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Measure epithelialization as part of wound?

Wound   (2,710 Views 7 Comments)
by msnurse1234 msnurse1234 (New Member) New Member

845 Profile Views; 6 Posts

Hello all,

The question: I have a wound bed that is a "crater", about 0.1 cm deep; the right half of the crater bottom has epithelial tissue over it.

I know the epithelial tissue is "baby skin", but it is skin nonetheless. So, when measuring this wound, would I measure the size of the crater, from edge to edge (including the epithelial tissue that makes up the right half of the crater bottom), or only the size of the granulation tissue?

I'm looking for answers from people who have been doing this for a while--no guesses, please! Thanks!

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Eagle2110 has 5 years experience as a ADN, BSN, CNM and specializes in Wound Care.

108 Posts; 5,378 Profile Views

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!!

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Eagle2110 has 5 years experience as a ADN, BSN, CNM and specializes in Wound Care.

108 Posts; 5,378 Profile Views

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

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28 Posts; 1,479 Profile Views

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

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18 Posts; 707 Profile Views

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

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85 Posts; 3,142 Profile Views

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.

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