Freaking out over wound vac

snowfreeze, BSN, RN · Jun 23, 2006

Sending you to do a procedure you have not been oriented to is not good management practice.

NrsJena · Jun 23, 2006

I agree with Tweety- after a few, it gets easier. :) I have never used any powder under the foam, but if that was the order, I'm sure there was a reason. She will be fine without it though. For future reference, adaptic can be applied to the tissue under the foam. This helps prevent the foam from adhering to the tissue so much. As for the plastic circle where the tube connects: you are right. This should be placed completely over the foam. The fun part is trying to "bridge it"-UGH. But that is another story.... :)

You did fine. Next time will be easier :)

allele, LPN · Jun 23, 2006

Hi!! First, I want to say you did a FANTASTIC job under the circumstances! I've been working with VACs for years and it really does get easier with practice, like many have been saying. I also think it was unfair to send you out alone with no experience...as easy as they get they're still VERY intimidating to people that don't regularly work with them!

I'm with everyone else that never used a powder on the skin, so I'm sure the patient will be just fine! As far as the foam sticking, NrsJena is right in that adaptic really helps, and if there's no adaptic then I often use saline and let the sponge soak it up a little bit, helps it come off. Representatives for VAC recommend it around here, actually. And you're right, the disc isn't supposed to go on skin, I've seen this happen, makes some very ugly marks on the patient. If the sponge is too small to fit the entire disc over, just protect the patient's skin with tegaderm first, then put more sponge over the tegaderm to make a wider area for the disc. As long as all sponges are touching the system will work fine. Never let sponge touch naked skin, it could mascerate.

Again, you did a terrific job! :)

P.S. Will KCI reps go out to houses to help you out? They are a LIFE SAVER for us in the hospital!!

lsyorke, RN · Jun 23, 2006

If I have a known hard sponge removal, I cut the tubing and "fill" the sponge area with saline using a bulb syringe(with the covering still intact). Let it soak for a few minutes and then take the sponge out.. works like a charm!!!

Tweety, BSN, RN · Jun 23, 2006

That's a new trick I'll have to try with the saline. I use saline, but not in that fashion.

Also injecting 2% Lidocaine with a needle in various parts of the sponge can sometimes help with the pain.

I learned the other day that fresh blood releases healing properties, so drainage/blood is a good thing in a wound vac.

nursie-nurse · Jun 23, 2006

In the hospital where I do my training I saw them do a wound vac and they used ns to get the foam off and it was very painful for the lady-they gave her ms before they started and when they sarted the vacuum it was very, very painful to her. They used foam on hers. Her wound was 4.5X3X2-3in.

I know my problems are meaningless to you all but that doesn't make them go away. Please help with some words of encouragement.
I was called out today to a new admits house to change a dressing (no one told me what it was) because the nurse who covered that area was a man and the patient didn't want a male nurse. So the nurse meets me with the papers and I go over. It is a patient with an abdominal abscess and a wound vac. The wound was directly next to the pt's ileostomy bag.
I wish I had checked the orders in detail before I started, but I got ahead of myself and got really nervous.
I have had an inservice on wound vacs but have not done one on a live person before, and of course, the first thing the patient asked was, have you ever done this before?
But I get to work on taking off the old dressing. The patient's skin is very sensitive and she winces and yells out even though I am as gentle as I can be. But the bad part doesn't come until I try to remove the foam from the wound bed. It is stuck very tightly and it takes an hour to get the foam out because the patient is nearly jumping out of her skin from the pain (she took two Lortab before I started, but it didn't help much). So I call the wound center where she at the hospital and asked them for help. The nurse said it was odd this happened because she didn't act like it hurt when *they* changed it. The patient is a very alert woman who quickly reminded the nurse over the phone that when *they* changed the dressing she was still receiving IV pain meds and was still feeling the effects of being sedated from having the wound opened.
The wound had virtually no drainage after two days and I asked the nurse if it would be permissible to leave the wound vac off and use a sterile dressing instead?
Anyway, the doctor is not in today so they tell me to call back tomorrow and advise I put the wound vac dressing on. The DON told me anytime I needed help to call her, but everytime I have needed help and called her so far she has acted like I'm on my own and I should know what to do.
So I cut out my foam all neat and tidy and fit it on the wound bed, just like the old dressing was. Only when I start putting the membrane on I get really nervous and start sweating and I'm finding it increasingly difficult to function because the pt's granddaughter (who is a 1st year nursing student at a 4 yr college) has her face pressed practically in mine questioning everything I am doing and making me really doubt myself. So after I finished and she informed me the wound care center had it covered differently and that the way I had it the suctioning would not be right I told the patient that like it or not I was going to have to call in the nurse who was supposed to cover her area in the first place. So she said do what I need to. The male veteran RN, sweetheart he is, comes out. Well, he puts a different dressing on, in my opinion not as good as the one I had fixed (that round thing with the tube that connects to the wound vac was partly on her skin and I had been told the foam should be under that so it doesn't leave marks on the skin, but I really trust him so I don't say anything. When patient is comfortable we leave.
I'm home tonight going through the many papers and I see where it says home health nurses are to apply Miradex powder before applying the wound vac.
I DIDN'T APPLY MIRADEX POWDER!!! > insert smiley crying out in agony here
I'm worried sick here. Am I done? Will I be fired? She is scheduled to have the wound vac dressing changed again Saturday. Do you think it will be okay?

chadash · Jun 23, 2006

I love it when you all talk wound care.

