Wound Care
Artist/ Title/ Date
Domenico di Bartolo. Caring for the Sick. 1440. Fresco, height c. 450 cm. Pellegrinaio, Spedale di Santa Maria della Scala, Siena
Description of Disease & Etiology
Wound care is a longstanding and evolving medical practice. The skin serves as a protective barrier against the external environment and the loss of large portions of the skin’s integrity from injury or illness can lead to major disability or even death.1 A wound is a disruption of normal function and anatomic structure of an involved organ resulting from an internal or external pathological process. Wounds can be further categorized as acute or chronic. Acute wounds proceed through an orderly and timely reparative process that yields restoration of the anatomic and functional integrity. They can repair themselves or be repaired through the appropriate process. Chronic wounds are those which fail to complete that process or undergo a repair process that doesn’t meaningfully restore the integrity of the organ. The orderly wound healing process includes infection control, resolution of inflammation, angiogenesis, formation of a functional connective tissue matrix, wound contraction, re-epithelialization, differentiation, and tissue remodeling. Timeliness depends on the severity of the wound, the pathologic process, host status, and the environment.2
Other attributes that describe wounds include infection, blood flow, duration, oxygen, edema, inflammation, repetitive trauma and/or insult, wound metabolism, nutrition, innervation, prior wound manipulation, and systemic factors.2 Previous studies have shown that between 27% - 50% of hospital beds are occupied by patients requiring some form of wound management.3 Approximately 6.5 million patients have chronic wounds in the United States.4 Certain patient populations are at increased risk of developing chronic wounds, including the elderly, individuals with diabetes, and those with genetic disorders such as sickle cell disease. These conditions predispose patients to impaired wound healing and subsequent long-term complications. Effectively treating chronic wounds in these high-risk groups is an ongoing priority in wound care.5
Signs/Signifiers of Illness
Keast et al. introduced the MEASURE mnemonic, which provides a structured framework for evaluating wounds. MEASURE stands for: Measure (length, width, depth, and area), Exudate (quantity and quality), Appearance (wound bed tissue type and amount), Suffering (pain type and level), Undermining (presence or absence), Reevaluate (regular monitoring), and Edge (condition of edge and surrounding skin).6 Wound healing involves a complex series of events that starts with injury and ends with successful closure. It typically goes through four stages: hemostasis/coagulation, inflammation, proliferation, and maturation/remodeling. Throughout the healing process, these phases overlap as cytokine and growth factors guide the wound’s course. Chronic wounds often don’t make it past the inflammatory phase. In the practice of wound care, the wound’s location, size, depth, and tissue type, as well as the presence of drainage, should be recorded.7 Acute wounds can include lacerations, abrasions, burns, and puncture wounds common in outpatient settings.8
Chronic wounds come in various types. Venous ulcers are the most common and are typically shallow, located on the medial supramalleolar aspect of the lower extremity. There can be classic signs of venous hypertension; edema, hemosiderin staining, and lipodermatosclerosis. Arterial ulcers are usually located on the distal extremities and can be deep with tendon or bone exposed. Diabetic ulcers are the leading cause of lower extremity amputation. They result from neuropathy affecting sensory, motor, and autonomic nerve function, which leads to structural foot deformities, dry and poorly hydrated skin, and a reduced ability to perceive pain and repetitive injury. They are typically located on the toes or the plantar aspect of the metatarsal heads and have a characteristic crater-like appearance. The wound bed may be covered with eschar or necrotic tissue and, in severe cases, may expose underlying bone or tendon.7
Pathology
