Fundamentals of Wound Healing & Management
Target Audience: Nurses, RPNs, Health Professionals
Duration: 8:30 AM – 4:30 PM
Goal: To increase competency in wound identification, assessment, and management through theory and practical application
Start
Land Acknowledgment
The City of Oshawa is situated on lands within the traditional and treaty territory of the Michi Saagiig and Chippewa Anishinaabeg and the signatories of the Williams Treaties, which include the Mississaugas of Scugog Island, Hiawatha, Curve Lake, and Alderville First Nations, and the Chippewas of Georgina Island, Rama and Beausoleil First Nations.
We are grateful for the Anishinaabeg who have cared for the land and waters within this territory since time immemorial
We recognize that Oshawa is steeped in rich Indigenous history and is now present day home to many First Nations, Inuit and Métis people.
Schedule
Modules 1-3
LUNCH
Modules 4-6
Activities
Assessment
Certificate
Feedback
Course-Learning Outcomes
By the end of this course, learners will be able to:
Knowledge and Understanding:
Clinical Assessment and Decision Making:
Intervention and Management:
Hands On Skills and Application:
Modules
Session 1: Introduction to Wound Care (8:30 AM – 9:15 AM)
Session 4: Dressing Selection & Wound Care Interventions (12:45 PM –2:15 PM)
Session 2: Types of Wounds & Etiologies (9:15 AM – 10:30 AM)
Session 5: Hands-On Skills Lab (2:30 PM – 4:00 PM)
Session 3: Wound Assessment Skills (10:45 AM – 12:00 PM)
Session 6: Wrap-Up & Evaluation (4:00 PM – 4:30 PM)
Session 1: Introduction to Wound Care
Welcome
Introduction
Definitions and Terms
Session 2: Types of Wounds & Etiologies
Acute vs Chronic Wounds
more Info
more Info
Wound Classifications
more Info
Visual Case Review
Assessment
1/5
Assessment
2/5
Assessment
3/5
Assessment
4/5
Assessment
5/5
Break (10:30 AM – 10:45 AM)
Session 3: Wound Assessment Skills
Time
Infection
Moisture
Edges
Measuring wound size and depth
Pain assessment
Assessment T.I.M.E.
Purulent drainage, spreading/systemic infection signs, strong odour, fever, or increased pain.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Too much causes maceration; too little dries the wound. Moisture supports cleansing and epithelialisation.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Edges appear pink and healthy—indicating healing.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Granulation: red, moist, bumpy; indicates healing.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Title
Title
Title
Title
Write a brief description here
Write a brief description here
Write a brief description here
Write a brief description here
Describe one tissue type you would expect to see in a healing wound and what it looks like.
Give one example of a wound infection indicator that requires escalation.
Describe what “advancing edges” look like.
Explain why moisture balance matters in wound healing.
LUNCH (12 PM – 12:45 PM)
Session 4: Dressing Selction and Wound Care Management
Dressing Selection
Primary Dressings:
Dressings that have direct contact with the wound and have the ability to change the wound (e.g. moisture donation/ retention, debridement and decreasing bacterial load)
Secondary dressings:
Dressings that cover/ compliment primary dressings and support the surrounding skin.
Management
Healing
Effective wound management requires a collaborative approach between the nursing team and treating medical team. Referrals to the Stomal Therapy, Plastic Surgery, Specialist Clinics or Allied Health teams (via an EMR referral order) may also be necessary for appropriate management and dressing selection, to optimise wound healing.
Frequency
Procedure
Technical Skills Sterile Wound Dressing Change Video
The video titled “Sterile Wound Dressing Change - Clinical Nursing Skills | @LevelUpRN” provides a thorough, step-by-step demonstration of how to perform a sterile dressing change on a wound. It walks the viewer through preparing the sterile field, donning gloves, removing the old dressing, assessing the wound, cleaning and irrigating the wound, applying the new dressing, and safely disposing of materials. The instructor emphasizes critical practices like maintaining sterility, preventing infection, and documenting findings,making it a useful refresher for practicing nurses or a solid instructional resource for nursing students.
