Literature to support measuring depth on surgical wound

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by horsecrazy1 horsecrazy1 (New) New

Could anyone provide me with best practice regarding measuring depth of a new surgical wound please? I’m having difficulty finding literature to support how to capture depth of a new surgical wound healing via primary intention. Ex: 0 or 0.1 to symbolize that full epithelialization has not yet occurred. Thank you in advance for your assistance  

CalicoKitty, BSN, RN

Specializes in Med-Surg, Geriatrics, Wound Care. Has 10 years experience. 969 Posts

If it is healing by primary intention, I would consider the depth to be 0 since it should be a closed surgical line. If it is an open surgical wound (I&D, debrided wound) or if it begins to dehisce, then I would measure depth.

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 45 years experience. 11 Articles; 17,400 Posts

Intact closed surgical incisions with sutures present usually have 0 depth.  Any opening between sutures should be measured for depth by inserting sterile qtip to measure and record depth noted.  Posted several articles to help you with assessing  and documenting wound measurements.

Assessment of Surgical Wounds in the Home Health Patient

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Guideline: Assessment & Treatment of Surgical Wounds Healing by Primaryand Secondary Intention in Adults & Children

Surgical Wounds & Incisions A Comprehensive Review Assessment & Management

How to Measure Wounds   steps includes pictures

Agency for Healthcare Research: Wound Classification

Wound Care: The Basics

SURGICAL CARE IMPROVEMENT PROJECT -- reducing the incidence of surgical complications

 

FifthBeetle

FifthBeetle, ADN, LPN, RN

Specializes in Wound Care. 4 Posts

My interpretation of these wounds, as they are defined in texts, is that a new surgical wound of primary intention should become approximated (being joined by bond, strips, staples, or sutures) and exhibit a “healing ridge” by around post op day 5. It should not be necessary (nor do I believe is it desirable) to obtain a depth on these wounds. To probe the wound for depth is to potentially disrupt the joining of fascia, skin and tissue matrices, etc. If an area of the wound is showing signs of dehiscence after this 5 day period,  there is an area of slough or eschar, or it’s not showing signs of remaining approximated, you may want to get a depth with your measurement. Also look to the peri-wound- is there ridge development? Is the skin cool, pale, and edematous? or ecchymotic? or in some other way raising doubt that the wound is approximating normally? Is it draining a lot? 
We already know a primary intention wound has depth- so unless an abnormality is developing, I don’t think this information is needed. Measure the length, call it a linear wound.