Measure epithelialization as part of wound?

Eagle2110, ASN, BSN, APRN · Dec 5, 2016

Hi!

Does your company have a file for policies and procedures regarding wound care? I've worked for a nursing home before that didn't specify and use to wonder the same thing! But anyway, to answer your question......at my facility, we only measure what's open, not healed. Hope this helps!!

msnurse1234 · Dec 5, 2016

Thanks, Eagle. So, just to clarify, you mean you would not measure the epithelial tissue, just the granular?

Eagle2110, ASN, BSN, APRN · Dec 10, 2016

Thanks, Eagle. So, just to clarify, you mean you would not measure the epithelial tissue, just the granular?

Sorry for the late response, no I don't measure it. I only document that it is there

NN2BVE · Dec 12, 2016

Hi there,

No, I do not include the epithelial tissue in the measurement. However, in my nursing documentation of the wound description I might add something like " epithelial cell migration is noted at the right wound margin" or if there is an epithelial tissue formed right in the middle of the wound that caused one big open area to separate into two smaller areas, i will write: " wound noted with epithelial island formation in the middle resulting in one big area separating into two smaller areas. area #1(distal/proximal/lateral/medial) measures xxxx, Area #2 (distal/proximal/lateral/medial) measures xxxx" . You will need to clarify with your facilities policies if you need to create separate record for each of those areas. In my facility, I do not create a new record but continue to record that previously one bigger area now presents as two distinct smaller areas. I see that a lot with the wounds that just about to heal. Hope i did not make it confusing.

The more important question is why is there a more favorable condition at the right wound margin and not on the other areas? It is possible that initially, the wound presented in the form of the shape that is narrower at the right wound side, and of cause in that case epithelial cells need to travel less distance to cover the surface. But if the wound is round, the epithalization should have happen around all wound margins. If there is any necrotic tissue or may be epiboly (curled, rolled edges) that is present, the epithelial cells would not be able to progress and the wound would stall and the healing will be delayed.

Again, I hope that I did not make it confusing as I normally tend to do!. Please let me know if you need any clarification.

Inna

Mistyrose123 · Dec 12, 2016

msnurse1234, check with your facility policy. I worked at a facility that the policy said to use linear measurements. meaning 12 to 6 in a straight line and 3 to 9 in a straight line. If you have a wound that is diagonal, then 12 is the very top and 6 is the very bottom and your epithelial would be included in this measurement. I worked at another facility that wanted wound edge to wound edge in length and then perpendicular to the length measuring the width this included open only. I have found if measuring a circle shape 12 to 6 and 3 to 9 wound edge to wound edge in straight line you will not get the epithelial tissue. I usually chart what is in the wound bed then 1 cm or whatever of epithelial tissue around the wound perimeter. In the case you described I would measure the granulation tissue and then document about the epithelial tissue. hope this helps

rn_nxt_dr · Sep 12, 2017

Wounds are not considered "healed", it is closed or newly epithelialized until granulation is achieved which is the sign of would healing.

Only open areas are measured.