Our CEO, Kathleen Cesarin, introduces basic wound care for healthcare professionals during the Better Wellness PT Virtual Summit 2019.

1. www.aoservices.ca
WOUND CARE
BASICS FOR HEALTH CARE PROFESSIONALS
Presentation for Better Wellness PT-Virtual Summit 2019
By
Kathleen Cesarin
LPN, Orthopedic Technician, Foot Care & Wound Management Certified
CEO, Accelerated Cast Clinic & Limb Preservation Centre
Edmonton, Alberta, Canada
NO PART OF THIS PUBLICATION MAY REPRODUCED, IN PART OR IN WHOLE, OR SHARED
ONLINE, WITHOUT PERMISSION OF ACCELERATED ORTHOPEDIC SERVICES & MEDICAL
SUPPLY. ALL RIGHTS RESERVED

2. What education should be provided to patients to care for
their post-op wound at home?
Firstly, prior to discharge, while in hospital patients should be given instruction on how to care for
their wound at home, verbally and WRITTEN, as patients normally absorb only a small amount of
information due to pain, fatigue, fear or other reasons.
For common post-op wounds the following information is recommended:
• Keep the wound dry for the first 24 to 48 hours. After this, showering and pat dry with new, clean
towel. NO BATHS until 24 hours after stitches/staples are removed. Some surgeons place dressings
meant to last 7-10 days until first post-op follow up.
• If they have stitches, do not remove. They are normally left for 7-14 days depending on the surgery.
• If they have Steri-Strips, leave them on until they fall off.
• If possible, prop up the injured area on a pillow anytime they sit or lie down during the first 3 days.
Try to keep it above the level of the heart. This will help reduce swelling and prevalence of
dehiscence.
• Inform the patient about signs & symptoms of infection and who to speak to if the wound is
infected.
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3. When working with post-op patients
we expect pain and swelling.
How do we know things are not progressing normally?
All surgical wounds will be painful, red and may have small amounts of blood or serous drainage in the first 7-10
days.
Direct your patient to see their physician or provide immediate medical care if you observe the following signs &
symptoms:
• New pain, or the pain gets worse.
• A stitch/staple falls out leaving an open area.
• The skin near the wound is cold or pale or changes colour.
• Tingling, weakness, or numbness near the wound.
• The wound starts to bleed, and blood soaks through the bandage.
• Oozing small amounts of blood is normal.
• Symptoms of infection, such as:
• Increased pain, swelling, warmth, or redness.
• Red streaks leading from the wound.
• Pus or foul smelling exudate draining from the wound.
• A fever.
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4. Offloading is a typical recommendation after a surgical procedure, ex: NWB or WBAT.
What affect does that limited weight bearing have on the skin healing and function besides
stabilization of a fracture or joint replacement?
Off-Loading after a surgical procedure provides the following important benefits:
• Key Principle: Pressure is the “enemy” of wound healing. (Not to be confused with intentional compression. Ex:
Coban wraps for venous leg ulcers or Total Contact Casting for diabetic foot ulcers)
• After a surgical procedure, swelling, which causes pressure and pain, is expected.
• To minimize swelling and pressure, off-loading and elevation are always recommended if possible, especially in the
first 3 days.
• Use of anti-inflammatories, such as Ibuprofen are helpful for pain and inflammation. (These may be contraindicated
if the patient has hypertension)
• Ex: Many patients require off-loading for lower leg injuries to stabilize for 4-6 weeks on average. If provided
innovative, practical mobility aids such as knee scooters or the Iwalk Hands Free Crutch they will be more likely to
consistently off-load and be more active. (Rather than traditional crutches which are cumbersome, painful and don’t
allow them to be “hands-free” so they can continue to work or care for family needs.)
• Increased mobility will also decrease muscle atrophy and improve circulation in the healthy parts of the body, allow
the patient to feel more productive and overall speed up recovery.
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5. Comorbidities like poor circulation and diabetes can play a major factor in
healing and delayed healing outcomes.
What other factors can affect wound healing?
Diabetes and poor circulation are definitely factors which effect wound healing. Other factors which
can predictably impair wound healing are:
• Patient or Family History of prior wounds or poor healing
• HIV/Acquired Immunodeficiency Syndrome
• Rheumatoid Disease
• Malnutrition: Weight Loss or Obesity
• Hypoxic conditions: COPD, Anemia
• Ischemic Disease: PAD, CHF, Shock, Dehydrations
• Heath habits: Drug use/abuse, Smoking
• Drugs that impair healing: Corticosteroids, Anti-inflammatories, Chemotherapeutic
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6. If the wound is not healing in a typical timeframe (within 7-10 days), when are
advanced dressings/modalities recommended?
If the patient has been properly and consistently off-loaded, the wound has been
cared for per standard protocols, but still isn’t healing, the wound may need a
topical antimicrobial or antibiotic. Firstly, some important distinctions and
definitions must be understood.
CRITICAL COLONIZATION: Replicating microorganisms present on the wound and
attached to the cells and structures in the wound. Level of bacteria inhibits wound healing.
No systemic signs of infection are present. Topical antimicrobials are indicated.
INFECTION: Microrganisms invade tissue and yield a systemic response. Cultures are
obtained to direct antibiotic selection. Signs and symptoms of infection are present.
NERDS acronym is helpful to assess these type of wounds. (Sibbald et al)
BIOFILM: Complex community of aggregated bacteria embedded in a self-secreted
extracellular polysaccharide matrix. Highly resistant to and poorly penetrated by
antimicrobials. Can be removed by debridement and prevented by antimicrobials. Biofilms
are more pervasive in chronic wounds versus surgical wounds.
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Wound with Biofilm