Activity - Quick Check Cards
Quick Cards - Pair up
Instructions
Spice up the boring content in your presentation: make it engaging
Feedback
Session 5: Hands-on Skills Practice
Apply today’s learning through collaborative, lab-based skill applicaton
Teach, Try, Troubleshoot
Choose Your Challenge
Skill: Peer CoachingRotate through roles: Teacher, Practitioner, Coach. Demonstrate, perform, and give feedback on a wound-care skill. Focus on clear steps, rationale, and accuracy.
What Would You Do?
Skill: Self-Directed Practice Select a wound-care skill you want to strengthen. Rotate to the equipment station and practice at your own pace. Note one improvement and one area for feedback.
Skill: Experience-to-ActionReview a brief wound-care scenario with your group. Assess the wound using available equipment. Decide on priorities and justify your actions using past experience.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Title
Title
Title
Write a brief description here
Write a brief description here
Write a brief description here
Session 6: Recap-Learning Outcomes
This is the end of this course, learners are able to:
Knowledge and Understanding:
Clinical Assessment and Decision Making:
Intervention and Management:
Hands On Skills and Application:
Feedback
Thank you for your time and attention.
Your input helps me improve future sessions and better support health care professionals like you.
Link
Thank you for taking the course!
Achievement Certificate
Awarded in recognition of successful completion of specialized training in wound care nursing.
Presented by the Canadian Phlebotomy Technician Group Inc. In collaboration with healthcare education partners.
Congratulations!
Signature
December, 2025
Edges
Advancing of edges can be assessed by measuring the depth (cavity/sinus), length and width of the wound using a paper tape measure.
Advancing: edges are pink. Healing is taking place.
Not advancing: edges are raised, rolled, red or dusky. Go back to stages of wound healing and goals of wound management and consider factors affecting wound healing (see below). Is there something that is not being addressed?
Surrounding skin
Assess the surrounding skin (peri wound) for the following:
Cellulitis: redness, swelling, pain or infection
Oedema: swelling
Macerated: soft, broken skin caused by increased moisture
Knowledge and Understanding
Explain the physiological phases of wound healing (hemostasis, inflammation, proliferation, and maturation) and their clinical relevance.
WOUND CLASSIFICATION
Acute wound: a wound which occurs suddenly and progresses through the stages of healing as expected. Chronic wound: a wound which fails to progress or progresses slowly through the stages of healing. Healing can be greater than 4-6 weeks.
Surgical wound: a wound which is secondary to surgical intervention e.g. scalpel incision, surgical drain. Non-surgical wound: an acute or chronic wound which is not secondary to surgical intervention.
Instructions -
With your partner - Each explains their assigned phase in one minute, covering: What happens in the phase A key sign you would observe The goal of wound management
Introduction
A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection. The skin is the body’s largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. Poorly managed wounds are one of the leading causes of increased morbidity and extended hospital stays. Therefore, wound assessment and management is fundamental to providing quality nursing care. Aim
The guideline aims to provide information to assess and manage a wound in paediatric patients. Ongoing multidisciplinary assessment, clinical decision-making, intervention, and documentation must occur to facilitate optimal wound healing.
Intervention and Management
Select appropriate dressing types based on wound etiology, exudate level, and healing goals.
Wound Assessment
TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement.
Tissue
Tissue is usually described by colour.
Epithelial tissue: Appears pink or pearly white and wrinkles when touched. Occurs in the final stage of healing when the wound is covered by healthy epithelium.
Granulating tissue: Appears red and moist. Occurs when healthy tissue is formed in the remodelling phase that is well vascularised and bleeds easily.
Slough tissue: Appears yellow, brown or grey. Slough is devitalised tissue made of dead cells or debris.
