What is wound care and how do we look at it daily? Most people treating wounds are not specialists in this field and 78% of these people treating wounds are from our communities and from hospitals or care facilities. If we look at the holistic approach to assess, diagnose, treat, plan, document, and communicate, it will be clear that wound care is more than just a hole.

As we always say in wound care, it is the hole in the whole person that needs to be looked at. A dressing should form part of a holistic wound management plan with patient-centered goals. If our goal is to heal the wound faster, by providing the optimal environment for healing, we must view the whole patient with their underlying causes and the patient’s related concerns must be taken into consideration. 

It is important to keep in mind the patient-centered concerns. We are dealing with individuals with chronic or acute wounds. These individuals face the unfulfilled expectations of healing with its consequences for example odor, leakage, maceration (exudate that leaks from the wound and cause softening or sogginess and breakdown of the skin and this results from ongoing contact with excessive moisture on the skin. The tissue around the wound appears white in color) and with pain, infection, and social isolation.

Despite a huge range of wound dressings and education in this area, some wounds remain a challenge to heal. Making it impossible for the patient to have a quality of life and their dignity intact. The question then is, how are we going to achieve this optimal wound management? The answer is simple – with a holistic assessment, which will help with more efficient management, goal setting, and the potential increase for better outcomes of treatment.

We can achieve this through a holistic approach to assess all three areas of the wound while remembering the patient behind the wound with their social context. If we look at our patients and the social context, we need information like the patient’s age, gender, medical history, medication, mobility, and all other habits like smoking. Co-mobilities like diabetes, vascular impairment, and medication like anti-inflammatories, blood thinning medication play a big role when we treat our patients with wounds.

On the wound side, we need to look at the type of wound, location of the wound, how long has it been there, and the size. It is very important to note the pain in the area of the wound. These factors all play a vital role in the wound assessment, planning, treatment, and management to get to the goals that have been set. All these factors have an influence on the skin and the functions of the skin. 

Our skin is our biggest organ and weighs about 3.5 – 10 kg, depending on our body mass. If we look at the surface of our skin, it can cover about 1.5 – 2 square meters. If we look at the thickness of all the layers of the skin it is about 0.5mm, which is not very thick. The skin can tell a lot about the person like their age and health. A good example is that people with a few red blood cells in their body can appear pale, while people with jaundice appear yellowish. 

The skin has certain functions like protecting us against harmful things like germs, toxic substances, and things like moisture, cold, and the sun. Our skin also communicates with us through sensations like warmth, cold, pressure, itching, and pain. The skin also regulates our body temperature and prevents us from dehydration. The skin is a large storeroom, it stores water, fat, and metabolic products. Our skin also produces the hormones our bodies need. When our skin is injured the blood supply to the skin increases in order to deliver various substances to the wound to protect it from infection and to heal faster. New cells are produced to form new skin and blood vessels, depending on the depth of the wound. It heals with or without scars. The thickness of our skin depends on our age and gender too. In older people, their skin is thinner than younger people, and men, in general, have thicker skin than women.

The epidermis or outer layer of the skin is the part we can see. It is mostly made of cells and this is where our body produces keratin. Other cells in the epidermis with special functions are melanocytes which produce and store black pigment. The skin produces melanin when exposed to sunlight and then becomes darker. This protects the skin from the sun and harmful UV rays. Lymphocytes and Langerhans cells are our fighting cells and they fight the germs by grabbing them and taking them to the nearest lymph nodes. Then there are the Markell cells which are our special nerve cells, and which enable the sense of pressure.

The dermis or the middle layer of the skin is just under the epidermis and is made up of a dense network of tough, elastic collagen fibers. This makes the skin strong and robust. They bulge into the connective tissue that surrounds the muscles and bones and connects them with the skin. In this layer, we also get a network of nerve fibers and very small blood vessels called the capillaries. The capillaries transfer the nutrients and oxygen in the blood into the cells. This layer is mostly sensory cells and sweat glands are found here. This layer is responsible for cooling our bodies down.

The deepest layer or subcutis is also known as the hypodermis where the fat and connective tissue are formed. Subcutis is between the folds of the dermis and bulge in and where there are small cavities. The cavities are filled with storage tissue which is formed from water and fat. The fat acts as a shock absorber and protects our bones and joints from blows or bumps, it is also called body insulation. Our hormones are produced in the fat cells of the hypodermis. Essential vitamins are also made in this layer like vitamin D when we are exposed to sunlight. In the hypodermis, we will also find blood vessels, lymph vessels, nerves, sweat glands, sebaceous glands (oil glands), scent glands, and our hair roots.

When we look at an injury to the skin we need to determine if it is an acute wound or a chronic wound. Acute wounds are when we have an injury that causes a break in the skin and sometimes the tissue. There are two classifications of acute wounds: traumatic wounds like abrasions, lacerations, bites, and burns. Surgical wounds are made by a surgical incision.

