The dramatic rise in incidence of chronic ulcerated wounds in the United States can be attributed to increasing numbers of persons with uncontrolled diabetes, frail older adults, and bedridden, severely ill, and nutritionally impaired patients.1 Other patients who are impaired neurologically or those who undergo prolonged surgeries are also at high risk of developing chronic ulcerated wounds. Approximately 6.5 million persons develop chronic wounds annually in the United States, and in 2009, an estimated $25 billion was spent on wound care.2 In developing countries, it is estimated that 1% to 2% of people will experience a chronic wound in their lifetime.3 The wound care product market is expected to rise from $16.8 billion in 2013 to $21 billion in 2015.4,5 These figures do not include the hidden costs borne by patients and families resulting from loss of work, medical insurance, and self-esteem; social isolation; depression; increased stress; and the changes that become necessary in readaption to the demands of daily living with resulting disabilities.1 The purpose of this article is to the educate healthcare providers on the assessment, management, and evaluation of wounds with the goal of reducing the number of chronic wounds.
TYPES OF WOUNDS
There are many different types of wounds; each is unique in nature and has multifactorial etiology.6 Therefore, each wound should be managed differently. For the purpose of this article, however, 6 main types of wounds will be discussed. These wounds are venous stasis, pressure, arterial, diabetic, traumatic, and surgical (Table).7 Each of the wounds has a characteristic appearance.
Venous Stasis Wounds
Venous stasis wounds are thought to be caused by venous incompetence and associated venous hypertension.8 The reasons for venous insufficiency or incompetence include immobility, ineffective pumping of the calf muscles, valve dysfunction, or pheblitis.8 Once the venous stasis becomes chronic over a period, it causes pooling of blood in the venous system, triggering vessel damage and activation of an inflammatory process.7,8 These wounds are referred to as a venous ulcers, which are known to be painful, and normally found above the malleolus. They are often small to large, have an irregularly shaped border and shallow base, and are frequently exudative, with a characteristic pigmentation of the surrounding skin.9,10 Associated findings with these venous ulcers include edema, venous dermatitis, varicosities, and lipodermatosclerosis.8
Pressure wounds are ulcers that develop from pressure over an area of bony prominence, including the heels, trochanter, and sacrum, as well as the knees, ankles, shoulder blades, and spine. Pressure ulcers (PrUs) vary in size and depth, and may include tracking or undermining. They may also be round or irregular in shape with variable bases and margins.9
Arterial wounds are ulcers caused by ischemia and arterial insufficiency. These ulcers may present with other clinical findings such as claudication, pain at rest, abnormal pedal pulses, cool limbs, and gangrene.7,8 Arterial wounds are usually distal, small, and have a round, punched-out appearance. Unlike venous wounds, they are usually shallow, with pale bases and smooth margins. The surrounding skin is normally pale, shiny, and hairless.9,10
Diabetic wounds or ulcers frequently begin with injury or irritation to the skin of a person with diabetes. Because of diabetic neuropathy, meaning the diabetes affects the nerves and later causes damage to the nerves, the patient does not feel the breakdown in skin until it has developed into an ulcer. The ulcer may result from a single traumatic event or from repeated damage caused by tight shoes or hot-water bathing.7 Diabetic ulcers appear on pressure areas on the lower extremity, often on a bony deformity on the plantar foot. They are usually small, but may be large, are round, and can be shallow to deep with possible undermining and tracking. The bases may vary but can become necrotic if infected, usually have smooth margins, and frequently have calloused periulceration skin.7,9
Traumatic wounds are wounds caused by an outside force, including skin tears, cuts, burns, animal bites, and punctures.7 Depending on the condition and age of the patient, these wounds often heal quickly, particularly if they are not infected or contaminated with debris. These wounds are often managed by outpatient facilities and incur less costs and disability when compared with chronic ulcerated wounds.
The easiest wound to identify is the surgical wound, in which primary closure of a surgical site—by use of sutures or staples—is incomplete.7 Surgical wounds are often the result of procedures performed in hospital facilities or clinics. Incisions, graft donor sites, and excisions are considered acute surgical wounds, whereas dehisced or infected surgical sites are classified as chronic.7 Wounds become chronic when they are not healed after 30 days.
