Wound Management — Apply wound management principles considering stage of healing and skin integrity - Nbcot Registered Occupational Therapists Otr

SECTION 1

Historical Context & Motivation

Wound management has been a cornerstone of medical practice for millennia, yet the scientific understanding of wound healing physiology and the systematic application of evidence-based principles to guide clinical decision-making are relatively modern developments. For occupational therapists, wound management represents a critical intersection of biological science and functional rehabilitation — the therapist must understand tissue repair mechanisms at the cellular level while simultaneously considering how wound status affects a client's ability to engage in meaningful occupations. The progression from ancient wound care rituals to contemporary evidence-based wound management reflects centuries of clinical observation, scientific discovery, and interdisciplinary collaboration.

Early civilizations recognized that wounds required intervention, but the rationale behind their treatments was largely empirical and sometimes harmful. The ancient Egyptians documented wound care on papyrus scrolls as early as 1600 BCE, describing the use of honey, grease, and lint as wound dressings — practices that, remarkably, have some modern scientific support. The Greeks and Romans contributed observations about the importance of wound cleanliness and introduced the concept of primary versus secondary wound closure. However, it was not until the advent of germ theory and antiseptic technique in the nineteenth century that wound management began its transformation into a rigorous clinical discipline.

1600 BCE • Edwin Smith Papyrus

Ancient Egyptian surgical text documents wound classification and treatment with honey, grease, and lint — among the earliest recorded evidence-based wound care protocols.

1867 • Lister's Antiseptic Principles

Joseph Lister applies Pasteur's germ theory to surgery, introducing carbolic acid as an antiseptic and dramatically reducing surgical wound infections and mortality rates.

1962 • Moist Wound Healing Theory

George Winter publishes landmark research demonstrating that wounds heal faster in a moist environment, fundamentally changing dressing selection and wound management paradigms.

1990s • OT Scope Expansion

Occupational therapy formally incorporates wound management into its scope of practice, recognizing the impact of wound status on occupational performance and the role of OTs in rehabilitation settings.

2010s–Present • Evidence-Based Wound Care Frameworks

Integration of wound assessment tools such as the Braden Scale, TIME framework, and Wound Bed Preparation model into interdisciplinary clinical guidelines, including NBCOT competency domains.

The central question that contemporary wound management addresses is this: how can clinicians — including occupational therapists — systematically assess wound characteristics, identify the current stage of healing, evaluate skin integrity, and select interventions that support tissue repair while maximizing a client's functional independence? This lesson explores those principles in depth, providing the foundational knowledge required for NBCOT Domain 3 competency.

SECTION 2

Core Principles of Wound Healing & Skin Integrity

Effective wound management requires the occupational therapist to integrate knowledge from anatomy, physiology, and pathology into clinical reasoning. The skin — the body's largest organ — functions as a protective barrier, thermoregulatory surface, and sensory interface. When this barrier is disrupted, the body initiates a complex, overlapping cascade of biological processes collectively known as wound healing. Understanding the core principles that govern this process enables clinicians to match interventions to the wound's physiological needs at each stage of repair.

Phases of Wound Healing

Wound healing progresses through four overlapping phases: hemostasis, inflammation, proliferation, and remodeling (maturation). Each phase has distinct cellular activities and clinical signs that guide intervention selection.

Wound Classification

Wounds are classified by etiology (pressure, arterial, venous, diabetic, surgical), depth (superficial, partial-thickness, full-thickness), and healing intention (primary, secondary, tertiary). Classification directly informs prognosis and intervention.

Moist Wound Healing Environment

Evidence supports that maintaining optimal moisture at the wound bed — neither too wet nor too dry — accelerates epithelial cell migration, reduces pain, and minimizes scar formation. Dressing selection is guided by wound exudate levels.

Skin Integrity Assessment

Systematic evaluation of skin integrity includes assessing color, temperature, turgor, moisture, texture, and the presence of lesions or breakdown. Tools like the Braden Scale quantify risk for pressure injury development.

OT-Specific Considerations

Occupational therapists address wound management within the context of functional performance — positioning, pressure redistribution, splinting, edema management, scar management, and activity modification all fall within the OT scope when wound healing impacts occupational engagement.

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KEY TAKEAWAY

Think of wound healing like a construction project with four phases. Hemostasis is the emergency response team stopping a water leak. Inflammation is the demolition crew clearing debris. Proliferation is the construction crew building new infrastructure. Remodeling is the finishing crew refining and strengthening the structure over months to years. An OT intervening at the wrong phase — like sending in the finishing crew during demolition — can impede rather than support healing. Matching your intervention to the current phase is the cardinal rule.