Chronic wounds are when a person’s condition affects the circulatory system and/or immune response for normal wound healing and impairment results in chronic wound formation. Chronic wounds are sometimes defined by the underlying condition that prevents the wounds from healing. Such conditions are like your venous leg, arterial leg, diabetic foot, and pressure injuries. 

We also need to look at our wound classification; it can be superficial, partial thickness, and full-thickness. If we look at superficial it is where there is epidermis loss. Partial-thickness is where the epidermis and dermis are injured or lost, and our full thickness is where all the layers of the skin are lost or injured, and this sometimes involves bones and the fat in the skin. 

Thus far we can see that wound care is more than just putting a plaster or bandage on a  wound. It is important to consider the risk factors for our non-healing wounds, where multiple factors can lead to wounds not healing. The factors can be categorized into local and systemic factors. Many of these factors are related and the systemic factors act through the local factors that affect our wounds to heal. 

But what are the local factors that influence the wounds from healing? Those are oxygenation, infection, foreign body, and venous sufficiency where the systemic factors are the patient’s age and gender, sex hormones, stress, ischemia, disease (diabetes, fibrosis, hereditary healing disorders, uraemia, and keloids), obesity, medication (glucorticoid steroids, non-steroidal, anti-inflammatory and chemotherapy), alcoholism and smoking, immune-compromised conditions (cancer, radiation therapy, AIDS /HIV, nutrition.

As you can see there is so much we need to look at before we even get to the stages or phases of wound healing and if we do not do a full assessment like this how are we going to get to our goal of healing the wound?

Let’s look at our phases or stages of wound healing. Our first phase or stage is the hemostasis of wound healing and this starts with the onset of injury already. The hemostasis is where the body starts to stop the bleeding and the body activates the emergency repair system by clotting the blood to stop the drainage. The platelets meet the collagen in activating and aggregation. Then the thrombin forms fibrin mesh which strengthens the platelets to create a blood clot which is called coagulation and the healing processes have started.

The second phase or stage is the inflammation or defensive phase which focuses on destroying bacteria and removes the debris out of the wound bed. This is all part of the proportion of the wound bed for the growth of the new tissue. The white blood cells called neutrophils enter the wound to destroy the bacteria and the debris. This can take 24 – 48 hours after the injury. Protein attracts the immune system cells to facilitate tissue repair which can last 4 – 6 days and can be associated with oedema, erythema, heat and pain, and is sometimes confused with infection in the wound.

The third phase or stage is the proliferative phase where the focus is to fill and cover the wound. It has 3 distinct stages where it firstly starts filing the wound and the wound bed has a shiny deep red granulation tissue where it connects with the tissue and new blood vessels are formed. The second part is where the contraction of the edges of the wound is starting to pull upwards to the center of the wound and the third part is where the wound is covered (epithelization). This is where the epithelial cells arise from the wound bed or margins and begin migrating across the wound bed in leapfrog fashion until the wound is covered. This can last up to 24 days.

The last phase or stage is the remodeling or maturation phase, this is where the new tissue slowly gains strength and flexibility and the collagen fibers reorganize. The tissue remodels and matures by increasing the intense strength which is the strength limited to 80% for pre-injury strength. This can last up from 22 days to 2 years. 

Understanding these phases allows us to look at the closure of wounds. In wound closure, there are also three steps. The first one is primary wound closure which is the fastest way of closing a wound. Small clean injuries that have minimal risk or infection and require only new blood vessels and keratinocytes to immigrate only a small distance to heal the wound. This is normally with surgical incisions, paper cuts, and small cutaneous wounds. 

The second type of closure is the secondary wound healing where the wound edges cannot be approximated and need a granulation tissue matrix to be built and refill the wound. This requires more time and energy, and this can create scar tissue in the majority of wounds that are closing with this type of wound closure.

The last type of wound closure is the delayed primary closure, where the primary and secondary closure phase is delayed. The wound care specialist is normally involved in this phase to reduce risk – like infection and to clean the wound bed and observe the wound to make sure that there is no infection before it is surgically closed. This type of wound is where there are traumatic injuries like dog bites or lacerations involving foreign bodies.

What are wound complications? Wound complications are infections, osteomyelitis, tissue necrosis and gangrene, peri-wound dermatitis, oedema and peri-wound oedema, hematomas, and dehiscence of wounds.

There are specific signs of wound infection and if there are more than 4 of these signs present you need to suspect and need to treat the patient for wound infection immediately without delay. These symptoms are severe pain, delayed healing, erythema >0.5cm (abnormal redness of the skin caused by dilation of blood vessels), suboptimal granulation tissue (spongy or friable tissue), local warmth, induration, persisting or increasing exudate, and cellulitis. 

It is important if you suspect infection to do a wound swab and send it to the laboratory for analysis for Microscopic Culture and Sensitivity testing.

Wound infection leads to the interruption of several processes along the wound healing pathway. Bacteria produce inflammatory mediators which prolong the inflammatory phase. These bacteria cause cell death which prevents the growth of new tissue and causes necrotic tissue (It is the black and yellow tissue on the wound bed. It can be soft, or it may form a scab (Eschar), which contains bacteria and infects the wounds).