Wound healing occurs in overlapping phases: hemostasis, inflammation, angiogenesis, growth, re-epithelization, and tissue remodeling.9 Some wounds do not follow the typical healing process because of underlying factors including the patient’s age and the presence of underlying chronic conditions.10 Tissue injury disrupts blood vessels and leaks blood components, and thus the initial response to a wound is constriction of the injured blood vessels and activation of platelets to form a fibrin clot, reestablishing hemostasis and providing a provisional extracellular matrix for cell migration.1,11 Vasoactive mediators and chemoattractants are generated by the coagulation and complement pathways and by the injured/activated parenchymal cells, drawing leukocytes such as monocytes to the site of the injury.12 Monocytes infiltrate and activate macrophages to release more growth factors to initiate the formation of granulation tissue. Hours after the injury, reepithelization begins. One to two days after the injury, epidermal cells at the wound margin proliferate and behind actively migrating cells. After approximately four days, granulation tissue invades the wound space.1 The new granulation tissues require the formation of new blood vessels through a complex process called angiogenesis.13 After the inflammatory phase, the new granulation tissues must be sustained by the formation of new blood vessels through a complex process called angiogenesis. Angiogenesis involves endothelial cell proliferation, migration, and branching to form new blood vessels.13,11
Treatment
In its ideal form, a healed wound returns to normal anatomic structure, function, and appearance.2 The primary goals of treating cutaneous wounds are rapid wound closure and a functional and aesthetically satisfactory scar. Wound care includes the use of appropriate wound dressings, correction of underlying conditions such as hyperglycemia, debridement of nonviable tissue, restoration of adequate tissue perfusion, offloading pressure at the wound site, and control of infection.1 Wounds can quickly become infected, making irrigation and cleaning a crucial aspect of treating minor wounds.8
Initially, all chronic wounds should be managed according to the TIME principle: tissue debridement (except in arterial ulcers), infection control, moisture balance, and optimization of wound edges.14 Debridement involves removing dead cells and is an essential part of wound care, often serving as a first-line treatment for chronic wounds.7 Wound care has selective approaches to wound debridement including autolytic, enzymatic, biological, physical, surgical, and wet-to-dry methods.15 Surgical debridement is often used, but the other methods are used as deemed appropriate depending on the wound type.7 Debridement of biofilm, which are communities of microorganisms held together in an extracellular matrix and disrupt the healing process, is crucial in wound healing.16
Infection is usually controlled with topical agents, while antimicrobial washes are beneficial if biofilm is suspected. Oral antibiotics are indicated if cellulitis or systemic infection occurs. Moisture balance is maintained through proper dressings to hold moisture on the wound bed and prevent desiccation.7 Pain associated with wound dressing procedures can be effectively managed through accurate assessment, appropriate dressing selection, skilled wound care, and individualized analgesic strategies.17 In the case of large and life-threatening skin wounds such as extensive burns, cultured autologous epidermal-cell grafts or biologic skin substitutes may be used.1
Numerous aspects of wound care have traditionally fallen under nursing practices. This includes wound covering management, therapeutic nutrition, mobility, and psychosocial support.18 Chronic wounds often last longer than necessary either by not healing or indirectly causing patient deaths. With increasing care being conducted in the home, therapies aimed at restoring and maintaining structural integrity are essential. A complete wound assessment should include the extent of the wound, associated wound attributes, host factors influencing wound status, and environmental factors that impact wound management. Wound assessment requires repeated systematic evaluations to track and treat the wound. Wounds should also be assessed by their effect on the patient by taking into consideration the wound burden and severity, which can change throughout the healing process.2 Further developments in wound care will likely include substances which serve to stimulate wound healing.1
Social Determinants of Illness
The human burden of wounds can manifest in numerous ways, including pain, distress, social isolation, anxiety, extended hospital stays, chronic morbidity, or in severe cases, mortality.10 In addition to the emotional burden of living with a nonhealing wound, there is a significant and growing financial cost for patients, families, and society. Institutional care for chronic wounds can cost approximately $1,000 per day. As more patients are treated outside of hospital settings, variability in wound evaluation, access to supplies, and consistency of care has increased. A thorough assessment of the patient’s overall condition is essential to identify the underlying cause of the wound and evaluate the impact of systemic factors on healing. Environmental influences—such as demographics, access to care, and availability of resources—as well as systemic conditions and medications that affect wound repair, must also be considered.2