SECTION 3

Visual Explanation — Phases of Wound Healing

This diagram illustrates the four overlapping phases of wound healing. Note how each phase's activity peaks at different times but overlaps with adjacent phases. Hemostasis (red) peaks within minutes. Inflammation (orange) dominates days 1–6. Proliferation (green) peaks at 2–3 weeks. Remodeling (violet) can continue for up to 2 years. OT interventions must align with the dominant phase.

The diagram above reveals a critical clinical principle: the phases of wound healing are not discrete, sequential events but rather overlapping biological processes. During hemostasis, vasoconstriction and platelet aggregation form a fibrin clot to achieve initial hemorrhage control. Within hours, the inflammatory phase begins as neutrophils and macrophages migrate to the wound bed to phagocytize bacteria and cellular debris — the clinical signs of redness, warmth, swelling, and pain at this stage are expected and should not be confused with infection. The proliferative phase follows, characterized by granulation tissue formation, angiogenesis (new blood vessel growth), and epithelialization (migration of epithelial cells across the wound surface). Finally, remodeling involves the reorganization of collagen fibers to increase tensile strength, though healed skin typically achieves only 70–80% of its original strength.

For the occupational therapist, recognizing which phase dominates at the time of evaluation determines whether the clinical priority is wound protection (hemostasis/inflammation), tissue support and gentle functional engagement (proliferation), or progressive stress loading and scar management (remodeling). Misalignment between the intervention and the healing phase can cause setbacks — for example, aggressive range-of-motion exercises during the inflammatory phase may disrupt fragile clot formation and restart the healing cascade.

SECTION 4

Wound Assessment Mechanisms & Clinical Frameworks

Systematic wound assessment is the mechanism by which clinicians translate visual and tactile observations into actionable clinical decisions. Two dominant frameworks guide modern wound assessment: the Braden Scale for Predicting Pressure Sore Risk and the TIME framework for wound bed preparation. Together, these tools provide a structured approach to prevention, assessment, and intervention planning.

The Braden Scale — Pressure Injury Risk Assessment

The Braden Scale evaluates six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction/shear — each rated from 1 (most impaired) to 3 or 4 (least impaired). The total score ranges from 6 to 23, with lower scores indicating higher risk for pressure injury development.

BRADEN SCALE TOTAL SCORE

Total Score = Sensory Perception + Moisture + Activity + Mobility + Nutrition + Friction/Shear

Score range: 6–23. Risk categories: ≤ 9 = very high risk; 10–12 = high risk; 13–14 = moderate risk; 15–18 = at risk; 19–23 = no significant risk.

The TIME Framework — Wound Bed Preparation

The TIME framework provides a systematic approach to assessing and managing the wound bed itself. Each letter represents a clinical observation domain that must be evaluated and addressed for optimal healing.

TIME Component	Clinical Focus	OT Intervention Examples
T — Tissue (non-viable or deficient)	Assess wound bed color and tissue type: black (necrotic/eschar), yellow (slough), red (granulation), pink (epithelialization).	Refer for debridement as needed; protect granulating tissue during ADL training; adapt activities to avoid wound disruption.
I — Infection or Inflammation	Differentiate normal inflammatory signs from infection indicators: increasing pain, purulent drainage, erythema extending beyond wound margins, elevated temperature.	Monitor for infection signs during treatment sessions; educate client on infection awareness; modify intervention intensity during active inflammation.
M — Moisture imbalance	Evaluate exudate type (serous, sanguineous, purulent) and amount; assess whether wound bed is too wet or too dry.	Coordinate with nursing on dressing selection; position client to prevent moisture accumulation; educate on skin care routines.
E — Edge of wound (non-advancing or undermined)	Assess wound edge characteristics: rolled, undermined, tunneling, or epithelializing. Non-advancing edges suggest systemic or local barriers.	Assess and document wound measurements; educate client on nutrition; modify ADL techniques to reduce shear at wound edges.

TIME Framework Components with OT-Specific Interventions

Wound Measurement

WOUND SURFACE AREA ESTIMATION

Surface Area ≈ Length × Width (cm²)

Length is measured in the head-to-toe direction; width is measured perpendicular to length. For irregular wounds, the greatest length and greatest perpendicular width are used. Depth is measured by inserting a sterile cotton-tipped applicator into the deepest point. Document undermining and tunneling using the clock method (12 o'clock = toward the head).

