MEASURE Assessment Guide

A Pocket Guide for Clinicians

Measurement Parameter	Clinical Observation	Indicator
Measure	Length, width, depth, area	Reduction or increase in wound surface area and/or depth
Exudate	Amount, quality	Decreased or increased amount Decreased or increased purulence
Appearance	Wound bed appearance, tissue type and amount	Increased or decreased percentage of granulation tissue Increased or decreased percentage of necrotic tissue Friability of granulation tissue
Suffering	Patient pain level using validated pain scale	Improved or worsening wound-related pain
Undermining	Presence or absence	Decreased or increased amount
Re-evaluate	Monitor all parameters on regular basis - every one to four weeks	Parameters sequentially documented in patient record
Edge	Condition of wound edge and surrounding skin	Presence or absence of attached edge with advancing border of epithelium Presence or absence of erythema and/or induration Presence or absence of maceration