Necrotic tissue: Appears hard, dry and black. Necrotic tissue is dead tissue that prevents wound healing.
Hyper granulating tissue: Appears red, uneven or granular. Occurs in the proliferative phase when tissue is over grown.
WELCOME!
Welcome to the wound healing and management course, and thank you for joining us. This session is designed to support you in building confidence and skill in caring for patients with a wide range of wounds. Throughout the course, we will explore practical techniques, real-world scenarios, and evidence-informed practices that can strengthen your clinical judgment and enhance patient outcomes. We are glad you’re here and look forward to learning together in a supportive and engaging environment.
Feedback -
Partners give quick feedback using a 3-point checklist: Was the explanation accurate? Was the clinical goal correctly identified? Was the description concise and clear?
Learners will each get a card indicating: Haemostasis Inflammation Proliferation Remodelling
Methods of Measurement
The most commonly used wound measurements are length (L), width (W), and depth (D). Multiply L x W and you have the surface area (SA), multiply L x W x D and you have the volume of a wound, but only if the wound is the same depth in its entirety. Trace the wound with an indelible marker on an acetate sheet or transparent film, and you have the circumference. The wound measurement at the initial assessment is critical to calculate any change in wound size over time. Wound dimensions should become smaller as the wound heals with growth of granulation tissue and new blood vessels, reduction in tissue edema and migration of new epithelium from the edges.
Pain
Pain is an essential indicator of poor wound healing and should not be underestimated. Pain can occur from the disease process, surgery, trauma, infection or as a result of dressing changes and poor wound management practices.
Assessing pain before, during, and after the dressing change may provide vital information for further wound management and dressing selection. Accurate assessment of pain is essential when selecting dressings to prevent unnecessary pain, fear and anxiety associated with dressing changes. Prepare patients for dressing changes, using pharmacological and non-pharmacological techniques
Hands On Skills
Perform wound measurement, documentation, and dressing techniques using simulation stations.
Moisture/Exudate
Moisture/ exudate is an essential part of the healing process. It is produced by all wounds to:
Maintain a moist environment
Cleanse the wound
Provide nutrients and white blood cells
Promote epithelialisation
Exudate description:
Serous: appears clear to yellow. Normal, typical in the inflammatory phase. Serous drainage is clear, thin, and watery.
Haemoserous: appears clear to yellow with a pink tinge. Typical in the inflammatory or proliferative phase.
Sanguineous: common exudate blood. Can be associated with hyper granulation.
Purulent: containing pus milky, typically thicker in consistency, grey, green or yellow. This indicates infection.
Haemopurulent: blood and pus. Often due to an established infection.
Knowledge and Understanding
Explain the physiological phases of wound healing (hemostasis, inflammation, proliferation, and maturation) and their clinical relevance.
Key Components of a Visual Case Review
A thorough visual review incorporates the following elements at every assessment or dressing change:
Anatomical Location: Precisely document the wound's location using correct anatomical terms and diagrams/images to ensure consistency among clinicians.
Wound Type and Etiology: Identify the cause (e.g., pressure injury, surgical wound, diabetic ulcer) as the treatment plan often depends on the wound type.
Wound Size (Measurements): Measure length, width, and depth in centimeters. For consistency, the length is typically measured from head-to-toe axis and width side-to-side, with depth measured using a sterile cotton-tipped applicator to the deepest point.
Wound Bed Tissue Type: Describe the types and percentages of tissue present:
Granulation tissue: Beefy red/pink, moist, bumpy tissue indicating healing.
Slough: Yellow/white, soft, non-viable tissue.
Eschar: Black/charred, hard, leathery necrotic tissue.
Epithelial tissue: New pink/white tissue forming at the edges or on the wound bed.
Exudate (Drainage): Assess and document the color, consistency, and amount (scant, minimal, moderate, copious). Purulent (pus-like) drainage often indicates infection and should be reported.
