Senior Practicum Learning Objectives

• Practice professional nursing under the direction and supervision of clinical faculty staff.
• Build upon previously learned basic nursing skills and develop more advanced nursing skills within the Intensive Care Unit.
• Learn to prioritize in an effective manner for better patient outcomes. 
• Develop and utilize complex decision- making skills and critical thinking skills to create and manage plans of care for patients in order to optimize patient outcomes and health.
• Progress through the transition from student nurse to professional nurse by building a comprehensive understanding of clinical skills, theories, and concepts.

Angina Concept Map

This is a concept map I created for my Adult Health Nursing Class.  Click on the image to enlarge it.

References

Assessment Technologies Institute. (2006). Adult Medical Surgical Nursing: Review Module. United States of America: Assessment Technologies Institute.

Lilley, L., Harrington, S., Snyder, J. (2007). Pharmacology and the Nursing Process (5th ed.). St. Louis, MO: Mosby.

Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2008). Brunner & Suddarth’s Textbook of Medical- Surgical Nursing (11th ed., Vol. 1). Philadelphia, PA: Lippincott Williams & Wilkins.

Spring Semester 2009 Courses

1. Nursing 620: Childbearing/ child- rearing family
2. Nursing 620c: Childbearing/ child- rearing family clinical
3. Nursing 622: Clinical Decision Making II
4. Nursing 794: Cross Cultural Nursing in Mexico

