How to Measure Wound Granulation

Tissue granulation in a wound bed is a positive sign because it indicates the wound is healing. Healthy granulation tissue is shiny, bleeds easily and appears beefy-red or deep pink. The surface of this type of tissue resembles raspberries. Although granulation tissue is difficult to measure accurately, a measurement is generally achieved by calculating the depth of the wound and the approximate percentage of granulation tissue in the wound bed.

Things You'll Need

• Soap
• Water
• Three pairs of gloves
• Biohazard bag
• Sterile cotton-tipped applicator
• Sterile normal saline
• Wound measuring device or ruler
• Wound dressing

Show More

Instructions

• 1

  Wash your hands with soap and water and dry them well. Position the patient so the wound is easily accessible. Make sure the patient is comfortable.

• 2

  Put on the first pair of gloves. Remove the soiled dressing if applicable. Dispose of the dressing in a biohazard bag. Remove the gloves and dispose of them in the biohazard bag as well.

• 3

  Wash your hands again with soap and water. Dry them well and put on the second pair of gloves.

• 4

  Cleanse the wound as ordered by the physician.

• 5

  Moisten the soft tip of a sterile cotton-tipped applicator with sterile normal saline. Insert the soft tip of the cotton-tipped applicator into the deepest part of the wound bed. Grasp the portion of the applicator that is at the level of the skin with your thumb and forefinger. Remove the applicator from the wound bed.

• 6

  Measure the portion of the cotton-tipped applicator that is between the tip and your pinched fingers with a wound measuring device or ruler in centimeters and millimeters. Compare this depth measurement to previous depth measurements to see if the wound bed if filling with granulation tissue.

• 7

  Document the color of the granulation tissue and note any areas covered with soft, yellow-gray tissue (called slough) or hard, dark leathery tissue (called eschar).

• 8

  Estimate the amount of granulation tissue in the wound bed as a percentage of the wound surface.

• 9

  Complete your wound assessment. Take off the gloves and dispose of them in a biohazard bag.

• 10

  Wash your hands again with soap and water, dry them well, and put on the third pair of gloves.

• 11

  Apply a new wound dressing, if applicable, per physician order. Then remove the gloves and dispose of them in the biohazard bag. Wash your hands with soap and water and dry them well.