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Introduction ⬇

Negative-pressure wound therapy encourages healing of acute and chronic wounds by applying continuous or intermittent subatmospheric pressure to the surface of a wound using a well-sealed dressing. 1,2 Doing so removes excess wound fluids that can cause maceration and delay healing, reduces edema and bacterial colonization, and stimulates the formation of healthy granulation tissue. It also increases local blood flow and draws wound edges together. (See Understanding negative-pressure wound therapy.)

Negative-pressure wound therapy is indicated for acute and traumatic wounds, pressure injuries, and chronic open wounds, such as diabetic ulcers, dehisced surgical wounds, partial-thickness burns, meshed grafts, and skin flaps. 1,3 It’s contraindicated in patients with exposed vital organs, necrotic tissue wounds with eschar, untreated osteomyelitis, malignancy disease in the wound, nonenteric and unexplored fistula, wounds with inadequate debridement, an untreated coagulopathy, or an allergy to any component of the procedure. This therapy should be used cautiously in patients with active bleeding, in those taking anticoagulants or platelet aggregate inhibitors, and when achieving wound hemostasis has been difficult. 4,5

There are negative pressure wound therapy units that enable continuous wound irrigation to the wound bed. Also available are portable, single-patient-use, and disposable negative pressure wound therapy units. The use of such devices promotes patient mobility, increases the ease of performing activities of daily living, and facilitates early hospital discharge. 6

No consensus of expert opinion exists regarding the use of clean or sterile technique when caring for chronic wounds. 7

Equipment ⬆ ⬇

Equipment

Emesis basin • sterile normal saline irrigating solution • gloves • sterile gloves • fluid-impermeable pad • irrigation kit with syringe • suction tubing • evacuation canister tubing • skin protectant wipe • evacuation canister • negative-pressure wound therapy unit • wound assessment tool and guide • label • Optional: gown, goggles, prescribed pain medication, scale, prescribed cleansing agent, additional skin barrier product, prescribed wound irrigation solution, irrigation tubing set.

For Foam Packing

Sterile scissors • foam packing • transparent dressing therapy drape • transparent semipermeable dressing.

For Gauze Packing

Nonadherent gauze • antimicrobial gauze packing moistened with sterile normal saline solution • drain • ostomy strip paste • transparent dressings.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Assemble the negative-pressure wound therapy unit at the bedside according to the manufacturer’s instructions. Make sure the unit functions properly and the tubing and canister are appropriate for the unit and the patient’s size, weight, condition, and wound characteristics. A large canister shouldn’t be used for an older adult patient, a patient at high risk of bleeding, or a patient who can’t tolerate large-volume fluid loss. 4 Set negative pressure according to the practitioner’s order and the manufacturer’s instructions (25 to 200 mm Hg). Prepare a place for the supplies that’s within reach.

Warm the sterile irrigating solution to 90° F to 95° F (32.2° C to 37.8° C) to promote comfort. Studies show that warm solutions may be more comfortable for patients than room-temperature solutions.8 Pour irrigating solution into the container of the irrigation kit.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order for the appropriate wound cleaning agent, frequency of dressing change, type of negative-pressure unit, type of wound packing, and settings for the negative-pressure device. 9
  • Review the patient’s medical record for allergies or contraindications to treatment. Also assess the patient’s bleeding risk before initiation of therapy. 4,9,10
  • Confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record, as required. 11,12,13,14
  • Gather and prepare necessary equipment and supplies.
  • Perform hand hygiene. 15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers. 21
  • Provide privacy. 22,23,24,25
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.26
  • Assess the patient’s condition.
  • Screen for and assess the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand. 27
  • Treat the patient’s pain as needed and ordered using nonpharmacologic, pharmacologic, or a combination of approaches. Base the treatment plan on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals. 27
  • Closely monitor the patient at high risk for adverse outcomes related to opioid treatment (if prescribed).27
  • Raise the patient’s bed to waist level before providing patient care to prevent caregiver back strain.28
  • Perform hand hygiene. 15,16,17,18,19,20
  • Put on gloves and, if necessary, a gown and goggles to comply with standard precautions, and protect yourself from wound drainage and contamination.29,30
  • Place a fluid-impermeable pad under the patient to catch any spills and avoid linen changes.
  • Position the patient to allow maximum wound exposure and patient comfort.
  • Place the emesis basin under the wound to collect any drainage.
  • Using sterile technique, prepare a sterile field and place all the supplies on it.
  • Remove the soiled dressing and weigh it as ordered. Verify that the number of removed pieces correlates with the number documented in the patient’s medical record. 4 Then discard them in an appropriate receptacle. 31
  • Thoroughly inspect the wound to ensure that all pieces of dressing components have been removed.
  • Remove and discard your gloves29,31 and perform hand hygi­ene. 15,16,17,18,19,20
  • Replace your gown as needed and put on a new pair of gloves. 29,31
  • Irrigate the wound thoroughly using normal saline solution and an irrigation syringe. (See the "Wound irrigation" procedure.)
  • Clean the area around the wound with normal saline solution or ordered cleansing agent. 9
  • Wipe the intact skin with a skin protectant wipe and allow it to dry to prevent blistering when removing the dressing. Apply an additional skin barrier product, as indicated. 2,4
  • Remove and discard your gloves29 and perform hand hygi­ene. 15,16,17,18,19,20
  • Put on sterile gloves. 29,31
  • Assess the wound. Note the wound’s precise location, any tunneling, tissue type and loss, size, color, odor, and the presence of warmth, edema, or drainage. Also observe for signs and symptoms of wound infection, including increased pain, fever, and elevated white blood cell count. 2

