RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Assessment & Management of Stage I to IV Pressure UlcersMeasurement and Documentation of Undermining and TunnelingIllustrated by N. Bauer. Published with permission.The location of undermining and tunneling should be documented. This is generally donein terms of “time”. The “clock face” is oriented according to the location of the wound on the client’sbody, with the head of the body at 12 o’clock and the feet at 6 o’clock.In this illustration the undermining would be described as noted at approximately 2 o’clock.90