SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

Transcription

1 SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: VACUUM-ASSISTED CLOSURE (VAC) THERAPY Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: RN, LPN 04/99 5/18 1 of 7 Instillation- RN 7WT/ICU/7CYT/5WT/IRF/6ET/ Neuro/Orthopedics/Trauma Progressive Care Unit only ABthera MD OR only Trauma patients (who are stable) with ABthera dressing may be transferred out of ICU but only to TPCU with the ABthera dressing PURPOSE: KNOWLEDGE BASE: Vacuum Assisted Closure (V.A.C). Therapy promotes wound healing through Negative Pressure Wound Therapy (NPWT) by delivering negative pressure (a vacuum) at the wound site through a patented dressing. This helps draw wound edges together, removes infectious materials, and actively promotes granulation at the cellular level. A physician s order is required to initiate VAC therapy. Obtain order for wound VAC pressure settings. A physician or RN must assess the wound with each dressing change. The VAC Ulta Negative pressure wound therapy system is an integrated wound management system that provides negative pressure wound therapy with an instillation option. The initial application of the ABthera system for active abdominal therapy and subsequent dressing changes should be performed under sterile conditions in the OR. Patients with the ABthera system should be cared for in the ICU and Trauma Progressive Care Unit only. NOTE: See procedure below for steps to take for patients who are admitted with an outpatient wound VAC. EQUIPMENT: For VAC dressing change: VAC unit Canister (to be changed weekly or PRN)

2 PAGE: 2 of 7 Foam dressing TRAC pad Drape Gloves Mask Eye protection Scissors Saline Gauze Gather if needed: Sterile scissors Suture removal scissors Scalpel Cotton tip swab with measuring guide Skin prep Duoderm Eakin-seal Stomahesive paste Adaptic Needleless syringe Y-connector For VAC therapy system with Instillation: VAC Veraflo Dressing and advanced drape with instillation therapy VAC verilink cassette VAC Vera TRAC pad Topical Instillation solution as ordered by the MD PROCEDURE: (for dressing changes) 1. Perform hand hygiene. Apply gloves, mask and eye protection. 2. Remove existing dressing, count foam pieces and check previous count. Irrigate wound with normal saline. Perform hand hygiene. Apply new gloves. 3. Assess wound. (RN or MD must do assessment) 4. Measure wound size (RN/LPN/MD). 5. Cut appropriate dressing to size. (Do not cut dressing over wound as this could result in foam particles falling into the wound). 6. If necessary, drape around the wound. 7. Place dressing in wound (Note number of pieces of foam used in the wound). 8. Adaptic may be used to cover the exposed bone or tendons in the wound. May place adaptic over staples if necessary to apply VAC drape over these. 9. Trim VAC drape to size. (Peel back one side of Layer 1 and place adhesive side down over wound. Remove the remaining side of Layer 1, the green striped stabilization

3 PAGE: 3 of 7 Layer 2 and the perforated blue handling tab). 10. TRAC Pad Application identify site for location. 11. Pinch drape and cut a 2 cm round hole. 12. Remove backing Layers 1 and 2 from TRAC pad. 13. Place directly over hole. 14. Connect TRAC pad tubing to canister tubing. 15. Turn on power to VAC unit. 16. Record number of foam pieces on dressing or tubing and in computer chart. 17. Change dressing every 2-3 days (recommend to find out which MD (surgeon/ida) may want to assess the wound while the wound is open). PROCEDURE: (for patients admitted with an outpatient wound VAC) PROCEDURE(for VAC Incisional management): 1. If patient is admitted with an outpatient wound VAC, attempt to determine from patient (or records) who was managing the VAC therapy (Infectious disease; vascular, cardiac, etc.). 2. Call primary MD and get order for consult for that same MD to manage the wound VAC while patient is hospitalized. 3. Contact the MD regarding patient admittance and advise them that by policy we remove the VAC upon admission to assess the wound bed. There are exceptions to taking the VAC off such as a skin graft. To keep an outpatient wound VAC, obtain an MD order. 4. Otherwise, remove wound VAC upon admission; assess and document in the assessment/reassessment flowsheet the wound size and condition of wound bed. 5. Do not re-connect a patient to an in-house wound VAC without taking the existing sponge out and performing a thorough wound assessment. 6. Pack gently with wet-to-moist dressing and secure loosely with kerlix or ABDs until the MD can assess the wound bed himself. 7. A complete wound VAC order set must include the machine, change frequency, and any information regarding wound location, use of adaptic (or not), white foam for packing narrow tunnels, silver foam, whether it is being used for incisional management, wound management (or both). VAC Incisional Management (due to compromised incision with staples or sutures intact): Done by Wound/Ostomy RN. 1. Perform hand hygiene. Apply gloves. 2. Remove existing dressing. Cleanse wound with normal saline. 3. Assess the incision.