Wound Edges and Periwound Skin: Examine the surrounding skin (periwound area) for signs of maceration (soft, waterlogged appearance), erythema (redness), edema (swelling), or induration (hardening). Assess wound edges (e.g., rolled, defined, attached).
Undermining and Tunneling: Gently probe with a cotton-tipped applicator to check for tissue destruction under intact skin or narrow passageways extending from the wound base. Document their location using the clock-face analogy (12:00 pointing towards the patient's head) and measure the depth.
Signs of Infection and Pain: Monitor for increased pain, odor, warmth, swelling, or purulent drainage. Assess the patient's pain level using a standardized scale.
Intervention and Management
Select appropriate dressing types based on wound etiology, exudate level, and healing goals.
Clinical Assessment and Decision Making
Demonstrate competency in wound assessment, including describing the wound bed, measuring size/depth, evaluating drainage, and identifying periwound concerns.
Hands On Skills
Perform wound measurement, documentation, and dressing techniques using simulation stations.
Infection/Inflammation
Inflammation is an essential part of wound healing; however, infection causes tissue damage and impedes wound healing.
Contamination: The presence of microorganisms that are contained and do not multiply. It does not provoke a host response so healing is not impaired. Antimicrobials are not indicated.
Colonisation: Microorganisms multiply but do not provoke a host response. The infection is contained but wound healing may be delayed. Antimicrobials are not indicated.
Local infection: Invasion by an agent that, under favourable conditions, multiplies and produces effects that are injurious to the patient. When microorganisms and bacteria move into the wound tissue and invokes a host response. Healing is impaired and can lead to wound breakdown. Topical antimicrobials are indicated.
Spreading and systemic infection: Microorganisms spread from the wound through the vascular and or lymphatic systems and involves either a part of the body (spreading) or the whole body (systemic). Healing is impaired. A systemic approach is needed e.g. topical antimicrobials and the use of antibiotics to prevent sepsis.
Biofilms: represent a survival mechanism of microorganisms and are therefore ubiquitous in nature. They are complex, slime-encased communities of microbes which are often seen as slime layers on objects in water or at water-air interfaces. The degree of bioburden in the wound from the microorganisms is indicated by a poor response to antimicrobial or antibiotic treatment, delayed wound healing or increase in exudate or inflammation.
Odour
ODOUR can be a sign of infection. It can be described as:
No odour
Slight malodour: odour when the dressing is removed
Moderate malodour: odour upon entering the room when the dressing is removed
Strong malodour: odour upon entering the room when dressing is intact
Definitions
PHYSIOLOGY OF WOUND HEALING
Wound healing occurs in four stages, haemostasis, inflammation, proliferation and remodelling, and the appearance of the wound will change as the wound heals. The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly.
Haemostasis(occurs within the first few seconds): blood vessels constrict to stop bleeding and form blood clots
The goal of wound management: to stop bleeding
Inflammation(0-4 days): neutrophils and macrophages work to remove debris and prevent infection. Signs and symptoms include redness and swelling.
The goal of wound management: to clean debris and prevent infection
Proliferation(2-24 days): the wound is rebuilt with connective tissue to promote granulation and repair the wound
The goal of wound management: to promote tissue growth and protect the wound
Remodelling(24 days- 1 year): epithelial tissue forms in a moist healing environment
The goal of wound management: to protect new epithelial tissue
Acute and Chronic Wounds
Acute wound: a wound which occurs suddenly and progresses through the stages of healing as expected.
Chronic wound: a wound which fails to progress or progresses slowly through the stages of healing. Healing can be greater than 4-6 weeks.
Clinical Assessment and Decision Making
Demonstrate competency in wound assessment, including describing the wound bed, measuring size/depth, evaluating drainage, and identifying periwound concerns.