7. N.E.R.D.S : CRITICAL COLONIZATION
In an effort to help clinicians identify wounds which are critically colonized, Sibbald et al (2006)
offered this acronym:
N – Non-healing. Wounds which are not 30% healed (with documented photos/measurements) within one month.
E- Exudate increased. (Usually with greater than 50% of the dressing stained with exudate)
R – Red and bleeding wound. Wound bed bright red with exuberant granulation tissue. Bleeds easily with
manipulation.
D – Debris. Wound bed discolored with slough (thick, yellow), necrotic (brown/black) or non-viable tissue.
S – Smell. Unpleasant or sweetened odor AFTER wound has been cleansed.
Presence of 3 or more of the NERD signs is considered diagnostic of critical colonization. When critical colonization is identified,
topical antimicrobials and anti-inflammatory dressings are recommended.
Some authors recommend topical antibiotics, however, if a topical antibiotic is used, is should target a specific organism and its
effect on that organism monitored to document effectiveness (Gotrrrup et al, 2013)
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8. S.T.O.N.E.E.S : DEEP TISSUE INFECTION
In an effort to help clinicians identify wounds which are INFECTED, Woo & Sibbald et al validated
this acronym in 2009:
S – Size. Wound size is increasing. (Consistent, accurate, documented measurements)
T- Temperature increased. Increased peri-wound temperature >3 degrees Fahrenheit.
O – Os. (Exposed bone or probes to bone)
N – New area of breakdown. Or satellite lesions.
E – Erythema/Edema. Reddening or swelling in the peri-wound skin.
E – Exudate. Increased amount of drainage.
S – Smell. Unpleasant or sweet, sickening odor (after wound is cleansed)
Wound infection occurs when microorganisms on the wound surface penetrate the wound tissues or bone. A local or
systemic response is indicative of an infection. Infection develops when wound bioburden is significant enough to
overwhelm the body’s defenses. A quantitative bacterial count of >103 in the wound is the gold standard for
diagnosing a wound infection (Leaper et al, 2012; Robson and Heggers, 1969)
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9. D.I.M.E : Wound Management
The healing of acute wounds follows a fairly predictable
sequence of overlapping stages: Inflammation, Proliferation,
Re-epithelialization and Remodeling.
• Unlike acute wounds, however, chronic wounds such as pressure
ulcers, venous leg ulcers and diabetic foot ulcers do not always
follow this predictable pattern because of disruption to 1 or more
elements of the healing process.
• The treatment of chronic wounds requires a systematic approach
under the fundamentals of wound bed preparation (preparation
and optimization of the wound bed for functional healing).
• Within this framework, it is important to treat the cause and
address patient-centered concerns before addressing local wound
care.
• Local wound management consists of the mnemonic DIME
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Debridement
Infection/Inflammation
(reduction of bacterial bioburden) or
abnormal prolonged inflammation
Moisture balance
Moist wound healing is optimal.
( Not too wet/Not too dry)
Edge effect of the stalled
chronic wound.
https://www.woundscanada.ca/docman/public/wound-care-canada-
magazine/2012-vol-10-no-4/487-wcc-autumn-2012-v10n4-wound-care-mgmt/file

