Systemic analgesia Antidepressant

AnticonvulsantNonpharmacologic Pain-reducing wound Pain-reducing wound Relaxation strategiesinterventions care products, techniques care products, techniques, Transcutaneous

patient empowerment electrical nerve stimulation

Evaluation Monitor and reevaluate pain level, adjust intervention strategy and continue reevaluation and treatment adjustment

Adapted from Krasner.31


susceptible to adverse reactions.32 Research has shownthat nociceptive pain is best treated with analgesics,following the scheme laid out in the World HealthOrganization pain ladder.36,37 Neuropathic pain, however,may best be managed using tricyclic antidepressants oranticonvulsants such as gabapentin.31 Nonpharma-cologic approaches include using atraumatic or gentlewound management techniques, selecting appropriatedressings to encourage moist healing, and approachesto reduce suffering, such as relaxation therapy.

RecommendationsIntensity of pain should be measured using a validatedpain instrument and reevaluated using the same instru-ment. Each institution should develop a protocol forcomprehensively assessing wound pain that incorp-orates the multiple facets of chronic wound pain anda schedule for monitoring and reassessing pain.

U – UnderminingComplete wound assessment includes measuring theinternal wound area, including the degree of undermin-ing, tunneling, and sinus tracts.10 This is a critical eva-luation, as healing will not occur unless the woundedge is firmly attached to the wound bed and anyundermined areas have resolved. The extent anddegree of undermining are correlated with the severityof tissue necrosis.38 Necrosis of subcutaneous fat initi-ates undermining of skin, and penetration of deep fas-cia permits rapid undermining of deeper structures.Ulcers with undermining contain more bacteria thanthose without undermining.

Both the depth and extent of undermining can bemeasured. To assess the presence of wound undermin-ing, a sterile swab can be used to probe the entirewound margin, and the extent of undermining simulta-neously can be marked on the skin.10 The extent oftunneling and the path of sinus tracts can be identifiedin the same way. If possible, the undermined areashould be inspected, using a sterile tongue depressorto gently lift the lip. If significant quantities of fibrin,slough, or necrotic tissue are present, both the lip ofthe wound and the internal wound margins may benefitfrom excision and debridement. Healing does not pro-ceed until the wound edges adhere.

Information about undermining should be carefullydocumented to facilitate evaluation of change (Figure 8).2

A clock system can be used to record the extent ofundermining in four quadrants, with 12:00 o’clockrepresenting the cephalad direction, with the body inthe anatomic position. To facilitate comparison andincrease accuracy of progress assessments, measuringand recording procedures should be standardized andconsistently used.

RecommendationMeasurement of undermining should be a routine part ofwound assessment, and the clock system is proposed asthe standard approach to measuring this parameter.

R – ReevaluateNumerous factors affect the decision on how often tomonitor and reevaluate the wound.2 In this context,monitoring refers to inspecting or checking thewound, for example, for signs of infection, and reevalu-ation refers to assessing selected wound parameters todetermine and quantify progress toward healing.

Information from the initial assessment of thepatient and the wound is a major determinant of theappropriate assessment frequency.2 The baselineassessment provides information about wound stage,severity, and depth, patient comorbidities, and otherfactors that might affect the healing rate or the risk ofinfection. Short- and long-term treatment goals and thepatient care environment may also influence thereevaluation frequency. In turn, assessment frequencyoften directs the choice of dressing or treatment.Various other factors may change monitoring or assess-ment frequency. For example, assessment frequencymay decrease once patient or caregiver wound careeducation is accomplished or after an initial responseto the intervention has been observed. Frequentmonitoring of a wound should be performed afterwound treatment has been initiated, to identify earlysigns of effectiveness, such as edema reduction inresponse to compression bandaging, and to detect thedevelopment of allergic or sensitivity reactions todressings or bandages used.

For some types of ulcers, guidelines or recommen-dations have been developed regarding appropriate

FIGURE 8. Undermining assessment. Undermining, due to a largehematoma from a traumatic wound, mapped out on skin.


monitoring frequency, whereas for other types, clinicaljudgment and the individual patient presentationremains the best guide. The United States Agency forHealth Care Quality and Research (previously theAgency for Health Care Policy and Research) has devel-oped guidelines for monitoring and reassessment forpressure ulcers.39,40 These guidelines recommend thatpressure ulcers should generally be monitored regu-larly and reassessed weekly. More frequent monitoringand assessment should be performed if deteriorationoccurs. Reassessment of venous ulcers every week orevery 2 weeks is often sufficient.2 The optimal reassess-ment frequency for diabetic ulcers has not yet beendefined.41 However, as diabetic ulcers are associatedwith a high risk of complications, such as infection andamputation, patients with diabetic ulcers shouldreceive frequent monitoring and reassessment. Theuse of appropriate validated assessment tools canassist in standardizing assessments and provide a com-mon language to discuss wound status.

It is important, however, not to reevaluate the pro-gress of healing too frequently, as the evaluation ofprogress becomes difficult, and too frequent evaluationmay lead to inappropriate treatment decisions.3,10 Over-all, however, wound parameters should be monitoredand documented at each dressing change, and woundsshould generally be reevaluated every 1–4 weeks orwhen a significant change in wound status occurs.

RecommendationWounds should be monitored for infection or deterior-ation at least at every dressing change, and they shouldbe fully reassessed every 1–4 weeks, based on clinicaljudgment.

E – EdgeThe wound edge and surrounding skin, or periwoundarea, provide important information that can assist theclinician in diagnosing and treating wounds appropri-ately.2 A comprehensive assessment can also help toascertain the status of the wound, response to treat-ment, stage of healing, and presence of other dermalpathologies. Careful inspection and assessment of theseareas is an integral aspect of the wound assessmentprocess.