Fundamentals of Wound Healing & Management
Shay-marie Chinambu
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Transcript
Fundamentals of Wound Healing & Management
Target Audience: Nurses, RPNs, Health Professionals Duration: 8:30 AM – 4:30 PM Goal: To increase competency in wound identification, assessment, and management through theory and practical application
Start
Land Acknowledgment
The City of Oshawa is situated on lands within the traditional and treaty territory of the Michi Saagiig and Chippewa Anishinaabeg and the signatories of the Williams Treaties, which include the Mississaugas of Scugog Island, Hiawatha, Curve Lake, and Alderville First Nations, and the Chippewas of Georgina Island, Rama and Beausoleil First Nations. We are grateful for the Anishinaabeg who have cared for the land and waters within this territory since time immemorial We recognize that Oshawa is steeped in rich Indigenous history and is now present day home to many First Nations, Inuit and Métis people.
Schedule
Modules 1-3
LUNCH
Modules 4-6
Activities
Assessment
Certificate
Feedback
Course-Learning Outcomes
By the end of this course, learners will be able to:
Knowledge and Understanding:
Clinical Assessment and Decision Making:
Intervention and Management:
Hands On Skills and Application:
Modules
Session 1: Introduction to Wound Care (8:30 AM – 9:15 AM)
Session 4: Dressing Selection & Wound Care Interventions (12:45 PM –2:15 PM)
Session 2: Types of Wounds & Etiologies (9:15 AM – 10:30 AM)
Session 5: Hands-On Skills Lab (2:30 PM – 4:00 PM)
Session 3: Wound Assessment Skills (10:45 AM – 12:00 PM)
Session 6: Wrap-Up & Evaluation (4:00 PM – 4:30 PM)
Session 1: Introduction to Wound Care
Welcome
Introduction
Definitions and Terms
Session 2: Types of Wounds & Etiologies
Acute vs Chronic Wounds
more Info
more Info
Wound Classifications
more Info
Visual Case Review
Assessment
1/5
Assessment
2/5
Assessment
3/5
Assessment
4/5
Assessment
5/5
Break (10:30 AM – 10:45 AM)
Session 3: Wound Assessment Skills
Time
Infection
Moisture
Edges
Measuring wound size and depth
Pain assessment
Assessment T.I.M.E.
Purulent drainage, spreading/systemic infection signs, strong odour, fever, or increased pain.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Too much causes maceration; too little dries the wound. Moisture supports cleansing and epithelialisation.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Edges appear pink and healthy—indicating healing.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Granulation: red, moist, bumpy; indicates healing.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Title
Title
Title
Title
Write a brief description here
Write a brief description here
Write a brief description here
Write a brief description here
Describe one tissue type you would expect to see in a healing wound and what it looks like.
Give one example of a wound infection indicator that requires escalation.
Describe what “advancing edges” look like.
Explain why moisture balance matters in wound healing.
LUNCH (12 PM – 12:45 PM)
Session 4: Dressing Selction and Wound Care Management
Dressing Selection
Primary Dressings: Dressings that have direct contact with the wound and have the ability to change the wound (e.g. moisture donation/ retention, debridement and decreasing bacterial load)
Secondary dressings: Dressings that cover/ compliment primary dressings and support the surrounding skin.
Management
Healing
Effective wound management requires a collaborative approach between the nursing team and treating medical team. Referrals to the Stomal Therapy, Plastic Surgery, Specialist Clinics or Allied Health teams (via an EMR referral order) may also be necessary for appropriate management and dressing selection, to optimise wound healing.
Frequency
Procedure
Technical Skills Sterile Wound Dressing Change Video
The video titled “Sterile Wound Dressing Change - Clinical Nursing Skills | @LevelUpRN” provides a thorough, step-by-step demonstration of how to perform a sterile dressing change on a wound. It walks the viewer through preparing the sterile field, donning gloves, removing the old dressing, assessing the wound, cleaning and irrigating the wound, applying the new dressing, and safely disposing of materials. The instructor emphasizes critical practices like maintaining sterility, preventing infection, and documenting findings,making it a useful refresher for practicing nurses or a solid instructional resource for nursing students.