SECTION 5

Wound Classification & Pressure Injury Staging

Accurate wound classification is essential for appropriate intervention selection and documentation. Occupational therapists frequently encounter pressure injuries (formerly called pressure ulcers or decubitus ulcers) in rehabilitation settings, and the National Pressure Injury Advisory Panel (NPIAP) staging system is the standard classification framework. Understanding staging informs the therapist's decisions about positioning, activity modification, splinting, and pressure redistribution strategies.

The NPIAP pressure injury staging system classifies wounds by depth of tissue involvement. Stage 1 involves intact skin with non-blanchable erythema. Stage 2 involves partial-thickness loss into the dermis. Stage 3 extends through the full dermis into subcutaneous tissue. Stage 4 exposes muscle, tendon, or bone. Unstageable and deep tissue pressure injuries are also recognized classifications.

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Critical Clinical Note

Pressure injuries are never reverse-staged. A Stage 4 pressure injury that is healing does not become a Stage 3, then Stage 2, and so on. Instead, it is documented as a "healing Stage 4 pressure injury" because the tissue that fills the wound bed is granulation tissue and scar — not the original muscle, fascia, and dermal structures that were lost.

Beyond pressure injuries, OTs encounter arterial ulcers (typically on the distal extremities, with well-defined wound margins and a pale wound bed due to inadequate arterial perfusion), venous ulcers (commonly in the medial lower leg/gaiter area, with irregular margins and high exudate due to venous insufficiency), neuropathic/diabetic ulcers (often on the plantar surface of the foot due to sensory loss and repetitive pressure), and surgical wounds healing by primary intention. Each wound type has a distinct etiology and requires tailored management strategies.

SECTION 6

Worked Example — Clinical Wound Assessment & Intervention Planning

The following worked example demonstrates the clinical reasoning process an occupational therapist uses when assessing a wound and selecting interventions that align with the current stage of healing and the client's functional needs.

Case: Mrs. Chen — Sacral Pressure Injury in Acute Rehabilitation

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Step 1 — Gather Client Information

Mrs. Chen is a 72-year-old woman admitted to acute rehabilitation following a left CVA with right hemiparesis. She has a history of Type 2 diabetes mellitus and peripheral vascular disease. She is referred to OT for ADL training and functional mobility. During the initial evaluation, the OT observes a wound on the sacral area. The nursing documentation indicates a Stage 3 pressure injury measuring 4.2 cm × 3.1 cm × 0.8 cm deep, with a red granulating wound bed and moderate serous exudate.

Key data: Stage 3 sacral pressure injury, proliferative phase (red granulation tissue), moderate exudate, diabetes and PVD as comorbidities.
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Step 2 — Assess Braden Scale Risk Factors

The OT evaluates Mrs. Chen using the Braden Scale: Sensory Perception = 3 (slightly limited due to right-sided neglect), Moisture = 3 (occasionally moist), Activity = 2 (chairfast), Mobility = 2 (very limited due to hemiparesis), Nutrition = 2 (probably inadequate — poor appetite since admission), Friction/Shear = 1 (problem — requires moderate to maximum assistance with transfers, frequently slides in wheelchair).

Braden Total = 3 + 3 + 2 + 2 + 2 + 1 = 13 → Moderate risk for additional pressure injury development.
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Step 3 — Apply TIME Framework to Wound Assessment

T (Tissue): Red, granulating wound bed — indicates proliferative phase; no necrotic tissue present. I (Infection/Inflammation): No signs of infection; no purulent drainage, no extending erythema, no elevated temperature. M (Moisture): Moderate serous exudate — current foam dressing is managing moisture appropriately. E (Edge): Wound edges are attached and show early epithelialization at the wound margins — a positive sign of healing.

TIME assessment confirms wound is in the proliferative phase with no barriers to healing at the wound bed level. Systemic barriers (diabetes, PVD, nutrition) require monitoring.
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Step 4 — Determine OT Interventions Aligned with Healing Phase

Given that the wound is in the proliferative phase, the OT prioritizes protecting the wound bed while promoting functional independence. Interventions include: (1) Pressure redistribution — ensure appropriate wheelchair cushion (e.g., alternating pressure or gel cushion); teach Mrs. Chen and nursing staff a weight-shift schedule every 15–30 minutes. (2) Positioning — avoid direct pressure on the sacrum during bed mobility and transfer training; use a 30-degree lateral tilt in bed. (3) Activity modification — adapt bathing and dressing routines to minimize shear forces on the sacral area. (4) Client education — teach Mrs. Chen to perform skin checks with a long-handled mirror and report changes. (5) Nutrition referral — collaborate with dietitian to address protein and caloric intake, as adequate nutrition is essential for collagen synthesis during proliferation.