Key factors to note are attachment or lack ofattachment of the wound edge and any undermining;ulcer shape and edge configuration; and the conditionof the surrounding skin, noting especially induration,inflammation, and maceration (Figure 9).10 Attachmentcan be identified by the presence of an indistinct edgewith epithelium advancing over the wound. Unattachededges are generally sharply demarcated from thewound. The nature of unattached edges should bedescribed and undermining identified and measured.

Induration is defined as firm swelling with or withoutredness, and it may indicate infection or an inflamma-tory process. The presence of maceration, which refersto white, waxy, soft and wet-looking tissue, may indi-cate poor exudate control.

The stage of development or resolution of the ulcermay be reflected in the condition of the wound edgeand the surrounding skin. As a pressure ulcer develops,a large area of skin without discernible edges becomesa shallow lesion with a visible edge.38 Progressivenecrosis produces a more distinct wound edge, untilthe established ulcer has a thick, inwardly rolled mar-gin comprised of proliferating epithelial cells migratingover the wound edge. Ongoing injury and repair mayproduce firm, indurated wound edges with fibrosis,which may affect epithelial cell migration. An indistinctwound edge may indicate epithelialization, and healingof chronic wounds is eventually completed by epithe-lial proliferation and migration across the wound.2

The ulcer shape and the appearance of the woundedge and surrounding skin may indicate the wound

(a)

(b)

FIGURE 9. Edge appearance descriptions. (a) Maceration:white, waxy appearance of periwound tissue as a result ofuncontrolled exudate from a venous leg ulcer. (b) Induration:firm erythematous border around a neuropathic diabetic footulcer may represent soft tissue infection.


etiology.42 Arterial ulcers tend to have a smooth, sharpmargin, often described as a punched-out or cookie-cutter edge, and surrounding skin is usually pale. Incontrast, an irregular margin with a more gently slopedborder and brown-pigmented periwound indicates lipo-dermatosclerosis and a venous ulcer. Vasculitic ulcersmay have an irregular edge and hyperemic skin aroundthe ulcer. Gangrene or edge necrosis may also be seenwith vasculitis, but these features may instead point toischemia or pyoderma gangrenosum.43 A rolled, possi-bly painful, skin edge also points toward an inflamma-tory etiology, such as rheumatoid vasculitis orpyoderma gangrenosum. Diabetic ulcers usually havea smooth margin and the surrounding skin is oftencallused.42 The appearance of the wound margin andsurrounding skin in pressure ulcers is variable.

Careful observation of skin appearance, color, andtexture may also provide additional clues to the woundetiology and valuable information about pathologicalprocesses that may be preventing wound healing. Abra-sions and island denuding may indicate subcutaneousdeterioration, friction, or shear. Abnormal skin color isan important observation. Red skin may indicate acellulitis pressure area, vasculitis, arterial disease, sub-optimal patient or wound care, or contact dermati-tis.2,43,44 Macerated skin indicates large amounts ofexudate or moisture at the wound base and prolongedexposure time of the skin to moisture. A purplish skintone may signal an underlying hematoma or an area ofischemia, or it may be related to cryoglobulinemia orvasculitis. Induration of the periwound may indicate anabscess, edema, or trauma. Ridges or undulations maysignify scarring within the subcutaneous tissue,whereas soft spongy or boggy areas may suggestsequestered areas of necrotic tissue, often seen insacral or coccyx pressure ulcers. The presence ofinflammation or bullae may point to dermal pathology,including fungal or yeast infection, bullous pemphigoid,psoriasis, or other conditions. Skin suppleness shouldbe noted, as both overly moist and very dry skin, whichmay be seen in patients with impaired peripheral cir-culation, is more prone to injury.2

Assessment of the wound edge and surroundingskin includes careful visual inspection, measurement,and documentation.2 The size and location of thewound should be well described and the periwoundarea assessed for skin integrity. The wound edge char-acteristics should be described in as much detail aspossible. The appearance, color, and texture of the sur-rounding skin and the location and extent of anyabnormalities or pathology should be noted. The inter-face of the wound base and skin should be gently pal-pated to determine whether the lip of the wound isattached to the wound base or if it is mobile and possi-bly concealing undermining. Induration and edema canbe assessed by gently pressing the skin within 4 cm of

the wound. The details of the assessment should bedocumented to facilitatecomparisonwith future reassess-ments and determine wound healing.

RecommendationAssessment of the wound edge should include an eva-luation of attachment or lack of attachment and anyundermining; observation of ulcer shape and edgeconfiguration; and inspection of the condition of thesurrounding skin, noting especially induration, inflam-mation, and maceration. Documentation should usestandard terminology and descriptions, such as thosedescribed here.

CONCLUSIONSWound assessment is an important clinical skill that isintegral to effective wound management. During thepast decade, evidence has been steadily accumulatingabout the prognostic value of wound assessment andthe accuracy and reliability of wound assessment tech-niques, especially measurement techniques. As a result,wound assessment is evolving into a clinical science.However, for this important aspect of clinical care toadvance further as a science, it is necessary to begin todefine terms uniformly, agree on concepts, and setpractice standards and guidelines. MEASURE is a sim-ple conceptual framework that can act as the basis fordeveloping a consistent wound assessment approach. Itis hoped that this uniform approach to wound assess-ment, using MEASURE, will stimulate discussion anddebate and assist in formulating best practice guide-lines for wound assessment.

ACKNOWLEDGMENTSThis supplement was supported by an unrestrictedgrant from Smith & Nephew, Inc.

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MEASURE: A proposed assessment framework for developing ... · of the patient and the chronic wound should begin with a general wound classification using categories such as cause