Activity - Quick Check Cards
Quick Cards - Pair up
Instructions
Spice up the boring content in your presentation: make it engaging
Feedback
Session 5: Hands-on Skills Practice
Apply today’s learning through collaborative, lab-based skill applicaton
Teach, Try, Troubleshoot
Choose Your Challenge
Skill: Peer CoachingRotate through roles: Teacher, Practitioner, Coach. Demonstrate, perform, and give feedback on a wound-care skill. Focus on clear steps, rationale, and accuracy.
What Would You Do?
Skill: Self-Directed Practice Select a wound-care skill you want to strengthen. Rotate to the equipment station and practice at your own pace. Note one improvement and one area for feedback.
Skill: Experience-to-ActionReview a brief wound-care scenario with your group. Assess the wound using available equipment. Decide on priorities and justify your actions using past experience.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.
Title
Title
Title
Write a brief description here
Write a brief description here
Write a brief description here
Session 6: Recap-Learning Outcomes
This is the end of this course, learners are able to:
Knowledge and Understanding:
Clinical Assessment and Decision Making:
Intervention and Management:
Hands On Skills and Application:
Feedback
Thank you for your time and attention.
Your input helps me improve future sessions and better support health care professionals like you.
Link
Thank you for taking the course!
Achievement Certificate
Awarded in recognition of successful completion of specialized training in wound care nursing.
Presented by the Canadian Phlebotomy Technician Group Inc. In collaboration with healthcare education partners.
Congratulations!
Signature
December, 2025
Edges
Advancing of edges can be assessed by measuring the depth (cavity/sinus), length and width of the wound using a paper tape measure. Advancing: edges are pink. Healing is taking place. Not advancing: edges are raised, rolled, red or dusky. Go back to stages of wound healing and goals of wound management and consider factors affecting wound healing (see below). Is there something that is not being addressed?
Surrounding skin Assess the surrounding skin (peri wound) for the following: Cellulitis: redness, swelling, pain or infection Oedema: swelling Macerated: soft, broken skin caused by increased moisture
Knowledge and Understanding
Explain the physiological phases of wound healing (hemostasis, inflammation, proliferation, and maturation) and their clinical relevance.
WOUND CLASSIFICATION
Acute wound: a wound which occurs suddenly and progresses through the stages of healing as expected. Chronic wound: a wound which fails to progress or progresses slowly through the stages of healing. Healing can be greater than 4-6 weeks. Surgical wound: a wound which is secondary to surgical intervention e.g. scalpel incision, surgical drain. Non-surgical wound: an acute or chronic wound which is not secondary to surgical intervention.
Instructions -
With your partner - Each explains their assigned phase in one minute, covering: What happens in the phase A key sign you would observe The goal of wound management
Introduction A wound is a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection. The skin is the body’s largest organ and is responsible for protection, sensation, thermoregulation, metabolism, excretion and cosmetic. Poorly managed wounds are one of the leading causes of increased morbidity and extended hospital stays. Therefore, wound assessment and management is fundamental to providing quality nursing care. Aim The guideline aims to provide information to assess and manage a wound in paediatric patients. Ongoing multidisciplinary assessment, clinical decision-making, intervention, and documentation must occur to facilitate optimal wound healing.
Intervention and Management
Select appropriate dressing types based on wound etiology, exudate level, and healing goals.
Wound Assessment
TIME is a valuable acronym or clinical decision tool to provide systematic assessment and documentation of wounds. It stands for Tissue, Infection or Inflammation, Moisture balance and Edges of the wound or Epithelial advancement.