Studies have shown that psychosocial factors, including anxiety and depression, are associated with delays in the wound healing process.19 A patient’s quality of life is significantly impacted by their living with a wound. Optimizing an individual’s wellbeing is a crucial goal of wound management.20 There is strong evidence supporting improved outcomes when individual patients are actively involved in their care.21
Author(s): Maria Burdjalov, BS
Citations:
* 1) Singer, A. J., & Clark, R. A. F. (1999). Cutaneous Wound Healing. New England Journal of Medicine, 341(10), 738–746. https://doi.org/10.1056/NEJM199909023411006 * 2) Lazarus, G. S., Cooper, D. M., Knighton, D. R., Margolis, D. J., Percoraro, R. E., Rodeheaver, G., & Robson, M. C. (1994). Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Repair and Regeneration, 2(3), 165–170. https://doi.org/10.1046/j.1524-475X.1994.20305.x * 3) Gottrup, F., Henneberg, E., Trangbæk, R., Bækmark, N., Zøllner, K., & Sørensen, J. (2013). Point prevalence of wounds and cost impact in the acute and community setting in Denmark. Journal of Wound Care, 22(8), 413–414, 416, 418–422. https://doi.org/10.12968/jowc.2013.22.8.413 * 4) Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Gottrup, F., Gurtner, G. C., & Longaker, M. T. (2009). Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair and Regeneration, 17(6), 763–771. https://doi.org/10.1111/j.1524-475X.2009.00543.x * 5) Rodrigues, M., Kosaric, N., Bonham, C. A., & Gurtner, G. C. (2019). Wound Healing: A Cellular Perspective. Physiological Reviews, 99(1), 665–706. https://doi.org/10.1152/physrev.00067.2017 * 6) Keast, D. H., Bowering, C. K., Evans, A. W., Mackean, G. L., Burrows, C., & D’Souza, L. (2004). MEASURE: A proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair and Regeneration, 12(s1), s1–s17. https://doi.org/10.1111/j.1067-1927.2004.0123S1.x * 7) Bowers, S., & Franco, E. (2020). Chronic Wounds: Evaluation and Management. American Family Physician, 101(3), 159–166. * 8) Worster, B., Zawora, M. Q., & Hsieh, C. (2015). Common Questions About Wound Care. American Family Physician, 91(2), 86–92. * 9) Gurtner, G. C., Werner, S., Barrandon, Y., & Longaker, M. T. (2008). Wound repair and regeneration. Nature, 453(7193), 314–321. https://doi.org/10.1038/nature07039 * 10) Lindholm, C., & Searle, R. (2016). Wound management for the 21st century: Combining effectiveness and efficiency. International Wound Journal, 13(S2), 5–15. https://doi.org/10.1111/iwj.12623 * 11) Clark, R. A. F. (2003). Fibrin Is a Many Splendored Thing. Journal of Investigative Dermatology, 121(5), xxi–xxii. https://doi.org/10.1046/j.1523-1747.2003.12575.x * 12) Clark, R. A. F. (Ed.). (1996). The molecular and cellular biology of wound repair (2nd ed.). Plenum Press. https://www.scirp.org/reference/referencespapers?referenceid=986340 * 13) Madri, J., Sankar, S., & Romanic, A. (1996). Angiogenesis. In The molecular and cellular biology of wound repair (2nd ed., pp. 355–371). Plenum Press. * 14) Leaper, D. J., Schultz, G., Carville, K., Fletcher, J., Swanson, T., & Drake, R. (2012). Extending the TIME concept: What have we learned in the past 10 years? International Wound Journal, 9(s2), 1–19. https://doi.org/10.1111/j.1742-481X.2012.01097.x * 15) Matsuzaki, K., & Upton, D. (n.d.). Wound treatment and pain management: A stressful time. Retrieved March 20, 2026, from https://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2012.01038.x * 16) López, D., Vlamakis, H., & Kolter, R. (2010). Biofilms. Cold Spring Harbor Perspectives in Biology, 2(7), a000398. https://doi.org/10.1101/cshperspect.a000398 * 17) World Union of Wound Healing Societies. (2004). Principles of best practice: Minimising pain at wound dressing-related procedures (pp. 188–188). https://doi.org/10.1177/1534734603024002 * 18) Corbett, L. Q. (2012). Wound Care Nursing: Professional Issues and Opportunities. Advances in Wound Care, 1(5), 189–193. https://doi.org/10.1089/wound.2011.0329 * 19) Cole-King, A., & Harding, K. G. (2001). Psychological factors and delayed healing in chronic wounds. Psychosomatic Medicine, 63(2), 216–220. https://doi.org/10.1097/00006842-200103000-00004 * 20) International Consensus. (2012). Optimising wellbeing in people living with a wound. Wounds International Enterprise House. * 21) Department of Health. (2011). Equity and excellence: Liberating the NHS. https://assets.publishing.service.gov.uk/media/5a7c5299e5274a2041cf33af/dh_117794.pdf