Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

How should the location of tunneling or undermining in a wound be documented?

1. Use a scale of 1 to 10

2. Benchmark by comparing to a similar wound

3. Use the clock face method

4. Record as a percentage of the wound

The correct answer is: Use the clock face method

Documenting the location of tunneling or undermining in a wound is essential for accurate assessment and monitoring of healing progress. Using the clock face method is effective because it provides a standardized way to describe the exact location of these features within the wound bed. In this method, the wound is conceptualized as a clock face with 12 o'clock at the top (toward the patient's head) and 6 o'clock at the bottom (toward the patient's feet). This allows clinicians to communicate the location of tunneling or undermining in relation to the anatomy of the patient in a clear and consistent manner. For example, if there is tunneling at the 3 o'clock position, it would indicate that the tunneling is located at the right side of the wound from the patient's perspective. This method promotes precise documentation, which is critical for ongoing treatment decisions and for other healthcare professionals who may be involved in the care of the patient. The clock face method minimizes confusion that might arise if other ordering systems were used, ensuring everyone on the care team understands the wound characteristics effectively.