The first stage of wound care is assessment of a wound to identify the type and possible cause and to decide what approach will be used to initiate the healing process and care for the wound. Assessment of a wound in the environment in which it occurs is essential for diagnosis, treatment, management, and patient education.11 Proper assessment includes location of the wound, depth (does the wound probe to bone or tendon? Is there undermining or tunneling present?), and exudate (amount, quality). In addition, it is essential to note odor, size, base (does the wound have granular, necrotic, slough, or fibrotic tissue?), wound border, and periwound skin. It is important to take pictures of the wound to monitor the wound’s progress.
Monitoring of Wounds by Classification Systems
Wounds should be monitored daily and assessed weekly to determine if the plan of care is effective or ineffective. Tools to determine progression of wound healing or deterioration vary depending on ulcer type. Other objective ways to monitor wound progress include decrease in wound length, width, depth, and amount of exudate.
Various wound classification systems are used that attempt to encompass different characteristics of an ulcer (namely, site, depth, the presence of neuropathy, infection, and ischemia).12 Both the well-established Wagner wound classification system and the University of Texas diabetic wound classification system provide descriptions of ulcers to varying degrees.12 Pressure ulcers can be tracked by use of the Pressure Ulcer Scale for Healing (PUSH) tool. All 3 of these systems are simple for healthcare providers to use and can provide a guide to planning treatment.
The Wagner system evaluates ulcer depth and the presence of osteomyelitis or gangrene by using the following grades: grade 0 (preulcerative or postulcerative lesion), grade 1 (partial- or full-thickness ulcer), grade 2 (deep ulcer, penetrating to ligaments and muscle, but with no bone involvement or abscess formation), grade 3 (deep ulcer with cellulitis or abscess formation, often with osteomyelitis), grade 4 (localized gangrene), and grade 5 (extensive gangrene involving the whole foot).12
The University of Texas system measures ulcer depth, the presence of wound infection, and the presence of clinical signs of lower-extremity ischemia. The University of Texas system uses grade 0 (preulcerative or postulcerative sites that have healed), grade 1 (superficial wound not involving tendon, capsule, or bone), grade 2 (wound penetrating to tendon or capsule), and grade 3 (wound probing to bone or joint). Within each wound grade, there are 4 stages: Stage A (clean wounds, noninfected, nonischemic), Stage B (infected, nonischemic wounds), Stage C (noninfected, ischemic wounds), and Stage D (infected, ischemic wounds).12
Pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel.13 The PUSH tool was developed by the National Pressure Ulcer Advisory Panel as a quick, reliable tool to monitor the change in PrU status over time. The PUSH tool tracks PrU healing by monitoring the wound’s length × width, tissue type, and exudate amount.14 The stages are as follows: with a Stage I PrU, there is intact skin with nonblanchable erythema of a localized area, usually over a bony prominence; color may differ from the surrounding area. In a Stage II PrU, there is partial thickness loss of epidermis and some dermis; the wound has the appearance of a shallow ulcer with a red-pink color base. Stage II PrUs may also present as an intact or open/ruptured blister. In Stage III, there is full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining or tunneling. Stage IV includes full-thickness skin loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often, there is undermining or tunneling. Suspected deep tissue injury is another stage, where there is an area of localized, discolored intact skin that is purple or may have a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear forces. Preceding skin changes may include skin that is painful, firm, or boggy or has a different temperature as compared with adjacent tissue. An unstageable ulcer, the final stage, is full-thickness tissue loss in which the base of the ulcer is covered by slough and/or an eschar in the wound bed.13
Patient assessment is important as well to ensure that the patient receives holistic treatment, as the wound is a part of his/her entire body system. It is fundamental to focus on the patient as a whole in order to understand the cause of the wound and to help heal the wound. Normal wound healing requires proper circulation, nutrition, immune status, and avoidance of negative mechanical forces.10 For example, the first line of management for ulcers is to remove the pressure, then to prevent friction and shearing over vulnerable skin surface areas, and finally to identify malnutrition. Many factors can delay wound healing, such as chronic disease, vascular insufficiency, diabetes, neurologic defects, nutritional deficiencies, and advanced age, as well as local factors, such as pressure, infection, and edema.10
In addition, it is also important to assess a patient’s mobility status. How much can the patient do for himself? Is the patient ambulant, or does he need assistance? Because some wounds are essentially created because of immobility, movement is important to healing and to ensure adequate circulation to the affected area. Lifestyle habits such as intravenous drug, tobacco, and alcohol use should also be noted, because they are associated with decreased wound healing. These habits may interfere with the patient’s ability to focus on the wound and thus delay healing. It is pertinent to understand each individual patient’s motivations, capabilities, home environment, family support, and financial resources because these factors directly affect wound care.10 Financial resources are needed by the patient to purchase materials needed for wound care, to pay for transportation to and from the clinic where care is received, and to purchase healthy foods necessary for wound healing.