Tissue Tissue is usually described by colour. Epithelial tissue: Appears pink or pearly white and wrinkles when touched. Occurs in the final stage of healing when the wound is covered by healthy epithelium. Granulating tissue: Appears red and moist. Occurs when healthy tissue is formed in the remodelling phase that is well vascularised and bleeds easily. Slough tissue: Appears yellow, brown or grey. Slough is devitalised tissue made of dead cells or debris. Necrotic tissue: Appears hard, dry and black. Necrotic tissue is dead tissue that prevents wound healing. Hyper granulating tissue: Appears red, uneven or granular. Occurs in the proliferative phase when tissue is over grown.
WELCOME!
Welcome to the wound healing and management course, and thank you for joining us. This session is designed to support you in building confidence and skill in caring for patients with a wide range of wounds. Throughout the course, we will explore practical techniques, real-world scenarios, and evidence-informed practices that can strengthen your clinical judgment and enhance patient outcomes. We are glad you’re here and look forward to learning together in a supportive and engaging environment.
Feedback -
Partners give quick feedback using a 3-point checklist: Was the explanation accurate? Was the clinical goal correctly identified? Was the description concise and clear?
Learners will each get a card indicating: Haemostasis Inflammation Proliferation Remodelling
Methods of Measurement
The most commonly used wound measurements are length (L), width (W), and depth (D). Multiply L x W and you have the surface area (SA), multiply L x W x D and you have the volume of a wound, but only if the wound is the same depth in its entirety. Trace the wound with an indelible marker on an acetate sheet or transparent film, and you have the circumference. The wound measurement at the initial assessment is critical to calculate any change in wound size over time. Wound dimensions should become smaller as the wound heals with growth of granulation tissue and new blood vessels, reduction in tissue edema and migration of new epithelium from the edges.
Pain
Pain is an essential indicator of poor wound healing and should not be underestimated. Pain can occur from the disease process, surgery, trauma, infection or as a result of dressing changes and poor wound management practices. Assessing pain before, during, and after the dressing change may provide vital information for further wound management and dressing selection. Accurate assessment of pain is essential when selecting dressings to prevent unnecessary pain, fear and anxiety associated with dressing changes. Prepare patients for dressing changes, using pharmacological and non-pharmacological techniques
Hands On Skills
Perform wound measurement, documentation, and dressing techniques using simulation stations.
Moisture/Exudate
Moisture/ exudate is an essential part of the healing process. It is produced by all wounds to: Maintain a moist environment Cleanse the wound Provide nutrients and white blood cells Promote epithelialisation
Exudate description: Serous: appears clear to yellow. Normal, typical in the inflammatory phase. Serous drainage is clear, thin, and watery. Haemoserous: appears clear to yellow with a pink tinge. Typical in the inflammatory or proliferative phase. Sanguineous: common exudate blood. Can be associated with hyper granulation. Purulent: containing pus milky, typically thicker in consistency, grey, green or yellow. This indicates infection. Haemopurulent: blood and pus. Often due to an established infection.
Knowledge and Understanding
Explain the physiological phases of wound healing (hemostasis, inflammation, proliferation, and maturation) and their clinical relevance.
Key Components of a Visual Case Review
A thorough visual review incorporates the following elements at every assessment or dressing change: Anatomical Location: Precisely document the wound's location using correct anatomical terms and diagrams/images to ensure consistency among clinicians. Wound Type and Etiology: Identify the cause (e.g., pressure injury, surgical wound, diabetic ulcer) as the treatment plan often depends on the wound type. Wound Size (Measurements): Measure length, width, and depth in centimeters. For consistency, the length is typically measured from head-to-toe axis and width side-to-side, with depth measured using a sterile cotton-tipped applicator to the deepest point. Wound Bed Tissue Type: Describe the types and percentages of tissue present: Granulation tissue: Beefy red/pink, moist, bumpy tissue indicating healing. Slough: Yellow/white, soft, non-viable tissue. Eschar: Black/charred, hard, leathery necrotic tissue. Epithelial tissue: New pink/white tissue forming at the edges or on the wound bed. Exudate (Drainage): Assess and document the color, consistency, and amount (scant, minimal, moderate, copious). Purulent (pus-like) drainage often indicates infection and should be reported. Wound Edges and Periwound Skin: Examine the surrounding skin (periwound area) for signs of maceration (soft, waterlogged appearance), erythema (redness), edema (swelling), or induration (hardening). Assess wound edges (e.g., rolled, defined, attached). Undermining and Tunneling: Gently probe with a cotton-tipped applicator to check for tissue destruction under intact skin or narrow passageways extending from the wound base. Document their location using the clock-face analogy (12:00 pointing towards the patient's head) and measure the depth. Signs of Infection and Pain: Monitor for increased pain, odor, warmth, swelling, or purulent drainage. Assess the patient's pain level using a standardized scale.
