This title is also available as an e-book.
For more details, please see
www.wiley.com/buy/9781119590507
or scan this QR code:
Second Edition
Ian Peate
OBE FRCN
Head of School
School of Health Studies
Gibraltar Health Authority, Gibraltar;
Visiting Professor, St George's University
University of London and Kingston University
London, UK
Dr Melanie Stephens
PhD
Senior Lecturer in Adult Nursing
Lead for Interprofessional Education
Module Lead for Tissue Viability and Leg Ulcer
Management Modules
School of Health and Society
University of Salford
England, UK
Series Editor: Ian Peate
This edition first published 2020
© 2020 John Wiley & Sons Ltd
Edition History
John Wiley and Sons (1e, 2015)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Ian Peate and Melanie Stephens to be identified as the author(s) of this work has been asserted in accordance with law.
Registered Office(s)
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data
Names: Peate, Ian, author. | Stephens, Melanie, author.
Title: Wound care at a glance / Ian Peate, Melanie Stephens.
Other titles: At a glance series (Oxford, England).
Description: Second edition. | Hoboken, NJ : Wiley Blackwell, 2020. | Series: At a glance series | Includes bibliographical references and index.
Identifiers: LCCN 2019034343 (print) | LCCN 2019034344 (ebook) | ISBN 9781119590507 (paperback) | ISBN 9781119590484 (adobe pdf) | ISBN 9781119590590 (epub)
Subjects: MESH: Wound Healing | Wounds and Injuries | Handbook
Classification: LCC RD93 (print) | LCC RD93 (ebook) | NLM WO 39 | DDC 617.1–dc23
LC record available at https://lccn.loc.gov/2019034343
LC ebook record available at https://lccn.loc.gov/2019034344
Cover Design: Wiley
Cover Image: © Johner Images/Getty Images
This second edition of Wound Care at a Glance has been revised and reviewed in light of the on‐going developments in wound care practice. In preparing this new edition, we have listened to readers’ feedback, which has encouraged us to provide updates to the chapters in order to reflect changes and advances in the field, and we have added an extended reference list so as to support practice with an evidence base. As wound care management develops, it is also a requirement that nurses and other health care practitioners update their knowledge base as they respond to the needs of the people they offer care and support to. The field of wound care is a dynamic and ever‐changing field; keeping up‐to‐date, and ensuring that care provision is safe, effective and patient centred, are key requirements of any practicing nurse (Nursing and Midwifery Council, 2018).
In order to provide wound care to people across the lifespan, from all socioeconomic backgrounds and in all care specialities and communities, the nurse has to be confident and competent. There is need to understand the anatomy and physiology of the skin, as well as to adopt a holistic and patient‐centred approach. This edition again emphasises that wound care has to incorporate patient care. This must involve and engage patients and their families with regards to decisions about their health and care, as this has the potential to enhance individual well‐being and care outcomes. When the nurse understands the patient’s experiences of the services provided, this can help identify areas of waste and inefficiency, as well how to make improvements to the overall patient experience. When there is a breakdown in skin integrity, this is likely to have a negative impact on the person’s health and well‐being, as well as the individual’s family and society. There will also be implications for the wider health and care economy.
There are often a wide range of professional challenges associated with wound care – from the technological aspects of care to the ethical and sociological questions that should be and are always present when a nurse makes clinical decisions. The provision of high‐quality, safe and effective, patient‐centred wound care is complex, and success will depend on effective integration of scientific breakthroughs and wound care practices. The provision of wound care and the promotion of wound healing is very much interdisciplinary in nature.
This second edition of Wound Care at a Glance retains its easy‐to‐access approach. This book stays true to the underlying philosophy of the ‘At a Glance’ series by providing the reader with full‐colour illustrations and bite‐size information that is easy to digest, as the authors are fully aware that keeping up‐to‐date with the latest developments in the science of wound care can often be overpowering.