Application of the Transition and Trajectory Theories to Clinical Practice

Application of the Transition and Trajectory Theories to Clinical Practice

Introduction
Health and illness are part of the human experience. Unfortunately, most people have encountered or know someone that has been diagnosed with a chronic illness at some point in their lives. As nurses, we often encounter chronic illnesses when caring for patients. Nurses must learn how patients experience chronic illness and the best ways to care for those patients. The transition and trajectory theories are important for nursing care because they frame a patient’s experience with and progression through the stages of chronic illness.
The trajectory theory refers to the developmental stages of illness. These include the physiological aspects of the disease as well as the effects a chronic illness can have on the emotional and psychological well-being. The theory allows for framing the patient and family’s experience of living with a chronic illness. According to Corbin (1998) a trajectory “refers not only to the illness/ condition course, but to the actions taken by various participants to shape or control that course” (p. 35). Therefore, it is imperative that nurses and other healthcare providers intervene effectively in the chronic illness trajectory to allow the patient to achieve the best health status possible. The interventions provided should not only be treatments but education and emotional support as well.
The trajectory theory has eight stages: pre- trajectory, onset, crisis, acute, stable, unstable, downward and dying. The pre-trajectory stage begins before the onset of the illness. The onset stage is when the illness presents itself and signs and symptoms appear. The crisis stage is a situation that threatens the health of the client, prompting the client to seek treatment. The acute stage is the active illness stage where clients typically require hospitalization for treatment of their disease. The stable stage is one where the illness is controlled by the treatments being received. If, however, the treatment cannot successfully control the disease, the client moves into the unstable stage. In this stage, however, hospitalization is not necessary. The downward stage is a deterioration in the client’s health with worsening of symptoms. Finally, the death stage is where the client succumbs to their chronic illness (Corbin, 1998, p. 36). Not all clients progress through every stage and clients do not necessarily move through the stages in a linear manner. As a nurse, it is important to intervene with treatments, medications, emotional support and patient teaching. The goal of the nurse is to first prevent the illness from developing and to keep the client in the pre-trajectory stage. However, should an illness develop, the goal is to effectively manage it and to keep the client in the stable stage. Finally, if an illness progresses, the nurse should provide comfort measures and counseling for a client who is in the death stage.
The transition theory is equally as important for nursing because patients in the hospital will often be experiencing turbulent and unstable periods in their lives. Many patients are experiencing a health crisis or the health crisis of a friend or family member. These crises can cause a wide range of emotional responses. Patients and their families will be moving through different transitional periods of their lives and the transition theory provides a framework for thinking about the different types of transitions and how a patient experiences this process. According to Schumacher and Meleis (1994), there are four different types of transitions: developmental, situational, health- illness and organizational (p.120). Developmental transitions are shifts from one developmental stage to another (i.e. becoming a parent). Situational transitions are life changes that arise out of various situations (i.e. becoming a widow). Health- illness transitions are transitions due to changes in health status. Finally, organizational transitions are those that affect persons within an organization or the organization’s clients (Schumacher and Meleis, 1994, p. 120). These two theories allow nurses to think of clients in a holistic manner: as a person going through life changes and transitions and reacting to those changes along a trajectory path. It allows nurses to visualize each unique client and to plan care in an individual manner.
Interview
I interviewed a 56 year- old male client, A.R., recently diagnosed with rectal cancer. Some of the key questions I had prepared prior to the interview were: “What coping mechanisms are you employing to cope with this new diagnosis? How has this diagnosis affected, if at all, your overall life goals and plans? Did this new diagnosis affect your family or friend relationships and if so, how?” Overall, A.R. seemed discouraged by the situation. He was not expecting such a serious diagnosis and stated, “All this… the seriousness of it… is just starting to sink in” (A.R., personal communication, October 15, 2008). In response to the first interview question about his coping mechanisms, A.R. stated that he tried to talk more with his family and friends, with whom he was very close. He also stated, “I try to laugh every day now. Laughter is good for you” (A.R., personal communication, October 15, 2008). According to Kyngas, Mikkonen, Nousiainen, Rytilahti, Seppanen, Vaattovaara, & Jamsa, (2000), “A chronic illness, such as cancer, brings about permanent changes in an individual’s life. These changes in lifestyle present coping demands…” (p.6). A.R. was responding to these increased coping demands he was experiencing by increasing the utilization of resources available to him to meet those needs. While discouraged by his situation, he appeared to be coping well and was utilizing effective mechanisms.