Intervention plan protects the wound during the proliferative phase, addresses modifiable Braden Scale risk factors (mobility, friction/shear, nutrition), and integrates wound management with ADL training goals.
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Step 5 — Establish Outcome Measures and Reassessment Schedule

The OT establishes measurable outcomes: wound surface area reduction by ≥ 20% within 2 weeks, improved Braden score through mobility and nutritional gains, independence in weight shifts and skin inspection, and modified independence in bathing and lower body dressing without wound disruption. Weekly wound measurements and Braden Scale reassessments will be documented, with interdisciplinary communication to nursing and the physician regarding wound status changes.

Expected outcome: wound area decreases from 4.2 × 3.1 = 13.02 cm² to ≤ 10.42 cm² within 2 weeks, with concurrent functional gains in ADLs.

SECTION 7

OT Interventions Matched to Healing Phases — Strengths & Limitations

The occupational therapist's ability to select appropriate interventions depends on accurately matching clinical actions to the dominant phase of wound healing. Each phase permits certain interventions and contraindicates others. The following table summarizes the key interventions, their therapeutic rationale, and limitations at each healing phase.

Healing Phase	Appropriate OT Interventions	Precautions / Limitations
Hemostasis (Minutes–Hours)	Wound protection; immobilization of affected area; elevation to reduce blood flow; gentle compression as appropriate; client education on wound care precautions.	Avoid any activity that disrupts clot formation. No AROM/PROM at or near wound site. Monitor for excessive bleeding. Limited functional training during this phase.
Inflammation (1–6 Days)	Edema management (elevation, gentle retrograde massage distal to wound); pain management positioning; ADL adaptations to protect wound site; splinting to prevent contracture if immobilization needed.	Avoid aggressive ROM or stretching. Do not mistake normal inflammatory signs for infection. Heat modalities are generally contraindicated. Monitor for prolonged inflammation (> 7 days) which may indicate chronicity.
Proliferation (4–21 Days)	Gentle AROM within pain-free range; pressure redistribution and positioning; scar prevention with silicone sheeting; progressive ADL engagement; client education on nutrition and hydration; splinting for optimal positioning.	New granulation tissue and epithelium are fragile — avoid shear and friction at wound site. No aggressive stretching or resistive exercise near wound. Dressing changes should minimize wound bed disruption.
Remodeling (21 Days–2 Years)	Scar management (massage, silicone, compression garments); progressive resistive exercise; full ADL training; desensitization for hypersensitive scars; custom splinting for scar contracture prevention; work hardening and return-to-occupation planning.	Scar tissue reaches only 70–80% of original skin tensile strength. Sun protection for maturing scars. Monitor for hypertrophic scarring or keloid formation. Adjust intervention intensity based on tissue response.

OT Interventions Aligned with Wound Healing Phases

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KEY TAKEAWAY

The relationship between wound healing phase and intervention intensity can be understood as a dial on a control panel: during hemostasis and inflammation, the intensity dial is set to minimum — protect and support. During proliferation, the dial gradually increases to moderate — gentle functional engagement with tissue protection. During remodeling, the dial advances toward maximum — progressive loading, scar management, and full return to occupation. Turning the dial too high too early disrupts healing; keeping it too low too late leads to contracture, deconditioning, and dependency.

SECTION 8

Connection to Advanced Theory — Chronic Wounds & Specialized Modalities

While the principles discussed above apply to wounds progressing through normal healing, occupational therapists frequently encounter chronic wounds — wounds that have failed to progress through the expected healing phases within the anticipated timeframe (typically defined as a wound that has not healed within 30 days). Chronic wounds are often stalled in the inflammatory phase, characterized by persistent inflammation, elevated matrix metalloproteinase (MMP) levels, and biofilm formation. Understanding the mechanisms of wound chronicity connects foundational wound management principles to advanced clinical decision-making and emerging therapeutic modalities.