The book has six parts, starting with the history of wound care, the anatomy and physiology, and the normal and abnormal healing processes. The section in the book on wound management in practice emphasises the need for a holistic assessment of skin and describes the various classifications of wounds; in this section, there are chapters dedicated to the ethical and legal aspects of wound care, as well as treatment options and pain management strategies. Dressing selection is a multifaceted process, and the nurse is required to bring together knowledge and understanding of the person as well as the many dressings that are available. Dressing selection and the factors that are required to be taken into consideration when choosing an appropriate wound care product are discussed. There is an emphasis throughout on ensuring that the person’s individual needs are addressed. The concluding section of the text takes into account wound care complexities and considers a range of circumstances that the nurse may face.
We were delighted to have been asked to prepare a second edition and have been enthused by the feedback. We are indebted to Wyn Glencross, co‐editor of the first edition. Our wish is that this text helps you enhance your practice, knowledge, skills and understanding of wound care.
Ian would like to thank his partner Jussi Lahtinen for his continued support and Mrs Frances Cohen for her ongoing assistance. Melanie would like to thank Ian for asking her to contribute to the second edition, and her husband James and children Jacob and Amber for their continued support.
We would like to acknowledge the contribution made by Wyn Glencross to the first edition.
Each topic is presented in a double-page spread with clear, easy-to-follow diagrams supported by succinct explanatory text.
The website icon indicates that you can find accompanying resources on the book’s companion website. 
Your textbook is full of photographs, illustrations and tables.
Visit the companion website at www.ataglanceseries.com/nursing/woundcare to test yourself on these topics.
Table 1.1 Historical references and wound care.
| Age | Occasion |
| Hippocrates (c. 460–c. 377 BC) Cornelius Celsus (c. 25 BC–c. 50 AD) Claudius Galen (c. 130–c. 210 AD) |
Early Greek and Roman physicians Wine or vinegar was used to cleanse wounds, and the follow‐up treatment included the application of honey, oil and wine |
| Ambrose Pare (1510–1590) | Encouraged wounds to suppurate |
| Ignaz Semmelweiss (1818–1865) Louis Pasteur (1822–1895) Joseph Lister (1827–1912) |
Accepted the germ theory and the introduction of antiseptics |
| Florence Nightingale (1894) | ‘Not in bacteriology, but looking into drains (for smells) is the thing needed’. Nightingale was a firm believer in the benefits of sanitation, hand‐washing and application of strict hygiene practices |
| George D. Winter (1962) | Discovered the importance of moist wound‐healing in experimental animals |
| Mary Ayton (1985) | Defined the terminology that is currently used for wound infection – wound contamination and wound colonisation |
| Vincent Falanga (1994) | Identified the concept of ‘critical colonisation’ with fresh insights into chronic wound‐healing and non‐healing wounds |
Table 1.2 Wound care timeline.
Wound care and infection is not a modern phenomenon; it spans from pre‐history to modern medicine. The healing of wounds is a complex process, influenced by a number of factors:
Those providing wound care can no longer stick to a single approach in the progressive care of a wound. Wound care practitioners must critically select such wound‐healing therapies that can respond to the healing phase of any wound using the best available evidence. For thousands of years, dressing materials have been continually developing so as to provide protection, absorption and act as a base for wound bed preparation. Over the last 30 years, the advances in would care have been more prolific as compared to the previous 2000 years.
Since the era of cave dwellers, humans have been tending to their wounds in one form or another. Wound care continues to evolve from casting magical spells and applying potions and ointments to a more systematic approach (see Table 1.1). See Table 1.2 for the wound care timeline.
As early as 14–37 AD, Cornelius Celsus (a Roman physician) described the four principal signs of inflammation using some form of ‘antiseptic’ solutions. Claudius Galen (130–200 AD), another Roman physician, had such expertise on the management of healing wounds that he is still considered the ‘father of surgery’ by many. Galen and some of his followers must be remembered for instigating the ‘laudable pus’ theory, whereby they incorrectly considered the development of pus in a wound as an encouraging aspect of the healing process.