To the second key question about how the diagnosis had affected his life goals, A.R. answered that he had put a new emphasis on his family. He stated, “My family has become so much more important to me now, especially my kids. I just want to try and spend as much time as possible with them” (A.R., personal communication, October 15, 2008). This response led into the third question about how the diagnosis had affected his personal relationships. Due to his diagnosis he had tried to grow closer with his children and fiancée. At this point, as I learned more about A.R. and what was most important to him, the interview progressed into talking more about his fiancée and children and his relationship with them. He said that he had had some ups and downs and his fiancée was one of the major positive forces in his life. He stated that she had become even more important in his life now because she had been so supportive. They had grown even closer as a couple due to her continued support. A.R. stated the progression of his illness had been fast. Though he was recently diagnosed with rectal cancer, he had also had a colostomy just two days prior to the interview. Obviously, the rapid progression of his illness was a little overwhelming, however, he stated that without the continued support of his fiancée, he “did not know how he would have done it” (A.R., personal communication, October 15, 2008). A.R. expects that since the cancerous part of his bowel had been removed and a colostomy placed that he could begin to recover and be discharged home. He hoped the cancer would not metastasize to other parts of his body so he would not have to get chemotherapy.
Within the trajectory theory A.R. is currently in the acute stage because he has an active illness (cancer) that requires him to get treatment in the hospital (colostomy). The nursing implications for A.R. would be to monitor him to make sure he is still stable after surgery, encourage deep breathing and coughing, and to teach him about colostomy care so that he can be discharged and hopefully move into the stable stage of the trajectory theory. A.R. is experiencing some difficult transitions at this time. He is dealing with a situational transition from being in the hospital and adjusting to his new colostomy. A.R. is also dealing with a health- illness transition from recently having a decline in his health status due to being diagnosed with rectal cancer.
Variables Affecting the Client’s Trajectory
There are many variables affecting A.R.’s trajectory within his chronic illness. The first key variable is his economic status. A.R. is unemployed but receives Medicaid financial assistance. However, he may not be able to afford adequate housing or food and not all of his medical expenses may be covered. This affects his care because in order to move into the stable stage of the trajectory theory he will need to effectively manage his care at home, which requires these necessary resources. It would be appropriate to refer A.R. to the social and financial services provided by the hospital. Another variable affecting A.R.’s trajectory is his family’s support. His strong emotional support from his fiancée is a positive influence in his life. A.R.’s children are fully grown and live out of the area, however, he reported that he was close with his children and frequently talked with them on the phone. This healthy relationship with his family and loved-ones has a positive impact on his trajectory. His family relationships will ease his situational transition as he deals with his recent hospitalization. A.R. also mentioned that his family was one of the most important influences in his life and a very effective coping mechanism. In fact, his fiancée was willing to attend the colostomy teaching provided by the colostomy nurse and wanted to learn as much as possible about proper care. Therefore, his family will help advance his stage in the trajectory theory to stable by helping to support him as he attempts to control his illness regimen.
The third key variable is A.R.’s other illness factors. A.R. suffered a heart attack a few years ago; however, his cardiac problems are effectively controlled by his medication regimen. This cardiac history could affect his stage within the trajectory theory because if he were to have another heart attack or other complications he could move to the crisis stage or other stages of the trajectory theory. Therefore, we as nurses must be aware of his cardiac history and work to prevent any future complications.
Conclusion
There are many factors that determine a patient’s placement within the trajectory theory. The patient’s stage can be altered not just by their most pressing illness but also by other factors such as previous illness, coping mechanisms or available support systems. All patients are unique and have different needs. In order to provide complete and adequate care as nurses we must formulate a plan encompassing many factors. The transition and trajectory theories allow nurses to frame their thinking and understand the patient’s needs and situation. Utilizing these frameworks in practice allows nurses to better plan care for better patient outcomes.