Adequate nutrition is essential for successful wound healing.10,15 Provision of adequate protein and energy is imperative for successful skin closure and wound healing. The daily requirement for energy in a healthy adult is 30 to 35 cal/kg of body weight. In severe wounds or traumatic lesions, this requirement is increased to as much as 35 to 40 cal/kg of body weight.15 In addition, proteins play an essential role in wound healing. Normal, healthy adults require an average of 0.8 to 1.0 g/kg of body weight. A compromised wound patient may require as much as 1.5 to 2 g/kg. High-protein oral supplements can be used to improve protein intake and therefore improve wound healing. Specific amino acids have been shown to improve the wound healing process. Arginine, in particular, is thought to have a major influence on collagen accretion and an improved immune reaction.15
Micronutrients and Electrolytes
In addition to energy and proteins, all electrolytes and micronutrients are necessary for wound healing. Sufficient quantities of vitamins A, C, and E; iron; selenium; thiamine; pantothenic acid; zinc; copper; and manganese have been reported to be essential for healing.10 Vitamin A assists with fighting infection and maintains a strong epithelium. Vitamin A is found in dark leafy vegetables, grapefruits, deep orange fruits, milk, and eggs. Vitamin C is an antioxidant and a cofactor in collagen formation that is important in scar tissue, bones, teeth, and blood vessels. It is found in dark leafy vegetables, oranges, and grapefruits. Vitamin E stabilizes cell membranes and is an antioxidant. It is found in vegetable oils, salad dressings, and margarines.
Frail, older, obese, and institutionalized patients are at risk of malnutrition.10 Nutritional deficiencies must be recognized early, and repletion initiated as soon as possible. Even mild malnutrition or brief periods of inadequate nutrition can have significant negative effects on wound healing. When the patient assessment is done, it is important to identify the nutritional status of the patient and resources needed to maintain or regain a nutritional status adequate to provide healing of the wound. This should be discussed with the patient in order to identify foods that are within the patient’s daily weight to support the need for additional nutrients for healing.
Diagnostics and Imaging
Initial imaging evaluation is necessary for a septic foot wound. This is typically done by taking plain film X-rays of the affected limb to examine for evidence of gas in soft tissue, foreign bodies, and osteomyelitis.6 Soft tissue gas is seen as a collection of radiolucent areas in the subcutaneous tissue. If prompt magnetic resonance imaging (MRI) is available, this should be used to locate abscess formation.6 For chronic neuropathic wounds, and MRI is recommended when there is a strong suspicion for osteomyelitis versus diabetic neuroarthropathy. By using the arterial Doppler, one can easily and quickly determine the patient’s vascular status. This test can be omitted if the patient has pedal pulses, digital hair, and brisk capillary filling time, as these are signs of adequate blood supply. Other important testing includes ankle-brachial index (ABI), pulse volume recording, and transcutaneous oxygen measurement.
Blood Pressure Measurements
Blood pressure measurements are important diagnostic tools that are useful to assess the level of circulation and blood flow to the wound. The ABI is a measurement of adequate circulation in the lower extremity. Normally, the blood pressure in the ankle and arm should be about the same. Transcutaneous oxygen measurement is a local, noninvasive measurement reflecting the amount of oxygen that the body is able to deliver to the tissue. Patients with an ABI of less than 0.7 or a transcutaneous oxygen measurement of 40 mm Hg or less will not experience wound healing without vascular reconstructive surgery.6 Vascular surgery should be consulted by the clinician when there is an ABI of less than 0.7 or a transcutaneous oxygen measurement of 40 mm Hg or less.
Pulse volume recording is a test that measures blood flow in the arteries of the leg. It can be used both to diagnose peripheral arterial disease and determine how severe the disease is. Normally, healthy arteries will have high, sharp waveforms, indicating that blood is flowing smoothly. If arteries are narrowed, in the case of peripheral arterial disease, the waveforms will become smaller and flatter, indicating blood is having difficulty flowing into the leg.
