The mnemonic MEASURE for wound assessment and management is becoming more and more popular for wound clinicians.
Wound assessment and management are complex processes for most health care professionals, and using a structured approach to wound assessment is very important.
MEASURE mnemonic for wound assessment
Using the MEASURE Mneumonic for wound assessment and management can simplify the process when systematically assessing a patient’s wound.
Let’s break down the mnemonic to show you what each letter represents.
- M- Stands for Measure. Measuring the wound is essential to determine if there is deterioration or improvement of the wound. Measurements should include wound length, width, depth, wound area if possible.
- E- Exudate, which consists of the exudate quality and quantity. Does the wound have purulent or serous exudate? What is the amount?
- A- Appearance, what does the wound look like? Is the wound sloughy with some area of granulation tissue? Break this down into percentages. For example, the wound presents with 60% healthy granulation tissue with 40% slough.
- S- Suffering, assess the patient for pain and identify the type of pain experienced, and the pain level. A common way to determine a person’s pain level is to use the 0-10 scale. 0 being no pain, and 10 being the most extreme pain imaginable. It is important to document the score the patient tells you as pain is a subjective experience.
- U- Undermining- is there any tunneling or undermining at the edges of the wound? Document the presents or absence of undermining
- R- Reevaluate- when should the next assessment or wound dressing be?
- E- Edges, this looks at the condition of the wound edge and the surrounding skin. Is there erythema present on the periwound? Is there a build-up of scales or is the skin clean and nil problems?
Using MEASURE in your wound assessments and documentation is a great way to guide the complex assessment of wounds.
TIME is another mnemonic that can be used, I will cover that at another date. Don’t forget to subscribe to my mailing list for more updates.
Please feel free to download and print off this graphic to remind yourself of the assessment process.
Written by Emilie Masi.
Registered Nurse, Clinical Nurse Consultant in Wound Management.
Masters of Advanced Nursing Practice (Deakin University)
Masters of Wound Management (Monash University)