References

Corbin. (1998). The Corbin and Strauss Chronic Illness Trajectory Model: An Update. Scholarly Inquiry for Nursing Practice: An International Journal, 12, 33-41

Kyngas, Mikkonen, Nousiainen, Rytilahti, Seppanen, Vaattovaara, & Jamsa. (2000). Coping with the Onset of Cancer: Coping Strategies and Resources of of Young People with Cancer. European Journal of Cancer Care, 10, 6-11

Schumacher and Meleis. (1994). Transitions: A Central Concept in Nursing. IMAGE: Journal of Nursing Scholarship, 26, 119- 127

Patient Teaching Plan

Patient Teaching Plan

The Importance of Patient Teaching
A teacher is one of the most crucial roles of many that nurses perform every day. One may not initially think of a nurse as a teacher, however, patient education is a primary duty shared by many healthcare providers. In fact, according to Freda, “Nurses and nurse midwives have historically considered patient education one of their most important responsibilities” (2004, p. 203). Patient teaching is especially critical when related to cardiac issues in the elderly because patient cases can be complex and involve numerous medications. There is often client confusion about the beneficial effects of different medications, their side effects, risks, and how often they should take each dose. Patient teaching is useful when introducing any new medication. It is especially important with cardiac medications because when these drugs are not taken properly their adverse effects can be damaging or even deadly.
Client Background
S.R., accompanied by her daughter, presented to the emergency room complaining of chest pain. S.R. is a widowed 89 year-old, Caucasian female who lives in Lowell, Massachusetts with her daughter. She was a home- maker for many years before the death of her husband and recent decline in health status. She has Medicare and Medicaid, and sees a doctor regularly. She finished high school and graduated with a diploma and did not attend college. S.R. considers herself a devoted Roman Catholic. She has a family history of heart disease; her mother died of a heart attack when S.R. was in her forties. She and her daughter were on vacation for the week in York, Maine. It was their last day of vacation and they were driving back home when S.R. began to experience chest pain. She described the pain as substernal pressure that came and went about every five minutes (personal communication, September 15, 2008). Eventually the pain would not go away and that was when her daughter became frightened for her mother’s health. Her daughter pulled the car over and called an ambulance. S.R. was transferred from the emergency department to the coronary care unit for monitoring and to receive a stress test after two days. Prior to this episode, S.R. had never experienced chest pain, however was on medications to lower her blood pressure. After evaluation, S.R. was diagnosed with chest pain and angina. Her nursing diagnoses were Fear related to separation from support system during hospitalization and unfamiliarity with the environment and Deficient Knowledge (of Stress Test Procedure and New Medications) related to lack of exposure and unfamiliarity with information resources. A nursing diagnosis of Fear was chosen because according to Newfield, S.A, Hinz, M.D., Scott Tilley, D., Sridaromont, K.L., & Maramba, P.J. (2007), Fear is defined as a “response to a perceived threat that is consciously recognized as danger” (p. 553). S.R. would be separated from her daughter, or support system, during the test and also perceived the test as an immediate threat. A nursing diagnosis of Deficient Knowledge was also applied because the patient verbalized a lack of understanding of concepts related to the procedures and medications.
Learning Needs
S.R. had a lot of new information to learn. She needed to learn what to expect with the procedure of a stress test and what the results meant to her care. The patient verbalized she was quite anxious about the test by stating, “I have never heard of a stress test. What will I have to do?” (Personal communication, September 15, 2008). Her doctor also prescribed Toprol- XL, which was a new cardiac medication for S.R. Its effect, use and side effects needed to be discussed. S.R. and her daughter had some questions about how this medication fit into her existing regimen and its side effects.
Based on the schedule for the day, the priority learning need was the information about the stress test because she was scheduled to leave the coronary care unit in the morning for the procedure. After she returned from the test, more discussion about the medications would take place and teaching would begin about her new medication. It was important to wait until after the test because S.R.’s anxiety level was so high. The patient’s responses helped to guide the decision about what was a top priority. S.R. needed to be reassured about her test in the morning so it was the most important goal.
Student Knowledge
I had to review some information and increase my own knowledge level prior to the patient education session. I had never seen an Adenosine stress test so I needed to learn how the procedure was going to be performed and its approximate length. I also had to understand the difference between the adenosine stress test for which she was scheduled versus the treadmill stress test. I needed to know what the Adenosine was going to feel like so she could be prepared to feel the side effects, like a racing heartbeat. S.R. needed to receive nuclear imaging before and after the test, so I had to learn how this procedure was performed, what radionuclides were, the position she would have to maintain throughout the test and its approximate length. Finally, I needed to know that the results would take approximately two hours to come back from the stress test. I got this information speaking with more experienced nurses and also from the American Heart Association’s Website. In terms of her medications, I needed to know Toprol’s action, use, dosage and how often she would have to take it, the side effects and adverse effects. I then needed to arrange all the information in a way that was easy to understand.
Client Learner Assessment
Assessing client readiness for learning is extremely important. If a client is not ready to learn then the amount of information they understand or retain from the teaching session is severely reduced. Because S.R. was anxious about her stress test, the first teaching session was limited to reassuring her and informing her about this specific procedure. Attempting to teach other material at the time would not have been effective. It was clear from the start that due to her anxiety the type of learner she was right now was one that was asking a lot of questions. She needed someone to sit down with her and explain the procedure calmly while immediately answering her questions so she would not have to dig for answers. Reading materials such as pamphlets at the time would have been less effective because she was too anxious to focus on the material. Similarly, her daughter was very concerned and would find it helpful to ask questions.
S.R. was in the acute stage of the Trajectory theory. According to Samuels, the acute stage of the Trajectory theory is characterized as an “active illness or complications that require hospitalization or management” (2008). S.R.’s illness had progressed from hypertension to angina, which ultimately required hospitalization. In addition to this somewhat fragile state, S.R. also had some barriers to her learning. She was hard of hearing and wore an assistive hearing device, however, would frequently have to ask people to repeat what they had just said or to speak up. In order to work around this barrier, it would be important not only to speak loudly and in a clear voice, but also to check more frequently to be sure that she was hearing and understanding the information correctly.