4 PAGE: 4 of 7 4. Pat the application site with sterile gauze. To ensure proper adhesion, the application site must be completely dry before the dressing is applied. 5. Protect intact skin on both sides of the staple/suture line with VAC drape leaving the suture/staple line exposed. 6. Lay single layer of Adaptic (non-adherent dressing) over the suture/staple line. 7. Cut strip of VAC Granufoam dressing over Adaptic. 8. Cover Granufoam with VAC drape ensuring drape covers at least 3-5 cm border of peri-wound tissue. 9. Initiate 125 mmhg continuous pressure or as ordered by the MD. 10. Change dressing every 2-3 days as ordered. PROCEDURE (for VAC INSTILLATION) RNs on 7WT/ICU/7CYT/5WT/IRF/ 6ET/Neuro/Orthopedics/ Trauma Progressive Care Unit only 1. There must be an order from the physician stating: Type of instillation solution being used. Amount of instillation infused each session. Dwell time or soak time. The time interval between soaks. 2. Instillation medication may time take to arrive on the nursing unit. Do not delay putting the wound vac dressing on the patient while awaiting medication OR waiting to transfer the patient to a unit allowed to do the instillation. 3. Pharmacy will send Veraflo cassette adapter cap with the first dose of medication. Remove the VAC Veralink Cassette from the packaging and insert the pivot connection of the cassette into the pivot slot on the VAC Ulta Therapy Unit. 4. Pivot the VAC Veralink Cassette release tab toward the unit and press firmly until it clicks into place. 5. To attach the solution bag/bottle: Extend the solution container hanger arm lock: a. Fully lift the solution container arm lock. b. Raise the solution container hanger arm lock down to lock the solution. c. Fully push the solution container arm lock down to lock solution container arm into place. 6. Hang solution container bag/bottle: a. Spike solution bag/bottle according to manufacturer s instructions using the VAC Veralink cassettes tubing spike. b. Hang solution bag/bottle from the therapy unit s solution container arm. c. Adjust solution container hanger arm while manipulating the bag/bottle to ensure that it is held inside the VAC Veralink Cassette basket. d. Power the VAC therapy unit ON e. Select the VAC Veraflo Therapy screen and select the physician ordered settings.

5 PAGE: 5 of 7 DOCUMENTATION: CONTRAINDICATIONS: Documentation should occur on the Assessment/Reassessment Flowsheet. Open a complex wound parameter and the wound vac parameter. The condition of the wound should be documented on the complex wound area to include measurements. The number of foam pieces should be documented along with the wound VAC settings on the wound VAC parameter. The number of foam pieces should also be written on the dressing or tubing. Wound dimensions should be documented at start of care and weekly and if clinician suspects wound deterioration. Do not place foam dressings of the VAC Therapy System directly in contact with exposed blood vessels, anastomotic sites, organs, nerves or intact periwound. Contraindicated in patients with malignancy in wound, untreated osteomyelitis, non-enteric and unexplored fistulas, necrotic tissue with eschar present. PRECAUTIONS: PRECAUTIONS : (additional Precautions for Instillation) Bleeding use VAC with caution of patients with compromised coagulation. Monitor closely for bleeding. Notify physician for active bleeding. Protect vessels, organs, tendons, ligaments, and nerves with multiple layers of fine meshed non-adherent material such as Adaptic. Extreme caution should be used when Vac therapy is applied in close proximity to infected or potentially infected blood vessels due to risk of uncontrolled bleeding. Do not use dressings with Octenisept, hydrogen peroxide, or solutions that are alcohol-based or contain alcohol Do not deliver fluids into the thoracic or abdominal cavity due to the potential risk to alter core temperature and potential for fluid retention within the cavity. Do not use VAC Veraflow Therapy unless the wound has been thoroughly explored due to potential for inadvertent instillation of topical wound solutions to adjacent body cavity. PREVENA Dressing: 1. A Prevena dressing is a powered negative pressure dressing designed specifically for management of closed surgical incisions that continue to drain following sutured or stapled closure. 2. Its uses include: Hold incisional edges together Removes fluids and infectious materials Acts as a barrier to external contamination Delivers continuous negative pressure at 125mmHg