Laboratory Tests and Wound Cultures
General laboratory values can provide important information about a patient’s overall health and ability to heal. Anemia or infection, as indicated by abnormalities in the complete blood count and protein malnutrition, reflected in serum albumin and prealbumin levels, can impair wound healing.6 Elevated C-reactive protein or erythrocyte sedimentation rate may indicate ongoing inflammation or infection. Hemoglobin A1c provides a measure of the blood sugar control of a person with diabetes over the past 3 months. Elevated hemoglobin A1c can impair a patient’s ability to heal wounds.16 In patients for whom there is suspicion of underlying vasculitis, hyperviscosity, or thrombosis, laboratory investigations for specific rheumatologic, infectious, or hematologic processes may be indicated. When a patient presents for the first time with neuropathy and no diabetes, folic acid, vitamin B12, and various rheumatologic tests should be ordered, as all are involved in the nervous system. Wound cultures are necessary in instances where there is concern of infection. In order to avoid misinterpreting positive cultures from superficial wound colonization, deeper tissue should be taken.
WOUND CARE TREATMENT
Bacteria are present on nearly all wounds. A wound is considered colonized when there is a delicate balance between the growth and death of microbes and host defenses.10 Wounds are considered clinically infected when host defenses become overwhelmed. Infected wounds often exhibit an increase in color, erythema, edema, pain, increased drainage, and sometimes malodor. Systemic signs of infection that may have progressed to bacteremia or septicemia include fever, chills, and leukocytosis. In older adults, who lack a quick inflammatory response, signs of infection are sometimes subtle. Whenever possible, suspicion of clinically infected wounds should be cultured and microorganism sensitivities determined before systemic antimicrobial agents are prescribed.10
The clinician must then determine if the wound is mildly or severely infected. Patients with a severe infection should be admitted to the hospital, as they may require special diagnostic studies, surgical interventions, fluid resuscitation, and control of metabolic derangements.17 Hospitalization should also be considered if the patient is unable or unwilling to perform proper wound care, unlikely to off-load the affected area, or unlikely to comply with antibiotic therapy.17 In the absence of these factors, most patients can be treated cautiously on an outpatient basis with frequent evaluation.17 Most patients will begin antibiotic therapy with an empiric regimen, pending results of wound cultures.17 Antibiotic therapy should aim to cover the most common pathogens.
Debridement is an important part of wound treatment. Debridement is the process of removing slough, eschar, exudate, bacterial biofilms, and callus from the wound bed in order to permit healing.10 Vascular assessment is recommended for ulcers in lower extremities prior to debridement to rule out arterial vascular compromise. There are 5 types of debridement: sharp, surgical, autolytic, enzymatic, and mechanical. Sharp debridement involves taking a scalpel, scissors, forceps, or curette and directly removing the nonviable tissue. Sharp debridement is recommended for venous, diabetic, and pressure wounds, but not in arterial wounds, as removing the eschar in arterial wounds will cause the wound to possibly desiccate after debridement.10 The clinician must not debride dry gangrene or a wound where there is inadequate blood supply.
Surgical debridement is the fastest and most effective method of debridement. Large wounds with purulence, deep infection, or a large area of necrotic tissue may require surgical debridement in the operating room. Likewise, soft tissue infections such as necrotizing fasciitis or gas gangrene require emergent surgical debridement of the involved tissue. It is important to remove the nonviable tissue until healthy tissue appears, thus converting the chronic wound to an acute wound to initiate the wound healing process. Autolytic debridement occurs when there is a mild separation of slough and necrotic tissue from the wound bed that occurs slowly in a moist wound environment. Moisture-donating wound dressings promote autolytic debridement by rehydrating desiccated and devitalized tissue, aiding its separation from healthy tissue.10 Autolytic debridement is a slower process and may take several weeks but can be useful for instances where sharp debridement is inappropriate (eg, in patients with bleeding tendencies).10
Another type of debridement is enzymatic and works by using enzymes that aim at collagen and fibrin of necrotic tissue and wound exudate. This type of debridement uses topical preparations to speed up the body’s autolytic process.7 To increase topical enzyme penetration of tough eschar, cross hatching by sharp incision before application can be effective.7,10 Mechanical debridement is the removal of foreign material by use of physical forces or external force (wet-to-dry dressings, irrigation, pulsed lavage, and hydrotherapy).7 Mechanical debridement is nonselective and does not differentiate between healthy and necrotic tissue. There may be pain upon removal of the dressing.