Each assessment prior to the teaching session was of utmost importance because it allowed the teaching to go smoothly and also to be individualized to the patient. Discovering S.R.’s readiness, her learning style, stage of change and some barriers allowed me to anticipate problems and work out solutions prior to the teaching. Similarly, the teaching plan must be altered and individualized, especially for the elderly, in order to be more effective. According to Ryan, A.A. & Chambers, M., (2000), “Older people are not a homogenous group and consequently education programs must be tailored to acknowledge individual differences in perceived need and motivation” (p. 733). Therefore, great care was taken to find out what S.R. considered to be most important and tailor the teaching to address those concerns.
Patient Goals
Several goals were set for S.R. by discussing her priorities and individual needs. The goals that were created were then reviewed and agreed to by the patient prior to beginning to achieve them. Due to the timing of her stress test and anxiety level, it was agreed that the teaching would be split into two sessions. The first session focused on teaching related to the stress test. The outcomes for this session were that S.R. should feel less anxious about the stress test and be able to describe the basic process of a stress test. During the first teaching session both of these outcomes could be completed because learning the basic steps of a stress test will lead to a reduction in anxiety. The behavioral objectives for achieving this outcome were:
• Client will verbalize the basic steps of a stress test prior to testing.
• Client will verbalize a reduction in anxiety/ fear level prior to the stress test.
The first objective is in the cognitive domain of Bloom’s Taxonomy of Learning (Bloom, B.S., 1956). It is in the cognitive domain because it requires the client to learn and understand the basic process of a stress test. The second objective is a combination of both the cognitive and affective domains in Bloom’s Taxonomy because through learning and understanding the process of the test the client will feel less anxious about the process (Bloom, B.S., 1956).
The second teaching session focused primarily on the new cardiac medications. The outcomes for this teaching session were that S.R. would understand why she is taking the new medications, the basic principles of how they work and when to take them. All of these objectives should be achieved within the timeline stated because the information is important for patient safety. The behavioral objectives for achieving these outcomes were:
• Client will verbalize at least one therapeutic effect and at least one adverse side effect of Toprol- XL prior to discharge.
• Client will demonstrate correct technique of checking for minimal pulse prior to administration of Toprol- XL prior to discharge.
• Client will verbalize one reason why Toprol- XL cannot be abruptly discontinued prior to discharge.
The first objective is in the cognitive domain of Bloom’s Taxonomy because she is required to learn information about the medications (Bloom, B.S., 1956). The second objective is a combination of the psychomotor and cognitive domains of Bloom’s Taxonomy because it requires S.R. to physically check her pulse to be sure it is not too low and also to cognitively remember what number is too low for the medication (Bloom, B.S., 1956). Finally, the third objective falls into the cognitive domain of Bloom’s Taxonomy because S.R. must understand the possible adverse effects of abruptly discontinuing Toprol- XL (Bloom, B.S., 1956).
Teaching Strategies
The Health Belief model was used to frame the teaching and proved to be a very effective strategy. According to the University of Twente (2004) a person will “take a health- related action if: they feel a negative condition can be avoided, have a positive expectation that by taking a recommended action he/she will avoid a negative health condition, and believe that he/she can successfully take a recommended health action (¶ 2)”. Due to S.R.’s fear about her recent change in cardiac status it had motivated her to avoid a negative outcome. She believed it could be accomplished through teaching because she could learn how to prevent further complications. My goal through teaching was to show S.R. that the best way she could avoid negative complications was to closely follow her medication regimen and to complete the stress test. Unfortunately, exercise was not an option for her due to her age and painful degenerative disk disease. The Health Belief model was the best approach because it allowed the teaching to be tailored to the patient’s situation.
The teaching strategy for the first teaching session was to talk calmly with S.R. and her daughter to ease their anxiety prior to the stress test. For the second teaching session the plan was to again speak with S.R. and be available to answer questions but also give a tailored hand- out so she has something to reference about her cardiac medications at home. The teaching strategy was based on the cognitive theory of learning. According to Rankin, S.H., Stallings, K.D. & London, F., the cognitive theory of learning is “one that requires thinking” (p.87). Most of the teaching involves the learning of new concepts and information.
The teaching will be evaluated based on whether the outcome was met by the timeline set. For example, if S.R. can verbalize a reduction in her anxiety level prior to the stress test then that objective will be considered successful. If the outcome was only partially met, for example, if S.R. can only verbalize one therapeutic effect of Toprol- XL but cannot verbalize an adverse side effect, then the teaching strategy will be adjusted. For example, if it were found that S.R. simply could not complete the outcomes, perhaps it would be helpful if just her daughter can understand the information about the medications because she lives with S.R. full-time and helps administer her medications at home. The quality of teaching will be evaluated by asking S.R. if she has understood the concepts and if she has met the goals.
Evaluation of Outcomes
S.R. was able to meet all of the objectives set for both of the teaching sessions. She was able to meet all of the objectives successfully for a number of reasons. She was motivated as indicated by the Health Belief model and was very involved in the planning of the goals. The goals were tailored to her specific needs and were relative to her situation at the time. Prior to beginning the teaching the goals were discussed and S.R. believed them to be realistic and achievable.
My thinking process for the teaching session was very structured by the Health Belief model and by the patient’s individual needs. The goals set were within the framework of the Health Belief model, however, they also kept the patient’s wishes and needs in mind. I specifically looked for information that the patient was telling me was the most important thing to her at the time, which for S.R. was her fear of the stress test. Therefore, the teaching was structured around her feelings and abilities. The only problem encountered was her anxiety level. Because of her stress the teaching session had to be split into two parts, otherwise the teaching would not have been as effective.
Conclusion
The patient education session was very successful. S.R. completed all the goals previously set. This was due to her involvement with the planning of the goals and also because of the individualization of the teaching plan. It is essential that these two principles be involved in the planning for subsequent patient education experiences. It was due to the incorporation of patient involvement in planning and also the individualization of the teaching that this particular experience was so successful. While nurses and other healthcare providers agree that patient teaching is one of the most important responsibilities of their roles, it is easy to rely solely on standardized teaching plans and pamphlets for patients due to time constraints. However, with careful planning and individualization of teaching a much more effective education session can take place. Patients will experience better completion of objectives and better outcomes.