After we have assessed the wound, we can diagnose the underlying cause of the wound, and then only can we treat the wound once we have identified and diagnosed it. Then we select the dressing for the specific patient and wound using the Time Model.

Looking at these factors we classify the degree of tissue damage visible, by our depth assessment where we look at 4 stages. The first stage is the non-blanchable redness or intact skin. This is where the skin is intact with non-blanchable redness or in a localized area. It is normally over a bony prominence. The skin shows discoloring, warmth, oedema, hardness, or even pain. Note that people with dark pigmented skin may not have visible blanching.

Stage two is the partial thickness, skin loss, or blister which is a shallow open wound with a red-pink wound bed without a slough. It can present with an intact or open or ruptured serum-filled or serosanguinous-filled blister. Stage three is the full-thickness skin loss where the fatty tissue is visible in the wound bed, but no bone tendons or muscles are exposed. Some of these wounds may have slough present and can have undermining or tunneling in the wound bed. It is important to explore the bound bed very carefully with these types of wound cavities. 

Stage four is full-thickness tissue loss where the muscle or bone is visible. You can see the exposed bone, tendon, or muscle. Slough or eschar may be present and often include undermining and tunneling.

Stage five is where the wound is unstageable and in these wounds, the skins’ full-thickness or tissue is lost and the depth of the wound is completely obscured by slough and or eschar in the wound bed. Wounds at this stage need to be cleaned and debridement is the best for this kind of wound. There are different methods to debride a wound, depending on the patient the wound specialist will discuss all the options available to the patient. The patient is part of the team and has input in how the wound needs to be treated. 

We often hear our patients say that the wound is oozing or very wet and we need to make sure that we get an optimal moisture balance to enable us to get the wound to heal. If we do not look at our exudate the wound will also not heal and this can cause more wound complications. We need to measure our exudate, this will determine our choice of top dressing. 

After we have taken all these steps into consideration, we need to treat the wound. We do it by relieving the pressure or removing pressure by appropriate measures. Make sure the wound is debrided of all necrotic tissue is removed. Cleaning the wound and surrounding skin with appropriate cleaning solutions and making sure that we choose the appropriate dressing to ensure there is optimal wound healing. Using a suitable dressing that is made of foam or alginate with superior absorption and exudate management properties will help prevent or resolve wound infection.

When choosing a dressing, consider the following factors as a wound healing goal. It must provide protection, maintain moisture, reduce pain, absorb exudate, do not itch, allow the skin to breathe, must be easy to change, and be cost-effective and available. The dressing must be transparent to prevent bacteria from entering. Wet or moist must minimize trauma to granulation tissue. The right dressing choice will reduce the risk of exudate leakage and maceration and this creates a moist balance that promotes optimal wound healing. 

There are also other therapies that can be used to promote wound healing like VAC Dressings (Negative Pressure – it removes exudate and provides a balanced moist wound bed and promotes wound healing), Hydrotherapy, Hyperbaric Oxygen, electrical stimulation, and hot or cold therapy (these must be discussed in advance with the patient’s doctor and the patient before it can be considered, as well as the risks and cost involved in these type of therapies).

If we look at all these steps, phases, classifications, etc., we need to understand that to promote proper wound healing – the wounds need to be well vascularized, free of devitalized tissue, and have a balanced moist bed. The dressing should eliminate dead space, exudate must be controlled to prevent bacterial overgrowth to ensure a fluid balance to get to the stage where the wound is healed. Wound care is very complex, and to fully understand it, it is essential to attend a wound care workshop where all these factors are discussed and explained in detail. 

For more information on workshops, you can contact Sr. Potgieter at Santro Nursing Care for details and availability. Contact our office at 021-554-1979 or email us at nurse@santronursingcare.co.za.

Bio‐ Antionette Potgieter, RN, Santro Nursing Care (PTY) LTD, SA

I started my nursing care at the Sasolburg Provincial Hospital in Sasolburg Free State in 1984. I completed the 2 years Enrolled Nurse Certificate and then the 2 years bridging course through the VKOVS. We were the 3rd group in the hospital completing this course. Nursing is my passion and since I can remember I wanted to be a nurse. I spent my holiday volunteering in the same hospital where I did my training. I also had been corresponding with a SR Pretorius from Bloemfontein during that time while I was still in high school. I qualified as a Registered Nurse in 1994. 

Currently, I am a Private Nursing Practitioner and my field of expertise includes wound care, simple to advance wound care, stoma care, incontinence care, palliative care, home base care, IV therapy, diabetic care, catheter care, general nursing, phlebotomy, and case management. I also do training in wound care, health and safety in the home for caregivers, a 6-month caregivers course, and a customer care course. These courses are all available at our practice and facility. We are currently busy with some new courses in peg feeding, pressure care, and diabetes care.