10. How important is debridement?
Debridement is integral to wound bed preparation by removing devitalized
tissue, foreign material, phenotypically abnormal or dysfunctional cells (cellular
burden) and bacteria sequestrum.
• Providing the wound has the potential to progress toward healing,
debridement has been demonstrated to stimulate the healing cascade,
advancing wounds that are trapped in the inflammatory phase through to the
granulation phase and then on to epithelialization and healing.
• Optimizing the debridement process will promote effective and rapid healing
of chronic wounds and can affect the cost of treatment.
www.aoservices.ca
https://www.woundscanada.ca/docman/public/wound-care-canada-
magazine/2012-vol-10-no-4/487-wcc-autumn-2012-v10n4-wound-care-mgmt/file

11. Methods of Debridement
Debridement of necrotic tissues in chronic wounds can be achieved with a number of methods:
• Surgical- Conservative sharp (forceps, curette to pick or scrape off necrotic tissue)
• Surgical - Sharp (scalpel cut away of non-viable tissue)
• Autolytic (patient’s endogenous collagenase)
• Biologic (maggots)
• Mechanical (wet-to-dry dressings, other devices)
• Enzymatic (collagenase)
Methods of debridement can be deployed as a single therapeutic modality or serially combined
to optimize the debridement process.
www.aoservices.ca
https://www.woundscanada.ca/docman/public/wound-care-canada-
magazine/2012-vol-10-no-4/487-wcc-autumn-2012-v10n4-wound-care-mgmt/file

12. Choosing a Method of Debridement
Different inherent conditions and nature of each patient’s wound will require individualization of therapy.
A variety of factors should be considered when choosing a debridement method or a combination of
treatment modalities in order to achieve optimal clinical outcomes.
• The patient’s condition
• Goals of care
• Ulcer/peri-ulcer status
• Type of wound
• Quantity and location of necrotic tissue
• Presence of infection
• The healthcare setting
*Professional accessibility or capability. Advanced education/certification in Wound Management
required for ALL types of debridement.
www.aoservices.ca
https://www.woundscanada.ca/docman/public/wound-care-canada-
magazine/2012-vol-10-no-4/487-wcc-autumn-2012-v10n4-wound-care-mgmt/file

13. TOPICAL ANTIMICROBIALS
Topical antimicrobial agents are chemical substances that, directly applied to the skin, inhibit the
growth or destroy any microorganism, either fungi, viruses or bacteria. Within this term, we generally
refer to those that are active against BACTERIA. They are divided into antiseptics and antibiotics.
ANTISEPTICS
• Antiseptics are directly applied to a living organism to eradicate the existing microorganism on the
mucocutaneous surfaces, preventing their proliferation.
• Due to the limited function of antiseptics, they are usually used topically to prevent more bacteria and other
microorganisms from entering open wounds, but some oral antiseptics do exist.
ANTIBIOTICS
• Antibiotics, are responsible for killing bacteria as well as some types of fungi and parasites.
• Antibiotics are primarily taken orally, usually in the form of penicillin, to kill off infection inside the body. There
are few antibiotics that may be taken topically, and as with oral antibiotics, they usually require a prescription.
Another important difference to note between antiseptics and antibiotics is that
bacteria are likely to develop immunity to certain antibiotics after an extended use.
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14. COMMON ANTIMICROBIAL DRESSINGS
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https://www.woundsinternational.com/download/resource/6086

15. RESOURCES FOR PRODUCT SELECTION
Product selection can be overwhelming with a multitude of dressing types available.
Here are some helpful resources to assist you:
Wound Dressing Formulary:
https://www.woundscanada.ca/docman/public/health-care-professional/1113-product-picker-
2017-formulary/file
Wound Dressing Selection Guide:
https://www.woundscanada.ca/docman/public/health-care-professional/1114-product-picker-
2017-selection-guide-1/file
Product Picker Skin & Wound Clean Up:
https://www.woundscanada.ca/dhfy-doc-man/public/health-care-professional/1307-product-
picker-skin-and-wound-clean-ip/file
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https://www.woundsinternational.com/download/resource/6086

16. Stay in touch with us to learn more!
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