References

Bloom B. S. (1956). Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc

Freda, Margaret. (2004). Issues in Patient Education. Journal of Midwifery & Women’s Health, 49, 203-209

Newfield, S.A, Hinz, M.D., Scott Tilley, D., Sridaromont, K.L., & Maramba, P.J. (2007). Cox’s Clinical Application of Nursing Diagnosis. Philadelphia, P.A.: F.A. Davis Company

Ryan, A.A. & Chambers, M. (2000). Medication Management and Older Patients: An Individualized and Systematic Approach. Journal of Clinical Nursing, 9, 732-741.

Samuels, Joanne. (2008, September 11). Transition and Trajectory: Module 1: Knowing your Patient. Presented at a Nursing 619 lecture at the University of New Hampshire

University of Twente. (2004). Health Belief Model. Retrieved September 23, 2008 from http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/

Fall 2008 Courses

1. Nursing 615: Adult Health Nursing
2. Nursing 615c: Adult Health Nursing Clinical
3. Nursing 619: Clinical Decision Making I
4. Nursing 645: Nursing Research

Wound V.A.C. Basics Paper for Clinical Presentation

Wound V.A.C Therapy

Wound vacuum-assisted closure (V.A.C.) devices are on the forefront of wound healing technology today. A wound V.A.C. device is a specialized dressing system that provides negative pressure to wounds to promote healing. As nurses, it is our responsibility to know how to provide competent care for patients with a wound V.A.C. device. We must know the basic principles of how a wound V.A.C. device works, what is to be expected for a patient with a wound V.A.C. device and how to change the dressings of this unique therapy tool.
Created as a device to assist the healing process of larger wounds, wound V.A.C.s work in a relatively simple manner. A wound V.A.C. uses specialized foam and an occlusive dressing that seals the vacuum at the wound site. The dressing is connected to a canister, which applies suction and collects the exudates fluids. The wound V.A.C. “removes fluids and infectious materials, helps protect the wound environment, helps promote perfusion and a moist healing environment and helps draw wound edges together” (KCI Licensing, n.d.). The wound V.A.C. works on the principles of macrostrain and microstrain. Macrostrain is the physical biological response of the tissue and is seen immediately as wound edges are drawn together (KCI Licensing, n.d.). Microstrain is how the V.A.C. device works on a cellular level. It is the straining or pulling of the individual cells by the negative pressure (KCI Licensing, n.d.). These cells respond to the strain by turning on certain pathways that promote healing. There is an increase in cell proliferation as well as metabolic activity. Both these factors lead to the formation of new granulation tissue (KCI Licensing, n.d.).
A wound V.A.C. therapy is initiated in a number of wounds that are generally difficult to heal. The most common wounds types are chronic, acute and traumatic wounds, chronic stage III or IV pressure ulcers, dehisced incisions, neuropathic (diabetic) ulcers, skin grafts and open abdominal wounds (Washington State Department of Labor and Industries, n.d.). However, wound V.A.C. therapy is not appropriate for all patients. Some major contraindications of a wound V.A.C. device are malignancy in the wound, untreated osteomyelitis and necrotic tissue with an eschar. The devices are also never placed over exposed blood vessels or organs (Washington State Department of Labor and Industries, n.d.).
One of the most important actions a nurse must do to deliver competent care is assessing patients. Assessment of the wound V.A.C. device should be incorporated into the standard assessment of a patient and is required every shift (KCI Licensing, n.d.). The nurse should assess the dressing integrity. If the negative pressure is intact, the dressing should feel hard and collapse into the wound. If a leak is present the pump alarm should sound and a whistling noise might also be heard. Press around the tubing and drape to ensure that an adequate seal is in place. If a leak is present excess drape can be used to seal leaks. However, if there is adequate drape seal and the suction is still not working, make sure the T.R.A.C. pad is attached to both the drape and the wound V.A.C. unit. Furthermore, be sure the therapy button is on and the unit has enough power or is connected to a power source. It is important the unit be assessed to make sure that it is working properly because active negative pressure must be maintained for a minimum of 22 hours per day and preferably for 24 hours per day. If the therapy is turned off more than 2-hours, the dressing must be removed and replaced with a moist saline dressing until therapy can be resumed. An important part of the assessment is noting the amount and color of the drainage so any changes can be dealt with properly. A sudden, rapid increase in bright, red blood in the tubing or canister requires immediate assessment (KCI Licensing, n.d.). Primarily, the client’s pain level should be assessed to provide adequate comfort especially if you are about to change the dressing. Finally, assess the client’s knowledge level about the purpose of the wound V.A.C. and purpose of dressing changes and provide any patient teaching necessary.