Feature	Acute Wound	Chronic Wound
Healing Timeline	Progresses through phases predictably; closed within 30 days for most wounds	Stalled or regressing; fails to heal within expected timeframe
Dominant Phase	Transitions sequentially from hemostasis → remodeling	Often trapped in the inflammatory phase with persistent elevated cytokines
Wound Bed	Healthy granulation tissue; minimal non-viable tissue	May show slough, eschar, biofilm; poor granulation; rolled wound edges
Contributing Factors	Typically a single etiology (trauma, surgical incision)	Multifactorial: diabetes, PVD, immunosuppression, malnutrition, sustained pressure, infection, smoking
OT Role	Phase-matched intervention, functional training, prevention	Address systemic barriers, advanced pressure redistribution, activity modification, patient/caregiver education, interdisciplinary coordination

Acute vs. Chronic Wound Comparison

Emerging & Specialized Modalities

Advanced wound management modalities increasingly intersect with OT practice. Negative pressure wound therapy (NPWT) uses subatmospheric pressure to promote granulation tissue formation and is commonly encountered in rehabilitation settings, requiring the OT to adapt functional training around the device. Electrical stimulation has evidence supporting its use in chronic wound healing, particularly for pressure injuries, and falls within the OT scope of practice in many states. Pulsed lavage with suction is a debridement modality that OTs may use for wound bed preparation. Understanding the indications, contraindications, and functional implications of these modalities is essential for advanced clinical practice and represents a natural extension of the foundational wound management principles covered in this lesson.

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NBCOT Exam Connection

For the NBCOT examination, expect questions that test your ability to identify the appropriate OT intervention based on wound characteristics (color, depth, exudate, stage) and the client's functional goals. You may also be asked to differentiate OT wound management scope from nursing or medical management, particularly regarding debridement, dressing selection, and modality use. State practice acts vary — the exam tests foundational principles applicable across settings.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

A client's wound bed is bright red and moist with visible granulation tissue. No signs of infection are present, and the wound edges show early epithelialization. Which phase of wound healing is this wound most likely in, and what is the primary OT consideration during this phase?

Show answer

The wound is in the proliferative phase, evidenced by the red granulating wound bed and epithelialization at the wound margins. During proliferation, the primary OT consideration is to protect the fragile new tissue while gradually engaging the client in functional activities. The OT should avoid shear and friction at the wound site, ensure appropriate pressure redistribution, and begin gentle active range of motion within pain-free limits. New granulation tissue and epithelial cells are delicate and can be disrupted by aggressive intervention.

Question 2: BASIC CALCULATION

An OT evaluates a client and assigns the following Braden Scale subscores: Sensory Perception = 2, Moisture = 3, Activity = 1, Mobility = 2, Nutrition = 2, Friction/Shear = 1. Calculate the total Braden Scale score and determine the client's risk level for pressure injury development.

Show answer

Total Braden Score = 2 + 3 + 1 + 2 + 2 + 1 = 11. According to Braden Scale risk categories, a score of 10–12 indicates high risk for pressure injury development. This client requires aggressive preventive interventions including a pressure-redistributing support surface, a turning/repositioning schedule (every 2 hours in bed), a wheelchair cushion evaluation, nutritional optimization, incontinence management if applicable, and education on skin inspection. The particularly low scores in Activity (1 = bedfast) and Friction/Shear (1 = problem) require immediate OT attention through mobility training and transfer technique education.

Question 3: INTERMEDIATE

An OT is treating a client with a Stage 2 pressure injury on the right ischial tuberosity that is 10 days old and in the proliferative phase. The client's primary goal is to return to independent wheelchair mobility for community participation. Using the TIME framework, outline how you would assess the wound and describe two specific OT interventions that address both wound management and the client's functional goal.

Show answer

Using the TIME framework: T: Assess wound bed tissue type — expect pink/red granulation tissue at day 10 in the proliferative phase. I: Evaluate for infection signs — increased pain, purulent drainage, periwoound erythema spreading. M: Assess exudate type and volume; ensure dressing is maintaining moist wound environment without maceration. E: Check wound edges for epithelialization or undermining. Two OT interventions: (1) Wheelchair seating and positioning evaluation — prescribe a pressure-redistributing cushion (e.g., air or gel-based) that offloads the right ischial tuberosity, and train the client in a weight-shift schedule (lateral or forward lean every 15–30 minutes). This simultaneously protects the healing wound and enables safe wheelchair use for community mobility. (2) Transfer training with technique modification — teach the client to perform a stand-pivot or sliding board transfer that minimizes shear forces on the ischial area, protecting the proliferating tissue while advancing functional independence.

