How to Assess Wound Margins

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Examination of the wound margin is a necessary part of any wound assessment. Wound margins vary greatly in size and shape. An examination of the wound margin is performed at regular intervals by a health care professional, a patient at home or a caregiver. Knowing the basic steps to assess wound margins can help track healing, check for signs of complications and identify if the current treatment is effective.

Things You'll Need

  • Wound measuring device
  • Measure the length and width of the wound. It is important that the wound is measured the same way each time since some people prefer to measure the longest length by the longest width and others measure the length from a head-to-toe orientation and the width from a side-to-side orientation.

  • Document the shape of the wound by tracing the outline with a wound measuring tool or drawing a simple picture.

  • Examine the wound edges to determine if you are able to distinguish the wound outline, if the edges are even with the wound base, if the edges are higher than the wound base and for the presence of callous-like tissue formation or scarring.

  • Examine the wound for the presence of undermining in which the edges of the wound may appear rolled over. Undermining is the absence of tissue under the wound edge. Measure the extent of any undermining.

  • Assess the skin surrounding the wound for signs of fluid buildup in the tissue, redness, firmness and breakdown.

  • Examine the edges for signs of infection which can include an increased amount of redness or pain, swelling, unusual odor, warmth over or around the wound and an abnormal drainage that may appear yellow, white or green.

  • Assess the edges of the wound for areas of healing that can appear as pink or red skin. Measure the amount of new tissue using a percentage.

Tips & Warnings

  • Measure wounds in centimeters and millimeters.

References

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