Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

MEASURE Assessment Guide

Source: Sibbald, Orsted et al. (2006). Reprinted with permission.

Measurement Parameter Clinical Observation Indicator
Measure Length, width, depth, area Reduction or increase in wound surface areaand/or depth
Exudate Amount, quality
  • Decrease or increased amount
  • Decreased pr 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