NrsJena · Jun 23, 2006

I love it when you all talk wound care.

me too :)

HappyNurse2005, RN · Jun 24, 2006

I've seen a few wound vacs in my day (ok, in my year) and the dressings are complicated. One was an infected sternal incision wound(post open heart surgery), right between her breasts, and that sure made getting that top layer airtight tough. took 3 tries on my part.

as far as pain control, had a 70 something year old man who had a big ol hole in his upper chest from an infected post chest tube post lobectomy site with a vac. he used the fentanyl lollipops adn did ok with it.

the most complicated looking one was on two harvest sites on a pt's leg post cabg. it was the site right above the knee and one right below the knee and they communicated below the skin. so the black foam was in both holes, and then using more foam and qtips black foam was put into the tunnel between the two wounds, 2 track pads to a y connector, to the vac. luckily, i was only the assist on that one.

the most intriguing one i've seen is when i was walking thru the ortho unit to get back to my unit. glanced in a room-a pt had a vac on her head!

Jo Dirt · Jun 24, 2006

The agency I work for has what they call "mentors." I talked to one this morning who told me about the adaptic and also said have the patient turn the wound vac off about 30 minutes before we get there. We also got an order to give valium 30 minutes before the procedure. But the pt has decided the male RN will work out just fine after all so he will be taking over from here.

I've got a new, different issue today that has me pulling my hair out.

tyvin, BSN, RN · Jul 23, 2010

It's as complicated as you make it. The drsg change can be simple if you break it down into steps. And of course I would never remove a sponge drsg without a saline soak first.

The round nipple "thing" that goes over the sponge is called a track dressing.

The sponge is polyurethane if it's black and polyvinyl if it's white. Sometimes the white will be used to cover deep recessed areas first then black but in most instances the order will call for the black sponge.

Always us skin prep or skin barrier. I like the "No Sting Barrier Film" by Cavilon

YouTube has several videos showing the drsg change that are quite good. It's called Negative Pressure Wound Treatment (NPWT). There are many ways to change this drsging.

The track drsging (that clear nipple thing with the hose) must always be on sponge and never allowed to be directly on the skin or bruises happen that are called "hickeys"

If the wound is smaller you cut a piece to fit the wound then cut a larger piece to cover the sponge on the wound large enough where the nipple does not touch the skin. Before all this put down tegaderm or the like surroundng the wound so the larger sponge does not touch the skin (don't cover the wound). One thing I like to do is use a strip of drape to stabilize the sponge before putting the drape down.

The clear film is called drape. It can be tricky to learn to work with this stuff but basically after the first try you should get it.

I really like this treatment when done right the wounds almost seem to disappear. Oh and I've never used anything inside the wound bed (powder etc...). The trick is to stimulate the wound bed with sterile gauze soaked with saline. Before applying sponge make sure the wound edges are dry. The sponge should only fit directly over the wound (unless it's small then you use two sponges; one to fit and one to cover the fitted piece. I like to cut the sponge just slightly smaller then the wound. The key is the oxygenation so covering the wound with powder seems counter productive unless the powder is oxygen. Many times the wound surrounding area can be covered with a barrier similar to tegaderm to prevent skin breakdown (along with the film first). But many people don't do this; it falls under the category of personal preference.

This is a clean procedure. If you hear hissing when turning the machine on it could mean there's a leak so listen with your ear close to the dressing if this happens and plug accordingly.

One of the problems with this is that the drsging orders need to specify which "type" of sponge to use and usually don't. The other problem with this is the machine and the monopoly the company appears to have with it. I mean in terms that the machine cannot be privately owned and must be rented through the health insurance company (don't get me started on DME and supply companies that overcharge because they can). This also makes it quite spendy and sometimes difficult for home health practices. It's always approved for in the hospital but when you want a portable one to use at home they are denied in many instances that I've experienced.

OK folks; go to YouTube and watch a couple videos on the drsging change procedure and it won't seen so ominous anymore. I encourage my docs to use NPWT as I've seen some pretty impressive results from it. Read up in the physiology behind it so you understand the science of why this works so well IMO.

This should only be changed 3 times a week depending on the wound and the drainage. Once the drainage is under control revert to the Mon/Wed/Fri changes. But if it's draining large amounts continually the order should call for drsg changes accordingly.

Katwel · Oct 25, 2010

Don't beat yourself up first. Hey we have all been there trying to learn something new and I have been in homecare for over 2 years and I am now just beginning to feel comfortable with Wound Vac's. Like someone else said the more you do them the more confortable you will feel. See if you can go out with another more experieced nurse, but I did that and I still see things out in the field when I cover for other nurses pts that have Vac's that I was taught never to do. You can alway call the supplier, we use KCI and I have had the rep meet me with a patient when I was starting out and it really did help. The problem with home care too, sadly is that you are out there alone, you can alway call your supervisior, but is a bit more stressful than being on a floor where you can call for help. Just try to relax next time, think about what your doing, plan your steps and then proceed, and good luck.

Katwel