6 PAGE: 6 of 7 3. The Prevena is: Battery powered, single patient use. One touch operation and is pre-set to 125mmHg Canister holds 45 ml Prevena unit works for 7 day and then shuts off 4. The Dressing: Purple foam dressing with integrated hydrocolloid Skin friendly surface layer wicks fluid from the skin surface Also an adjustable dressing that can be modified to meet a variety of surgical incisions Compatible to use with VAC Ulta unit Order the dressing kit from CSS. 5. Discharge: If the patient is going home with a Prevena, they need to follow-up with the physician on or before day seven (7). ADDITIONAL NOTES: 1. Therapy must be on continuously. If therapy is interrupted for more than two hours, remove dressing and apply saline wet to moist. 2. If patient comes from surgery with an ace bandage covering the wound VAC, obtain an order for the ace bandage and specifics when changing VAC, or an order to discontinue it. 3. Canister should be changed PRN or weekly. 4. Mepilex may be used on a compromised periwound area or to prevent compromised skin on periwound. 5. Explore all tracts and undermining areas in wound for retained sponge. Count all foam pieces removed at dressing change. Record number placed on dressing or tubing and in medical record. 6. Dressing choice: Black for deep wounds White for tunnels, sinuses or undermining. May be used for very painful wounds. Silver as barrier to bacterial penetration. 7. If needed, packages of tubing and drape are available from CS without the foam. 8. Creases or hard to manage areas may benefit from stomahesive paste or Eakins. 9. Bridging use to VAC more than one wound or to place TRAC pad away from bony prominence. Do not bridge wounds that are colonized with different organisms. Protect intact skin between the two wounds with piece of drape or other skin barrier Place foam in both wounds, then connect the two wounds with an additional piece of foam, forming a bridge. All foam pieces must be in direct contact with each other. It is important to place the TRAC pad in a central location to ensure that exudate from one wound is not

7 PAGE: 7 of 7 drawn across the other wound. 10. VACs applied on skin grafts or flaps are normally left on 5 days without changing. 11. Patient Discharge: ICM must be involved with the patient leaving the hospital requiring continued VAC therapy. If patient is going home, a home wound VAC must be ordered from KCI. Insurance approval/etc has to be obtained and this process can take hours. If the patient is to have Home Health Care, ICM will usually let Nursing know if the agency wants a home VAC placed or if they will do it at home (so a wet-to-moist dressing would be applied). If patient is going to an ECF, the wound VAC dressing is removed and a wet-to-moist dressing is applied. The ECF will assess the wound and re-apply the wound VAC. NOTE: There can be exceptions, so recommend checking with the MD. NOTE: Do not send an SMH wound VAC out of the hospital. NOTE: Do not discharge a patient with a wound VAC dressing in place and disconnected from the wound VAC unit. NOTE: If a Genadyne wound VAC is ordered for home and delivered to SMH, take the KCI VAC off. Dress wound with moist-to-dry normal saline dressing and send patient home with the Genadyne VAC. REFERENCE(S): 1. For more complete information, refer to the KCI web site: V.A.C. Therapy System or REVIEWING AUTHOR(S): Pam Jackson, BSN, RN-BC, CWOCN, Wound/Ostomy Jovan Huss, BSN, RN, WCC, Wound/Ostomy Sandy Davis, MSN, RN, Wound/Ostomy Karen Rinehart, RN, Wound/Ostomy Jackie Garabito, MSN, RN, Manager, Clinical Programs APPROVED: Clinical Practice Council 5/3/18