What is the recommended approach for wound healing assessment and treatment?

Wound Healing Assessment and Treatment

Use the T.I.M.E. framework (Tissue, Infection/Inflammation, Moisture, Edge) for systematic wound bed preparation, combined with standardized assessment tools like NERDS/STONES or MEASURE to guide treatment decisions and monitor healing progression. 1

Initial Wound Assessment

Physical Examination Components

• Measure wound dimensions (length, width, depth) using a sterile blunt metal probe to establish baseline and detect deep tissue involvement including bone or joint communication 2
• Document wound bed characteristics including tissue type (necrotic, sloughy, granulation, epithelial), percentage of each tissue type present, and presence of undermining or tunneling 3
• Assess surrounding skin for maceration, erythema, edema, induration, and callus formation which indicate infection or excessive moisture 1, 2
• Evaluate exudate quantity (none, minimal, moderate, heavy) and quality (serous, serosanguineous, purulent) as indicators of infection or inflammation 3
• Check for infection signs using NERDS criteria (Nonhealing, Exudate, Red friable tissue, Debris/discoloration, Smell) for superficial infection or STONES criteria (Size increasing, Temperature elevation, Os/probes to bone, New breakdown, Erythema/Edema, Exudate, Smell) for deep infection 1

Advanced Assessment When Indicated

• Obtain imaging (ultrasound, MRI, or CT) when deep tissue infection, abscess, or osteomyelitis is suspected to determine extent and guide surgical debridement 1
• Perform wound cultures only when infection is clinically suspected, using quantitative tissue biopsy (gold standard) or Levine technique swab to guide antibiotic selection 1
• Assess vascular status by checking distal pulses; weak or absent pulses require immediate CT angiography or surgical consultation 2

Treatment Framework: T.I.M.E. Protocol

T - Tissue Debridement

• Perform sharp debridement with scalpel to remove necrotic tissue, slough, biofilm, and surrounding callus at initial assessment and repeat as often as needed 1
• Sharp debridement is superior to enzymatic, autolytic, or biological methods because it is definitive, controllable, and immediately removes bacterial reservoirs 1
• Debridement facilitates proper wound assessment, enables appropriate culture collection, and is essential before any adjunctive therapy 1, 4

I - Infection/Inflammation Control

• Apply topical antimicrobials (iodine, medical-grade honey, silver, EDTA) to infected wounds to destroy microorganisms and prevent biofilm reformation within 24-72 hours 1
• Use collagen matrix dressings to reduce excessive protease activity and inflammation while promoting fibroblast proliferation 1
• Target wound pH of 4-6 using stabilized hypochlorous acid which has germicidal properties without cytotoxicity and promotes fibroblast/keratinocyte migration 1
• Do not use topical antimicrobials for clinically uninfected wounds 1

M - Moisture Control

• Select dressings based on exudate level: hydrogels for dry/necrotic wounds, alginates or foams for heavy exudate, hydrocolloids for moderate exudate to maintain moist wound environment 1
• Proper moisture balance promotes epithelialization and reduces pain 1

E - Edge Advancement

• Monitor wound size reduction: wounds should decrease by ≥50% within 4 weeks of standard care; failure indicates need for adjunctive therapies 4
• Consider adjunctive therapies only after 4 weeks of failed standard care: electrical stimulation for pressure ulcers (stage 2-4), negative pressure wound therapy for post-surgical diabetic wounds, or autologous leucocyte-platelet-fibrin patch for diabetic foot ulcers 1, 4
• Do not use growth factors, cellular/acellular skin substitutes, or most biologic therapies as routine adjuncts due to low-quality evidence 1

Reassessment Schedule

• Reassess weekly during active treatment to track healing progression, modify interventions, and detect complications early 3
• Calculate healing rate by measuring wound area/volume as percentage of baseline; lack of 50% reduction by week 4 warrants treatment escalation 4, 3
• Use consistent assessment tools (MEASURE or similar) at each visit to ensure reliable comparison over time 3

When Complete Healing Is Not Achievable: S-P-E-C-I-A-L Approach

For wounds where complete healing is impossible and surgery is not planned, shift goals to:

• Stabilize the wound
• Prevent new wounds
• Eliminate odor
• Control pain
• Infection prevention and control
• Advanced absorbent dressings
• Lessen dressing change frequency 1

Critical Pitfalls to Avoid

• Never use adjunctive therapies as monotherapy without concurrent sharp debridement, appropriate dressings, pressure offloading, and infection control 1, 4
• Do not continue ineffective standard care beyond 4 weeks without considering treatment modification or advanced therapies 4
• Avoid obtaining wound cultures from uninfected wounds as this leads to misdiagnosis and inappropriate antibiotic use 1
• Do not use negative pressure wound therapy for non-surgical diabetic foot ulcers as strong evidence shows no benefit 1