Dressing changes are an important part of a wound V.A.C. system and provide the nurse a chance to assess the wound bed for healing. The schedule for dressing changes may vary depending on the wound; “an infected wound may need a dressing change every 24 hours whereas a clean wound may only be changed three times a week: usually Monday, Wednesday and Friday” (KCI Licensing, n.d.).
There are a number of steps to completing a dressing change. First, equipment should be gathered which includes foam, the drape, T.R.A.C pad with tubing, the canister, pump, saline, disposable biohazard bag and clean or sterile gloves. If this is a new surgical wound, sterile technique is appropriate. Chronic wounds may use clean technique (KCI Licensing, n.d.). Next, position the client comfortably and drape to expose only the wound site. The therapy unit should be turned off. Then remove the drape by gently stretching the transparent film horizontally, and slowly pulling up from the skin. Using this technique reduces stress on suture line wound edges and reduces irritation and discomfort. Next, the old foam dressing should be removed. Observe the appearance of drainage on the dressing. Then irrigate the wound with normal saline. Irrigation is important because it removes wound debris. A skin prep may also be applied to the periwound skin if indicated for protection. The periwound skin should be cleaned and dried as well. In addition, wound cultures may be ordered on a routine basis. However, “when drainage looks purulent, there is a change in amount or color, or drainage has a foul odor, wound cultures should be obtained even when they are not ordered for that particular dressing change. An order can be obtained at a later time” (KCI Licensing, n.d.). Next, assess the wound and document measurements and color of the wound bed. Normally, exudate volume should decrease as extracellular debris is removed. However, exudate may become more sanguineous as perfusion to the wound improves. The wound bed will also become a deeper red as perfusion improves. As granulation tissue forms and the wound contracts, new epithelial growth should be noted at the wound edges. Decrease in wound measurements should be noted weekly (KCI Licensing, n.d.).
After the wound bed is assessed, new sterile/ clean gloves should be applied. The same gloves should not be used so as not to contaminate the wound. Next, prepare V.A.C. foam by cutting the foam to fill the wound without packing tightly or overlapping healthy tissue. Be sure to not cut the foam over the wound and rub the foam edges to remove any loose pieces. Place foam into wound cavity covering the entire wound base, side, tunnels and undermined areas. More than one piece of foam may be used if the wound is larger than the largest foam available. According to KCI Licensing, “if using more than one piece of foam, the pieces must touch one another. Note the number of foam pieces used on the dressing and in progress note” (n.d.). Cut the drape to cover the foam dressing plus a three to five centimeter border to cover the intact periwound skin. Also, cut a 2 cm hole in the center of the drape. Then, position the center of T.R.A.C. pad directly over the 2 cm hole in the drape and apply pressure around the pad to assure adhesion. If possible, avoid placing the tubing over bony prominences or in creases. Next, insert the canister into the V.A.C. unit and connect the T.R.A.C. pad tubing to the canister tubing and assure both clamps are open. Finally, place the V.A.C. unit on a level surface and turn the power button on. Using the screen touchpad and adjusting the settings as ordered can initiate therapy (KCI Licensing, n.d.).
Wound V.A.C. therapy in a new and developing technology that is becoming more and more common. The therapy can be very beneficial to patients when applied correctly. There are many aspects to applying wound V.A.C. therapy, however, with adequate knowledge, nurses can deliver safe and competent nursing care to all patients.



References:

KCI Licensing. (n.d.) How V.A.C .® Therapy Works. Retrieved April 30, 2008, from http://www.kci1.com/82.asp

Washington State Department of Labor and Industries. (n.d.) Wound VAC. Retrieved April, 30, 2008 from http://www.lni.wa.gov/ClaimsIns/Files/OMD/WOUNDVAC.pdf