The most important aspect of wound healing is to help the body heal itself.6 This can be done by choosing the appropriate dressing, which is critical to the healing process. The Greek physician Galen of Pergamum (120–201 AD) noted empirically that wounds heal optimally in a moist environment.10 Nevertheless, for the next 2000 years, therapeutic efforts focused on drying the wound site, with absorptive gauzes a mainstay of wound management.10 It was not until the 1960s that George Winter10 proved the critical role of moisture in healing, when he demonstrated that acute wounds covered with moisture-retentive occlusive dressings healed twice as rapidly as similar wounds exposed to air. Toward the latter half of the 20th century, as clinical data accumulated in support of moist wound healing, manufacturers began producing polymer-based occlusive wound dressings designed to preserve and protect a moist wound environment.10
The “Ideal Wound Dressing” Concept
There are many types of wound dressings, including contact layers, transparent films, foams, hydrocolloids, hydrogels, alginates, collagens, and antimicrobials.1,10 The current concept of the “ideal wound dressing” is one that removes excess exudate, maintains a moist environment, and protects against contaminants. In addition, the dressing should cause no trauma on removal, leave no debris in the wound bed, relieve pain, and be easy to apply and remove. It must also be easily obtainable, cost-effective, and induce no allergic reaction.1,10 Because wounds are very complex, it is unlikely that there will ever be one product that treats every wound.
Contact layers are placed on the tissue bed and are used to prevent removal of newly formed cells. They can be used on partial- to full-thickness wounds while preventing the pool of bacteria on the wound bed. Contact layers are often used under negative-pressure wound therapy to cover exposed structures such as tendons, vessels, bone, fascia, muscle, sutures, or staples. Contraindications include tunneled wounds, patients with a known sensitivity to silicon or cellulose, and wounds covered with eschar.
Transparent films are a thin, transparent membrane, which are permeable by moisture, vapor, and oxygen. They can be utilized as a secondary dressing. They protect the skin from shear forces. They are nonabsorbent and therefore should be used only in minimal exudate. Films can be left on for up to 1 week or longer.1,10
Foams are moderately absorbent, semiocclusive dressings that can be used over lightly to moderately draining wounds. Foams protect the surrounding skin and provide thermal insulation. They can be used as a primary or secondary dressing and promote development of excessive malodorous drainage.10 Foams have little value with dry wounds.1
Hydrocolloids are minimally absorptive and are available in gels, granules, and pastes.1,10 They absorb exudate and are good for wounds with low to moderate amounts of drainage. Hydrocolloids work by keeping the wound moist and promote autolysis of necrotic areas.7 Wounds with high amounts of exudate can cause maceration and the dressing to separate from the wound. This dressing is not appropriate for a wound with infection or heavy exudate. An advantage of hydrocolloids is that they can remain in place for up to 7 days.
Hydrogels contain a high percentage of water or glycerin and are indicated for dry wounds or those with eschar and low exudate. They add moisture to the wound bed, are nonadherent, and come in sheets or gels.1,7 Hydrogels facilitate granulation and epithelialization and maintain a moist wound-healing environment.10 Hydrogels promote autolytic debridement of slough and necrotic tissue and are applied and removed with minimal pain.
Alginate dressings contain calcium and sodium salts and come in sheets or ropes. Alginates are highly absorbent. They require moisture to function and thus are contraindicated in dry wounds or wounds covered with eschar.10 Alginates are nonadhesive and require a secondary dressing to keep them in place.
Collagen dressings are thought to support wound healing by laying down a matrix that favors deposition of new tissue and attracts cell types necessary for healing.5 These dressings are available in gel, powder, and sheet form from human, porcine, and bovine sources.
Antimicrobials include topical antibiotics, iodine-based products, hydrogen peroxide, dilute hypochlorite, and silver-releasing agents.10 Topical antibiotics contain an agent that prevents bacterial growth. Hydrogen peroxide and iodine are toxic to human tissue and should not be applied long term to wounds. Silver is bactericidal and can also be used to prevent infection. Contraindications include sensitivity to sulfa drugs, iodine, or silver.
