HHC Health & Home Care Clinical Policy And

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HHC HEALTH & HOME CARE Section: 7-20 Skin Care: Applying a V.A.C. Dressing __RN EQUIPMENT: Saline Gauze Sterile swabs Gloves Alcohol wipes Scissors Protective Barrier Wipes VAC Foam Kit (Foam, TRAC Pad/tubing, drape) PROCEDURE: 1. Applying the dressing: The VAC dressing should be changed once every 48hr, or every 12hrs in case of infection. Use gloves, gown and goggles if splashing or exposure to body fluids is likely. Treat all body fluids as if they are infectious. All steps should be taken under the direction of a physician and in accordance with institutional protocols. a. Gently remove the old VAC dressing (if applicable) and discard per agency protocol. b. Debride eschar or hardened slough if present. c. Achieve hemostasis (avoid use of bone wax). d. Aggressively clean wound according to agency protocol or physician order. e. Irrigate wound with normal saline or solution per physician order. f. Clean and dry periwound tissue: If skin is moist due to perspiration, oil or body fluids, a degreasing agent may be required. g. Apply skin prep such as Mastisol, No-Sting, etc. to periwound tissue. For patients with fragile periwound tissue, a thin-layered dressing such as KCI drape, Duoderm, or Tegaderm may be applied to the periwound area. h. Note wound dimensions and pathology and select appropriate foam. Cut the foam to the dimensions that will allow the foam to be placed gently into the wound. Do NOT cut the foam over the wound. Gently rub the freshly cut edges of the foam to remove any loose pieces. Also, do NOT pack the foam into the wound. i. Gently place the foam into the wound cavity, covering the entire wound base and sides, tunnels and undermined areas. Count the pieces of foam and annotate the total number in patient record. Also annotate on drape with permanent marker. If the wound is larger than the largest dressing, more than one dressing may be required. Ensure edges of multiple pieces of foam are in direct contact with each other for even distribution of negative pressure. j. Size and trim the drape to cover the foam dressing as well as an additional 3-5 cm border of intact periwound tissue. Do NOT discard excess drape, you may need it later to patch difficult areas. k. Once the wound is filled with the foam dressing, cover the entire wound with drape, including the foam dressing and about 3-5cm of surrounding intact skin. Cut a 2cm hole in the drape, large enough to allow fluid to pass through the dressing. Lift the drape with your thumb and forefinger and cut the drape. It is not necessary to cut into the foam. Apply the TRAC Pad opening directly over the hole in the drape. Apply gentle pressure around the TRAC Pad to ensure complete adhesion. Give particular attention to the position of the tubing, avoiding placement over bony prominences, or in creases in the tissue. Always cut a 2cm hole in the drape. Do NOT cut a linear “slit” in the drape. When negative pressure is applied a slit may collapse and close, preventing negative pressure from reaching the wound. DO NOT cut off the TRAC Pad and insert the TRAC tubing into the foam. This will cause the therapy unit to alarm. 2. Treating Multiple Wounds: a. “Y” connecting: By applying a Y-connector to the canister tubing, one VAC Therapy unit may be used to treat multiple wounds on the same patient simultaneously. b. Bridging: Wounds that are in close proximity to one another and of similar pathologies may also be treated with one VAC unit using another technique known as “bridging”. The advantage of bridging is that it requires only one tubing decreasing the possibility of leaks. (1) Protect intact skin between the two wounds with a piece of VAC drape or another skin barrier (such as Tegaderm). (2) Fill both wounds with foam, then connect the two wounds with an additional piece of foam, like a bridge. All foam pieces must come into contact with each other. (3) It is important to apply the tubing or TRAC Pad in a central location to ensure exudates from one wound is not being drawn across the other wound. 3. Applying the VAC Therapy Unit: a. Remove canister from the sterile packaging and push it into the VAC unit until it clicks into place. If the canister is not engaged properly the VAC alarm will sound. b. Connect the dressing tubing to the canister tubing. Make sure both clamps are open. c. Place the VAC unit on a level surface. The VAC Classic unit will alarm and will discontinue therapy if unit is tilted beyond 45 degrees. d. Turn on power button. Adjust the VAC unit setting per the Recommended Guidelines for Treating Wound Types (See Section 7.25). Press Therapy On/Off button to activate negative pressure therapy. In less than 1 minute of operation, the VAC dressing should collapse, unless leaks are present. If a leak is 130