ELDER ALERT Closely monitor older adult patients, certain small adults, and those with large exudating wounds in relation to body size and weight for fluid loss and dehydration. When monitoring fluid output, consider the volume of fluid in both the tubing and canister and the weight of the dressing removed. 4

  • Measure the wound (length, depth, and width) using your facility’s assessment tool and guide. Obtain measurements at the baseline assessment, with the first dressing change, weekly, and when negative-pressure wound therapy is discontinued.
  • If your gloves are contaminated, remove and discard them, perform hand hygiene, and put on a new pair of sterile gloves. 15,16,17,18,19,20,29,31

Using Foam Packing

  • Using sterile scissors, cut the foam to the shape and measurement of the wound to help maintain negative pressure to the entire wound. More than one piece of foam may be necessary, depending on the size of the wound. Don’t cut the foam directly over the wound to prevent foam fragments from falling into the wound. If a tunnel is present, cut the foam longer than the tunnel to ensure the foam makes contact with the wound.
  • Carefully place the foam in the wound, ensuring that the foam is in contact with the wound bed, margins, and any tunneled area or areas of undermining. (If there’s a groove in the foam, apply it with the groove side up.) The foam shouldn’t overlap intact skin. Don’t pack the foam tightly into any areas of the wound, because doing so may cause pressure on granulation tissue, which may delay healing.
  • Count the number of foam pieces you use and document the number on the dressing and in the patient’s medical record. 4,10 Confirm the count with another nurse if available.
  • Apply the transparent therapy dressing drape over the foam, leaving a 1" to 2" (3 cm to 5 cm) margin of intact skin covered by the dressing around the wound to ensure that the wound is covered completely and that the negative-pressure seal will be intact.4
  • If continuous wound irrigation isn’t prescribed, pinch the transparent therapy dressing drape and carefully cut a hole no larger than 1ʺ (2.5 cm) in the center of the drape (over the groove in the foam, if present). Do not cut a slit, because it could seal during therapy.4 The hole in the drape is the insertion point for the suction tubing. Depending on the equipment your facility uses, the tubing may be attached to an adhesive pad that you attach to this site. If you’re not using a preattached system, place the suction tubing into the center of the foam. The embedded tubing delivers negative pressure to the wound. Apply a transparent semipermeable dressing over the insertion point of the suction tubing.
  • If continuous wound irrigation is prescribed, connect the administration set to the prescribed irrigation solution bag and hang it on the device’s hanger arm. Select the instillation pad application site, giving consideration to fluid flow and tubing positioning to allow for optimal flow and exudate removal.5 Pinch the transparent therapy dressing drape and carefully cut a hole (based on manufacturer’s directions) no larger than 1ʺ (2.5 cm) in the selected location. Do not cut a slit, because it could seal during therapy. The hole must be large enough to allow for the input of the irrigant. 5 Peel the backing from the instillation pad and apply it over the hole in the transparent therapy dressing drape.
  • Select the vacuum pad application site, giving consideration to fluid flow and tubing positioning to allow for optimal flow and exudate removal. Avoid placing over bony prominences or within tissue creases. 5 Pinch the transparent therapy dressing drape and carefully cut another hole (based on manufacturer’s directions) no larger than 1ʺ (2.5 cm) in the selected location. Do not cut a slit, because it could seal during therapy. The hole must be large enough to allow for the removal of fluid and exudate. 5 Peel the backing from the vacuum pad and apply it over the hole in the transparent therapy dressing drape. Connect the tubing from the irrigation bag to the instillation pad following the manufacturer’s instructions. Connect the tubing from the vacuum pad to the device’s collection canister following the manufacturer’s instructions.