The lint provided a fibrous base promoting the covering of a wound site, the animal grease offered a protective barrier to the environmental pathogens, and the honey helped with its antimicrobial actions. The Egyptians and Greeks observed the significance of covering a wound. The Greeks were the first to identify the difference between acute and chronic wounds, correspondingly calling them ‘fresh’ and ‘non‐healing’. Around 120–201 AD, a Greek surgeon, who served the Roman gladiators, made a number of contributions to wound care by successfully covering a moist wound site and recognising its importance.
After the fall of the Roman Empire, many of these advances were lost. In the Middle Ages in Europe, there was a regression in the field of wound care, returning to the use of potions and charms.
The use of honey as a wound care treatment has recently seen a revival. Ancient Egyptians used honey as a wound treatment as early as 3000 BC, and its traces have been found in Egyptian tombs. Honey is said to have been an essential part of the ‘Three Healing Gestures’ used by the Egyptians.
Pasteur’s theories were associated with the impact of microbes on diseases, and the use of phenol by Lister introduced the modern ‘germ theory’ when he demonstrated the beneficial effects of carbolic acid (phenol) in the dressings of infected wounds at the turn of the century. Halstead introduced the wearing of gloves, gowns and masks, and silver was revived as an antiseptic used in dressings, enhancing the healing of wounds.
All of these events make the 19th century a significant and eventful era with regard to advances within the field of sterility and sterile surgical procedures. Skin cleaning, the use of antiseptics and debridement became common practices thereafter.
The 20th century brought some key advances, when there was a resurgence and rediscovery of the significance of a moist wound site with the invention and development of polymer synthetics used for wound dressings.
Fleming’s discovery and the subsequent development of antibiotics provided us with potent antimicrobial therapies with high specificity, transforming clinical therapy and marking the decline of a number of former remedies. Yet, the emergence of antibiotic‐resistant strains of pathogens, alongside the delayed discovery of newer antibiotics, led to a need for the discovery and development of alternative treatments.
Topical antimicrobials in the current wound care practice include iodine‐ and silver‐containing products. In the past, acetic acid, chlorhexidine, hydrogen peroxide, sodium hypochlorite, potassium permanganate and proflavine have been used. Some of these are making a comeback, and other options are being investigated and considered.
During the 1800s in the UK, natural products were being refined, leading to the development of absorbent natural products for dressings, including spun and woven cotton. During the First World War, absorbent dressings were being manufactured. Tulle gras, a paraffin gauze dressing, was developed by Lumière. Plastics were being added to cotton in the 1950s creating composite dressings, such as plasters. Throughout this timeframe, the key aim was to dry out the wound, focusing upon protection and absorption, reducing the trauma of dressing changes. There is much evidence to suggest that keeping wounds moist is more effective to letting them dry out.
Advanced wound care products were being designed in the 1970s taking advantage of this concept; nurses were using these products to successfully treat chronic wounds. Much research was undertaken in the late 1970s and 1980s.
In early 1980s, hydrocolloid, the second advanced dressing, was developed. Hydrocolloid wafers were established as first‐line treatment for pressure ulcers, leading to the development of more absorbent dressings, for example, foams and alginates.
The late 1980s witnessed the introduction of other advanced wound care products:
Nurses began to take the lead with wound care or tissue viability, managing and organizing outpatient wound clinics, influencing and enhancing patient care.
Product diversification and growth continued throughout the 1990s. Sustained‐release antimicrobial dressings were beginning to emerge and growth factor impregnated hydrogel as well as living skin equivalents.
Product modification continued throughout the 2000s, and this will continue with the emergence of negative pressure wound therapy and merging advanced wound care products along with suction.