Considerations for Dressing Selection
Dressing selection factors include the amount of exudate, anatomical location, depth of wound, caregiver ability, desired frequency of dressing change, and cost/reimbursement. Four weeks after a nonhealing ulcer, the clinician must consider advanced therapies. Advanced wound bed preparation includes negative-pressure therapy (indicated for cavity, pressure, and diabetic wounds), compression (single or multilayer bandages and stockings), and bioengineered skin (living skin equivalent that may contain living human cells; works by rebuilding damaged tissue and is indicated for diabetic and venous leg ulcers). Other treatments include hyperbaric oxygen therapy (which involves breathing 100% oxygen at supra-atmospheric pressures while inside a compression chamber and is based on the notion that tissue hypoxia impedes wound healing), growth factors (used to accelerate healing of chronic wounds in diabetic foot ulcers), and skin grafts (pieces of skin; can be full-thickness graft, split-thickness graft, or composite graft).10
The Figure offers an algorithm overview of wound care treatment options. The flowchart is a way for clinicians to identify the characteristics of the wound and then determine the appropriate type of wound care dressing and treatment.
Nursing management of patients with wounds includes identifying the etiology of the wound and then treating or removing the cause. It also includes consulting the dietary department to establish appropriate high-protein supplements for wound healing, the endocrinology department for uncontrolled diabetes, consulting the radiology department for imaging, consulting a wound care team including podiatry and wound care nurses for nonhealing or hard-to-manage wounds, consulting the infectious disease department when a wound is infected, and consulting vascular surgeons when there is poor circulation. Managing patients with wounds also includes weekly measurements and close monitoring of wounds for improvement that assist in determining whether the treatment is effective or ineffective. When photographing the wounds, be sure to have the proper patient consent forms signed. Confirm there is adequate lighting when taking pictures because shadows may make a healthy wound bed appear to have dark necrotic tissue. Once adequate circulation is determined, debridement of necrotic tissue is indicated to help the wound heal faster. Sharp debridement is recommended for venous, diabetic, and pressure wounds, but not for arterial wounds because removing the eschar in arterial wounds will cause the wound to possibly desiccate after debridement.10 Nurses must also ensure the wound is responding to the current treatment, which is noted by a decrease in wound length, width, depth, and amount of exudate. Treatment for wound care includes absorbing moisture, but not too much that the treatment dries out the wound bed. Educating the patient and caregivers on dressing changes and signs and symptoms of infection and documenting adherence to the plan of care are also important in nursing management. Whether in the hospital or clinical setting, making certain the patient is able to demonstrate his/her ability to change his/her dressing before discharge is important in assessing the need for home healthcare. Nursing management should also ensure that the patient has appropriate follow-up status after hospital discharge. The patients should be given the contact number of wound care specialists in the event they have questions or concerns.
Implications for Nursing Management
At a unit level, identifying causative factors for ulcerations such as pressure, moisture related to perspiration, or incontinence and friction/shearing can assist in improving the quality of care nursing provides as a whole. Identification of such causative factors implies the need for education and evaluating outcomes. It is important to identify patients at risk of moisture, pressure, and friction/shearing-associated wounds with the goal in mind to decrease the prevalence of such wounds. Identification helps aid in prevention, which is the most cost-effective treatment.
At an institutional level, the management of wound care is best accomplished by consulting specialty professionals. These professionals include dietitians, infectious disease physicians, endocrinologists, nephrologists, wound care nurses, prosthetists, and a group of surgeons: vascular, podiatric, orthopedic, and plastic. Effective management of wounds is most successful when employing all members of the healthcare team, which can lead to appropriate management, cotreatment, and earlier healing.
Proper management of wounds begins with an accurate diagnosis of the type of wound and then assessing the etiology. This is important in implementing proper treatment and management of the wound. The more accurate the assessment, the quicker the wound can be healed. More rapid wound healing of a chronic wound is significant because it decreases hospitalization and allows for earlier return of the patient to daily functions.11 It is important to establish protocols that allow us to quantifiably determine which materials are effective in facilitating wound healing while remaining cost-effective.10 Using the chart and table provided in this article will assist nurses in the right direction for providing standard of care for the patient in need of wound care. It is imperative that healthcare providers examine the patient as a whole to find out other factors affecting healing, including circulation, nutrition, immune status, and avoidance of negative mechanical forces. Interventions include removing the cause in addition to treatment of contributing factors. Diagnostic imaging, laboratory tests, cultures, and blood pressure tests may be indicated in certain wounds and will aid in the process of healing.