NEGATIVE PRESSURE WOUND THERAPY NURSING PROTOCOL

Definitions:

Wound Vac (WV) or Negative Pressure Wound Therapy (NPWT): Device to assist in wound healing using negative pressure. Performed to reduce edema and bacterial colonization and to provide a moist environment ideal for promoting wound healing.

NPWT promotes healing by removing wound exudate and creating mechanical stress on the tissue. Mechanical stress promotes growth factor expression, granulation tissue growth, and angiogenesis.

                Use a biomed number to in documentation.

Simple Wound Care with NPWT: Characterized as/by sutured or open surgical incisions and well approximated. Wounds that have no exposed underlying structures (muscle, tendon, organ, etc).

Complex Wound Care with NPWT: Characterized as/by- Extensive packing (using multiple types of packing products), more than 1 tunnel, WV setup that has frequent troubleshooting needs/ known issue. Wounds with exposed muscle, tendon, nerves, organs, vessel, unexplored fistula, etc. Unable to tolerate bedside care with typical pain control measures.

*A wound care nurse or provider will evaluate patients requiring complex wound vac dressings.

Utilization of WV

• Verify physician order
• Order must contain/specify:
• Amount of negative pressure (mmHg)
• Intermittent or continuous
• Who is responsible for changing WV
• How often WV is to be changed
• Amount of instillation and dwell time if using Veraflo system

Uses, Contraindications and Red Flags

• Prevena is used on closed incisions only and is generally used at discharge.
• WV on a graph site at discharge- Prevena is used for up to 7 days.
• Instillation Therapy with Veraflo is indicated for patients who would benefit from vacuum assisted drainage and controlled delivery of topical wound treatment solutions and suspensions over the wound bed.
• Note that minimal bleeding is normal if granulation tissue is injured during a dressing change, but be mindful of the risk of potentially fatal bleeding when managing NPWT. If bright red blood appears in the tubing or collection canister, immediately stop the vacuum pump and notify the treating clinician.
• Do not initiate NPWT in a patient taking anticoagulants because of the increased risk of bleeding.
• Never place foam dressing in direct contact with exposed organs, blood vessels, anastomotic sites, or nerves.
• Be aware that the NPWT system should be operational at least 22 hours in a 24-hour period. Never leave foam dressing in place without active vacuum therapy for more than 2 hours.
• Remove all foam dressing materials with each dressing change to avoid ingrowth of tissue into foam or infection, as these materials are not bio absorbable.

https://www.youtube.com/watch?v=uLv7MPDrKtQ

Pre-procedure Steps

1. Check care plans, treating clinician orders, and facility protocols on negative pressure wound therapy (NPWT).
2. Review patient’s medical history/medical record for indications for NPWT; indicated frequency of dressing changes; specific type of foam/gauze/other non-adherent dressings to be used; designated solution for wound cleaning/irrigation; vacuum settings to be used; any prescribed medication; labs/other diagnostic test results, particularly WBC count and nutritional markers; and allergies (use alternatives, as appropriate).
3. Introduce yourself to patient/family.
4. Identify patient using at least 2 unique identifiers (such as full name, date of birth, or medical identification number).
5. Identify and address any special communication needs patient/family may have.
6. Identify and accommodate, if possible, any specific cultural and religious beliefs that may enhance care.
7. Be aware of any assumptions you may have, and separate your own beliefs and values from those of the patient to minimize bias.
8. Ask patient if they would prefer a clinician of a certain gender if procedure involves steps that possibly compromise dignity/privacy. Meet request, if possible.
9. Provide privacy for patient.
10. Explain procedure. Verify completion of informed consent documents, if appropriate.
11. Verify supplies are in good working order and review manufacturer instructions for use.
12. Perform hand hygiene and put on personal protective equipment.
13. Assess volume and characteristics of drainage in collection reservoir of vacuum pump prior to dressing change.
14. Notify DCC to prepare for possible need for patient to discharge with a wound vac.