Using Gauze Packing

  • Using sterile scissors, trim a single layer of nonadherent gauze.
  • Lay the nonadherent gauze across the wound bed.
  • Apply saline-moistened antimicrobial gauze loosely into the wound, ensuring that the gauze is in contact with the nonadherent gauze, margins, and any tunneled area or areas of undermining. Don’t overpack the wound, because doing so can delay healing.
  • Count the number of gauze pads or rolls used and document that number on the dressing and in the patient’s medical record. 10 Confirm the count with another nurse if available.
  • Position the drain tubing on top of the gauze. If a channel drain (a small, cylindrical drain) or round drain (a round, perforated drain) is used, wrap a layer of saline-moistened gauze around the drain.
  • Apply ostomy strip paste to a small portion of the wound edge at the location where the drain tubing exits the wound to secure the tubing’s position. Position the drain tubing on top of the ostomy strip paste. Apply the ostomy strip paste over the top of the tubing and pinch it in place to secure the tubing’s position.
  • Apply one or more transparent semipermeable dressing(s) over the wound. Reinforce the seal by pinching the transparent occlusive film and ostomy strip paste together.

Completing the Procedure

  • Connect the free end of the drain tubing to the canister tubing at the adapter.
  • Position the drain tubing on flat surfaces, away from the perineal area, bony prominences, or pressure areas to prevent additional skin breakdown.4
  • Anchor the drain tubing several inches away from the dressing to prevent tension on the suction tubing.
  • Label the dressing with the date, time, and number of dressings you used.
  • Discard used supplies in appropriate receptacles. 31
  • Remove and discard your gloves and any other personal protective equipment worn,29,31 and perform hand hygiene. 15,16,17,18,19,20
  • Turn on the negative-pressure unit. Make sure the transparent dressing drape shrinks to the foam or gauze and the skin to ensure a good seal, as evidenced by a raisin-like appearance of the dressing. Failure of the dressing drape to shrink to the foam or gauze under negative pressure indicates a break in the seal and will trigger the device’s alarm. If administering continuous irrigation, set the instillation rate per the practitioner’s order.
  • Make sure the device alarm limits are set appropriately, and that the alarms are turned on, functioning properly, and audible to staff. 32,33,34
  • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment. 27
  • Make sure the patient is comfortable.
  • Return the bed to the lowest position to prevent falls and maintain patient safety.35
  • Monitor the patient closely; monitor and record the drainage at an interval determined by your facility and the patient’s condition.
  • Perform hand hygiene. 15,16,17,18,19,20
  • Document the procedure. 36,37,38,39

Special Considerations ⬆ ⬇

Special considerations
  • Many manufacturers have dressing kits that contain the necessary equipment. Make sure that you’re using the correct kit for your patient’s needs.
  • Change the dressing according to the manufacturer’s directions, usually 48 hours after the beginning of treatment and then two to three times per week. 2 More frequent dressing changes may be necessary if the wound has heavy drainage or drainage with sediment, or if the wound is infected. Try to coordinate the dressing change with the practitioner’s visit so the practitioner can inspect the wound.
  • Change the evacuation canister once per week or when it’s full according to the manufacturer’s instructions and as directed by your facility. 4 Never leave the dressing in place without suction. If the machine malfunctions, replace the dressing with a wet-to-damp dressing until the machine is repaired or replaced. Leaving the dressing in place without suction puts the patient at high risk for infection.9
  • Evaluate the effectiveness of negative-pressure wound therapy weekly using a comprehensive wound assessment tool and wound measurements. If the wound shows no response or improvement within 2 weeks, or if the wound worsens, reevaluate the use of negative-pressure wound therapy. 4
  • If the patient experiences pain from the negative-pressure wound therapy or dressing changes, consider premedicating the patient, decreasing the pressure settings, using continuous instead of intermittent suction, changing the type of filler dressing, applying a contact layer to the wound surface before inserting the foam, and instilling normal saline solution before removing the dressing. 40
  • For best results, ensure that the patient receives uninterrupted therapy for at least 22 hours daily. 4 If therapy is interrupted for more than 2 hours, remove the old dressing and irrigate the wound. Apply a new sterile dressing and reapply the therapy. Alternatively, if ordered, apply a sterile wet-to-moist gauze dressing to the wound. 4

Complications ⬆ ⬇

Complications

Local skin irritation may occur. Serious complications include bleeding and excessive fluid loss. 10 Cleaning and care of wounds may temporarily increase the patient’s pain and increases the risk of infection. 10

Documentation ⬆ ⬇

Documentation

Document the date and time; wound assessment, including signs and symptoms of infection; wound measurements; pain assessment and any intervention; and the patient’s response. Record the weight of soiled dressings (if appropriate). Note the type and number of dressings used and the settings for the negative pressure wound therapy unit. 4,10 Record the verification of components removed from the wound. 4 Document the patient’s tolerance of the procedure. Document teaching you provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

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