The field of medicine is constantly evolving with advancements in wound care techniques. A number of new laboratory tools have provided us with the ability to gather an incredible amount of scientific data related to the biological events associated with healing. Much more needs to be accomplished in this field, as pieces of the jigsaw, fitting together in a way that is important for the patient, are still missing. The future is unknown, but the people requiring wound care will still need a kind of treatment that is kind and compassionate.
Figure 2.1 The layers of the skin.
Figure 2.2 The hair.
Figure 2.3 The nail.
Figure 2.4 Sebaceous gland.
The skin is the largest organ of the body, consisting of accessory organs such as glands, hair and nails (the appendages). It is a multifunctional organ:
The skin has three layers: the epidermis (Figure 2.1), the dermis and the hypodermis. Skin health has a great impact on the overall health of the individual, and it is of profound psychological importance.
This predominantly consists of stratified epithelium; the outer layer continually sheds dead cells and is slightly acidic with pH 4.5–6. The basal layer constantly forms new cells, gradually moving towards the surface and flattening during this process, prior to being shed from the skin surface; this can take between 28 and 35 days. Depending on their location, these cells are normally four or five layers thick, and most layers are present on the palms and the soles.
The epidermis is divided into five layers: stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum and stratum basale.
The key purpose of the dermis is to support and provide nutrition to the epidermis.
The key component of the dermis is proteinous connective tissue made up of the arc‐shaped elastic fibres and undulated and practically inelastic collagen fibres (elastin). Other elements include fibroblasts, mast cells, other tissue cells, multiple blood and lymph vessels, nerve endings, hot and cold receptors and tactile sensory organs.
The dermis contains blood capillaries, sensory nerve endings, lymphatic vessels, sweat glands, sebaceous glands and hair follicles.
The flexible irregular connective tissue made from woven collagen and elastin fibres abound with blood vessels, nerve fibres and lymphatic vessels. Ridges formed from these bundles of collagen run downward, forward and horizontally around the body and are called cleavage lines; they are genetically determined and are unique for each person.
The superficial facia provides anchorage to the skin whilst allowing some capacity for it to move. It offers support to the dermis and is made up primarily of adipose tissue, connective tissue and blood vessels. The fat stored within the hypodermis offers protection to the internal structures, insulating against cold.
Made up of keratin, at the lower end is a bulb or root enclosed in a follicle that produces the hair. The root is indented by a hair papilla, connective tissue and blood vessels. The hair follicle is an epithelium‐lined sheath, the arrector pilli (smooth muscle) extends through the dermis, attached to the base of the follicle, and the hair stands on the end when the muscle contracts (Figure 2.2).
There are no hair on the palms of the hands, soles of the feet, nails, parts of the external genitals, lips and nipples. Protection of the skin by hair is constrained; however, its role is to protect the scalp specifically from ultraviolet rays, heat loss and injury. The eyebrows and the eyelashes offer protection from foreign bodies entering the eye.
The nails are a specialised type of keratin, situated over the distal surfaces of fingers and toes. The nail plate is surrounded on three ends by cuticles (see Figure 2.3).
The function of nails is to assist with the development of fine motor skills, such as grasping, scratching and manipulation. The nails provide protection against trauma to the fingers and toes.
These are located on all parts of the skin except palms and soles; they are more prominent on the scalp, face, upper torso and genitalia, producing sebum, made up of keratin, fat and cellulose debris. Sebum forms a moist, oily acidic film that has antibacterial and antifungal properties (Figure 2.4).
The blood vessels include arterioles, capillary networks and venules. Blood vessels in the skin are responsible for the transportation and distribution of oxygen, nutrients and hormones, as well as for the removal of waste products.
Both the sensory and motor nerves are present within the dermis. The sensory nerve endings are sensitive to touch, or initiate signals producing sensations of warmth, coolness, pain, pressure, vibration, tickling and itching.
The lymphatic system matches the supply and function of blood vessels.