Procedure Steps

1. Position patient for comfort, privacy, and easy access to wound.
2. Expose body area where wound is located, while keeping rest of body covered for warmth and privacy.
3. Verify rights of safe medication administration.
4. Assess current level of pain using an appropriate pain scale. Consider premedication with analgesia, if ordered and appropriate.
5. Remove soiled dressing with nonsterile gloves.
6. Note that a heavily colonized or infected wound can require dressing change every 12-24 hours but, typically, plan to change dressings 48 hours after initial application, followed by 2-3 times weekly (every 2-3 days) thereafter.
7. Protect work area with an absorbent linen saver pad to collect any discharge or drainage.
8. Drain all fluid from tubing into collection canister or reservoir.
9. Clamp all tubing and power off vacuum pump.
10. Do not allow exudate to reenter wound once vacuum unit has been powered off.
11. Allow foam or gauze to decompress.
12. If collection reservoir will not be replaced, disconnect tubing between collection reservoir and tubing connected to transparent drape or dressing. Position exposed end of collection reservoir tubing so it does not become contaminated.
13. Gently remove transparent dressing and foam from wound. Be aware foam and tubing can adhere to adhesive transparent drape.
14. Gently loosen adhesive edges of adhesive dressing.
15. Use your non-dominant hand to gently press against patient’s skin while using your dominant hand to lift an adhesive edge.
16. Stretch (do not peel) outer edge of border laterally to release adhesive grip against patient’s skin.
17. Continue lifting and stretching until adhesive side of dressing is completely removed from patient’s wound and surrounding skin.
18. Lift foam from wound.
19. If foam is adhered to wound bed, introduce sterile water or normal saline (NS) into dressing.
20. Allow time for foam to absorb solution and soften dried exudate so foam can be gently removed. Minor bleeding can result when removing foam from areas where in-growth of granulation has occurred.
21. Count number of pieces of foam removed from wound.
22. Confirm removal of all pieces of foam by reviewing patient’s record or label placed on dressing at previous dressing change.
23. Use adhesive remover to clean any adhesive residue from skin surrounding wound.
24. Inspect and assess wound exudate.
25. Note volume and characteristics of wound exudate in collection canister or reservoir from date of previous dressing change.
26. If collection reservoir will be reused, mark level of exudate drainage on outside of reservoir.
27. If reservoir will be replaced, drain all fluid from tubing into collection reservoir, detach reservoir from vacuum pump, and place sealed reservoir in a biohazardous container for disposal.
28. Record volume of drainage in patient’s intake and output record.
29. If a sudden large increase in wound exudate is observed, contact treating clinician.
30. If wound or exudate suggest presence of infection, use aseptic non-touch technique (ANTT) to collect a sample of wound drainage for lab testing.
31. Verify clamps on tubing are closed.
32. Remove and discard soiled gloves.
33. Perform hand hygiene.
34. Put on nonsterile gloves.
35. Clean skin around wound using ANTT.
36. Irrigate wound bed to remove debris that could promote bacterial growth.
37. Use care to avoid disturbing granulation tissue.
38. Use a 30- to 35-mL syringe filled with NS and an 18- to 19-gauge needle to irrigate wound, directing flow of irrigation solution away from wound.
39. Use sterile gauze to blot excess moisture from wound bed surface. Use a new gauze pad for each pass.
40. Allow some moisture to remain in wound bed, as tissue will benefit from a moist wound environment.
41. Gently dry intact surrounding skin.
42. Assess wound site.
43. Observe wound appearance, as it can become a deeper, “beefier” red color as vacuum suction promotes perfusion to wound bed.
44. Observe for granulation tissue at wound edges.
45. Observe and measure wound dimensions, which should begin to decrease.
46. If wound bed is dry, contact treating clinician to decrease negative pressure or use alternative materials (per provider’s orders) against wound bed. Although wound assessment is performed each time dressing is changed, initial staging/grading does not change as wound healing progresses.
47. Remove and dispose of soiled gloves.
48. Perform hand hygiene.
49. Prepare foam or dressing.
50. Use a sterile drape to create a sterile field on which to place supplies. Note many clinicians use inner wrapping of a sterile package as a sterile field.
51. Open sterile supplies onto sterile field.
52. Inspect dressing package for tears and note expiration date prior to opening and placing dressing on sterile field.
53. Use scissors to cut foam to fit shape of wound. Note must be worn if foam is held by hand.
54. Prevent loose foam particles from falling into wound.
55. Do not cut foam over wound.
56. Gently brush any loose particles from foam edges.
57. Using appropriate aseptic technique, apply foam dressing per manufacturer directions (such as using polyvinyl chloride foam against wound bed or filling tunneled areas). This involves filling wound cavity with foam. Do not tightly pack compress foam into wound space. Exudate cannot be easily suctioned if foam is compacted into wound.
58. Use sterile applicator or cotton-tipped swab to assist in positioning foam or gauze into deeper wound recesses.
59. Do not allow foam or gauze to touch surrounding skin during placement.
60. Connect dressing to NPWT system (tubing, reservoir, and pump).
61. Apply a barrier film to skin surrounding wound.
62. Position transparent adhesive cover dressing over foam using nonsterile gloves.
63. Confirm dressing extends 3-5 cm (1.2-1.6 inches) beyond wound edges (or as recommended by manufacturer).
64. Avoid wrinkles or tenting when placing transparent adhesive dressing.
65. Avoid stretching transparent dressing during application because increased tension can create shearing forces against periwound tissue.
66. Cut a 2.5-cm (1-inch) hole (not a slit) in center of transparent dressing.
67. Cover hole in center of transparent dressing with device-specific tubing.
68. Connect tubing attached to transparent cover dressing to collection reservoir tubing.
69. Confirm clamps on all tubing are open.
70. Power on vacuum pump and adjust settings as prescribed. Most wounds will be managed at −125 mm Hg of continuous suction. However, skin grafts may have lower settings, such as −75 mm Hg, and pressure should be reduced if the wound is dry. Intermittent pressure is typically provided in cycles of 5 minutes at a higher pressure and 2 minutes at a lower pressure. Suction does not stop during the intermittent cycle.
71. Observe for collapse of foam or gauze. If compression does not occur, search for and remedy any leaks.
72. Add a label to dressing. Include date/time of dressing change and total number of foam or gauze pieces used to dress wound.
73. Include this information in patient’s medical record in event label is inadvertently removed prior to next dressing change.