Question 4: APPLIED

A 58-year-old carpenter with Type 2 diabetes presents to outpatient OT with a 3 cm × 2 cm × 0.5 cm neuropathic ulcer on the plantar surface of his right foot. The wound has been present for 45 days and has a yellow slough base with rolled wound edges. His goal is to return to work. Identify barriers to healing, determine what phase the wound is stalled in, and develop an OT intervention plan that addresses both wound management and return-to-work goals.

Show answer

This wound is chronic — it has been present for 45 days, exceeding the typical healing timeline. The yellow slough base and rolled wound edges indicate the wound is likely stalled in the inflammatory phase and has not effectively transitioned to proliferation. Barriers to healing include: (1) diabetes causing impaired cellular function, delayed angiogenesis, and reduced immune response; (2) peripheral neuropathy causing repetitive undetected pressure injury; (3) slough in the wound bed preventing granulation tissue formation; and (4) rolled wound edges suggesting the epithelial cells have migrated downward rather than across the wound. OT intervention plan: (1) Collaborate with the physician regarding need for debridement to remove slough and convert rolled edges. (2) Provide custom offloading orthotic or total contact cast referral to redistribute pressure away from the plantar ulcer during weight-bearing. (3) Conduct a work-site analysis of his carpentry duties, identifying activities requiring prolonged standing or pressure on the right foot, and develop activity modifications (seated workstation options, task rotation schedule, appropriate footwear). (4) Educate client on daily foot inspection using a mirror, glucose management, and signs of infection. (5) Establish measurable return-to-work criteria tied to wound healing milestones.

Question 5: CRITICAL THINKING

An OT working in an acute rehabilitation unit notices that three of her clients have developed new Stage 1 pressure injuries within the past week, all in the sacral area. One client has a spinal cord injury, one had a bilateral total knee replacement, and one had a stroke with left hemiplegia. Using your knowledge of wound management principles, skin integrity assessment, and the Braden Scale, analyze the systemic factors that may be contributing to this pattern. Propose a quality improvement intervention that the OT could implement at the unit level, and explain how this reflects the OT scope of practice in wound prevention.

Show answer

The cluster of three new Stage 1 sacral pressure injuries across different diagnoses suggests systemic unit-level factors rather than individual client variables alone. Common contributing factors across these three diagnoses include: (1) Immobility — all three clients have conditions that significantly limit independent mobility, increasing sustained sacral pressure in bed and wheelchair. (2) Potential gaps in repositioning protocols — nursing staff may be understaffed or the turning schedule may not be consistently implemented. (3) Inadequate support surfaces — standard hospital mattresses and wheelchair cushions may not provide sufficient pressure redistribution for high-risk clients. (4) Nutritional deficits common in the acute rehabilitation population. Quality improvement intervention: The OT could implement a standardized Braden Scale screening protocol at admission with automatic triggers for OT-driven interventions at each risk level — such as wheelchair seating evaluations for all clients scoring ≤ 14, pressure redistribution equipment recommendations, and a staff education program on proper positioning techniques during transfers and bed mobility. This reflects the OT scope of practice because occupational therapists are uniquely positioned to assess the interaction between a client's functional limitations, their environment (bed, wheelchair, bathroom), and skin integrity, and to implement population-level prevention strategies that integrate occupational performance with tissue protection.

SUMMARY

Lesson Summary — Wound Management Principles for OT Practice

Summary

Wound management in occupational therapy requires integrating knowledge of wound healing physiology with clinical reasoning about functional performance. Wounds progress through four overlapping phases — hemostasis, inflammation, proliferation, and remodeling — and the occupational therapist must match intervention intensity and type to the dominant phase. The Braden Scale provides a systematic framework for assessing pressure injury risk across six subscales, while the TIME framework (Tissue, Infection/Inflammation, Moisture, Edge) guides wound bed assessment and preparation. Wounds are classified using the NPIAP staging system for pressure injuries, and by etiology for arterial, venous, neuropathic, and surgical wounds.

OT-specific interventions include pressure redistribution, positioning, splinting, scar management, activity modification, and client education — all selected and graded based on the wound's healing status and the client's occupational goals. Chronic wounds, which are stalled in the inflammatory phase beyond 30 days, require additional clinical reasoning to identify and address systemic barriers such as diabetes, malnutrition, and vascular disease. Pressure injuries are never reverse-staged, and intervention planning must account for the fact that healed tissue reaches only 70–80% of its original tensile strength. For NBCOT preparation, focus on matching wound characteristics to healing phases, applying the Braden Scale and TIME framework to clinical scenarios, and articulating OT's unique role in wound prevention and management within the interdisciplinary team.