HHC HEALTH & HOME CARE Section: 7-20 Skin Care: Applying a V.A.C. Dressing __RN heard or suspected (small leaks may create a whistling noise), fix it by gently pressing around the tubing and wrinkles to better seal the drape. Also use excess drape to patch over leaks. 4. Follow-up on Dressing Integrity: a. It is recommended that a clinician or patient visually check the dressing every 2hrs to make sure that the foam is firm and collapsed in the wound bed while therapy is active. If not follow the tips below: b. Make sure the display screen reads THERAPY ON (on continuous 125 mmHg or ordered therapy. If not, press the THERAPY ON/OFF button). c. Make sure clamps are open and tubing is not kinked. d. Identify air leaks by listening with stethoscope or by moving your hand around the edges of the dressing while applying light pressure. e. If you find that the seal is broken and the transparent dressing has come loose, patch with strips of adhesive drape as needed. 5. Maintaining a Seal: Maintaining a seal in the dressing is an important key for successful use of VAC Therapy. The following are some ways to best maintain the integrity of the seal: a. Dry periwound area thoroughly after cleansing. Use a skin prep or degreasing agent to better prepare the skin for the drape application (e.g. Mastisol, No-Sting). b. Frame wound with a skin barrier to enhance the seal for wounds with delicate periwound tissue or in convoluted areas. c. Reduce the height of the VAC GranuFoam dressing by cutting or beveling it to treat areas that are shallower or near the perineal area. d. Try to position the dressing tubing on flat surfaces and away from the perineal area, bony prominences, or pressure areas. e. Secure or anchor tubing with an additional piece of drape or tape several centimeters away from the dressing/wound. This prevents pull on the wound area, which can cause leaks. f. Another application option for the VAC Classic only is: Seal the drape over the foam with the tubing removed. Then, make a slit in the top of the dressing through the occlusive drape and ½ to 1 cm into the foam. Lay tubing inside the shallow slit in the foam so that the foam surrounds holes in tubing. Cut strips of drape, and then patch over drape hole and tubing. 6. Disconnecting from Unit: Patients should only be disconnected from the unit for short periods, and no more than a total of two hours per day. a. To disconnect for short periods of time close both clamps on the tubing, turn the unit OFF, disconnect the dressing tubing from canister tubing, and cover the ends of the tubing with gauze and secure or, if available, use a tubing cap. b. To re-connect: remove the gauze from the ends of the tubing, connect the tubing, unclamp the clamps and turn therapy ON. Previous therapy settings will remain the same. 7. Canister Change: The VAC canister should be changed when full (unit will alarm), which averages about once every 3-5 days. At a minimum, the canister should be changed weekly to control odor. System may contain body fluids. Follow Standard Precautions: a. Tighten clamps on canister tubing and dressing tubing. b. Disconnect canister tubing from dressing tubing. c. Remove canister from unit. d. Dispose of canister according to specified protocol in setting. 8. Dressing Removal: a. Raise the tubing connectors above the level of the therapy unit. b. Separate clamp on the dressing tubing. c. Separate canister tubing and dressing tubing by disconnecting the connector. d. Allow the therapy unit to pull the exudates in the canister tube into the canister then tighten clamp on the canister tubing. e. Press THERAPY ON/OFF to deactivate pump. f. Gently stretch drape horizontally and slowly pull up from skin. Do NOT peel. Gently remove foam from wound. If dressing adheres to the wound base, consider applying a single layer of non-adherent, porous material (e.g. Mepitel, Adaptic, N-terface, or wide-meshed Vaselineimpregnated gauze) between the dressing and the wound when reapplying the dressing. The non-adherent material must have wide enough pores to allow unrestricted passage of air and fluid. Because tissue growth into the VAC dressing may cause adherence, also consider using the VAC VersaFoam or consider more frequent dressing changes. If pain is experienced during dressing change consider, with a physician’s order, introducing 1% lidocaine solution down the tubing, or injected into the foam with the pump turned on at a lower pressure (50mmHg). After instilling the lidocaine, clamp the tube and wait 15-20 minutes before gently removing the dressing. If previous dressing were difficult to remove, introduce 10-30 cc’s of normal saline into tubing to soak underneath foam (ensure dressing tube is unclamped). For best results, let it set for 15- 30 minutes. Saline can also be injected directly into the foam while low vacuum (50 mmHg) is applied to the dressing. Clamp the tubing once the saline starts to flow into the dressing tubing. Wait 15-30 minutes, then gently remove dressing. g. Discard disposables in accordance with applicable regulations. 131
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