Summary & References


Local wound care provides an opportunity to promote a wound environment that will support wound healing. Selection of appropriate wound cleansers and dressings will depend on the wound healing classification, detailed wound assessment, patient preference and their environment. It is important that local treatment is re-assessed in a timely manner to ensure the overall goal of the patient and their wound is met.

Key Takeaways

  • Wound documentation serves as a communication method to healthcare team members regarding wound status
  • Consistent and thorough documentation is required and should follow organizational policies
  • Comparing current wound assessment to previous documentation verifies wound trajectory often expressed as a percentage
  • Clinicians need to be familiar with the 4 wound tissue types in order to guide appropriate and optimal treatment methods



Caruana, M. F., Bradbury, A. W., & Adam, D. J. (2005). The validity, reliability, reproducibility and extended utility of ankle to brachial pressure index in current vascular surgical practice. European Journal of Vascular and Endovascular Surgery, 29(5), 443-51.

Dallam, L. E., Ayello, E. A. et al. (2016). Pain management and wounds. In Baronski, S., & Ayello, E. A., Wound care essentials: Practice principles (pp. 281-306). Philadelphia, PA: Wolters Kluwer.

Falanga, V. (2000). Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration, 8(5), 347-352.

Flanagan, M. (1997). A practical framework for wound assessment 2: methods. British Journal of Nursing, 6, 6-11.

Fletcher, J., & Probst, A. (2020). Managing dry wounds in clinical practice: challenges and solutions. Wounds Internationals, 11(2), 47-52.

Goldman, R. J., & Salcido, R. (2002). More than one way to measure a wound: an overview of tools and techniques. Advances in Skin and Wound Care, 15(5), 236-243.

Grey, J., Enoch, S., & Harding, K. (2006). ABC of wound healing: Venous and arterial leg ulcers. British Medical Journal, 332(2), 347-350.

Humber River Hospital. (2021). Wound/incision Assessment [Screenshot].

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, S1-17.

Keast, D. H., & Orsted, H. (1998). The basic principles of healing. Ostomy/Wound Management, 44(8), 24-28, 30-31.

Landes, S.J. (2008). Chronic wound infection and antimicrobial use. Advances in Skin and Wound Care, 21(11), 531-540.

Sibbald, R. G., Alavi, A., Sussman, G., Ayello, E., & Goodman, L. (2012). Dermatological aspects of wound care. In Krasner, D., Rodeheaver, G. T., Sibbald, R. G., & Woo, K.Y. (Eds.), Chronic wound care: A clinical source book for healthcare professionals (5th ed., pp. 207-222). Malvern, PA: HMP Communications.

Sibbald, G., Elliott, J. A., Ayello, E. A., & Somayaji, R. (2015). Optimizing the moisture management tightrope with wound bed preparation 2015. Advances in Skin and Wound Care, 28(10), 466-476.

Sibbald, R. G., Elliott, J. A., Persaud-Jaimangal, R., Goodman, L., Armstrong, D. G., Harley, C., Coelho, S., Xi, N., Evans, R., Mayer, D. O., Zhao, X., Heil, J., Kotru, B., Delmore, B., Leblanc, K., Ayello, E. A., Smart, H., Tariq, G., Alavi, A., & Somayaji, R. (2021). Wound Bed Preparation 2021. Advances in Skin & Wound Care, 34(4), 183-195.

Woo, K., & Sibbald, G. (2009). A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Management, 55(8), 40-48.

Wound, Ostomy and Continence Nurses Society. (2010). Guidelines for prevention and management of pressure ulcers. Mount Laurel, NJ: Author.