Intervention and Management
Select appropriate dressing types based on wound etiology, exudate level, and healing goals.
Clinical Assessment and Decision Making
Demonstrate competency in wound assessment, including describing the wound bed, measuring size/depth, evaluating drainage, and identifying periwound concerns.
Hands On Skills
Perform wound measurement, documentation, and dressing techniques using simulation stations.
Infection/Inflammation
Inflammation is an essential part of wound healing; however, infection causes tissue damage and impedes wound healing.
Contamination: The presence of microorganisms that are contained and do not multiply. It does not provoke a host response so healing is not impaired. Antimicrobials are not indicated. Colonisation: Microorganisms multiply but do not provoke a host response. The infection is contained but wound healing may be delayed. Antimicrobials are not indicated. Local infection: Invasion by an agent that, under favourable conditions, multiplies and produces effects that are injurious to the patient. When microorganisms and bacteria move into the wound tissue and invokes a host response. Healing is impaired and can lead to wound breakdown. Topical antimicrobials are indicated. Spreading and systemic infection: Microorganisms spread from the wound through the vascular and or lymphatic systems and involves either a part of the body (spreading) or the whole body (systemic). Healing is impaired. A systemic approach is needed e.g. topical antimicrobials and the use of antibiotics to prevent sepsis. Biofilms: represent a survival mechanism of microorganisms and are therefore ubiquitous in nature. They are complex, slime-encased communities of microbes which are often seen as slime layers on objects in water or at water-air interfaces. The degree of bioburden in the wound from the microorganisms is indicated by a poor response to antimicrobial or antibiotic treatment, delayed wound healing or increase in exudate or inflammation. Odour ODOUR can be a sign of infection. It can be described as: No odour Slight malodour: odour when the dressing is removed Moderate malodour: odour upon entering the room when the dressing is removed Strong malodour: odour upon entering the room when dressing is intact
Definitions
PHYSIOLOGY OF WOUND HEALING Wound healing occurs in four stages, haemostasis, inflammation, proliferation and remodelling, and the appearance of the wound will change as the wound heals. The goal of wound management is to understand the different stages of wound healing and treat the wound accordingly. Haemostasis(occurs within the first few seconds): blood vessels constrict to stop bleeding and form blood clots The goal of wound management: to stop bleeding Inflammation(0-4 days): neutrophils and macrophages work to remove debris and prevent infection. Signs and symptoms include redness and swelling. The goal of wound management: to clean debris and prevent infection Proliferation(2-24 days): the wound is rebuilt with connective tissue to promote granulation and repair the wound The goal of wound management: to promote tissue growth and protect the wound Remodelling(24 days- 1 year): epithelial tissue forms in a moist healing environment The goal of wound management: to protect new epithelial tissue
Acute and Chronic Wounds
Acute wound: a wound which occurs suddenly and progresses through the stages of healing as expected.
Chronic wound: a wound which fails to progress or progresses slowly through the stages of healing. Healing can be greater than 4-6 weeks.
Clinical Assessment and Decision Making
Demonstrate competency in wound assessment, including describing the wound bed, measuring size/depth, evaluating drainage, and identifying periwound concerns.