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