Freaking out over wound vac

[Jo Dirt]

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?

[Pepper The Cat, BSN, RN]

Yes - I think the pt will be fine - the nurse needs some serious TLC though!

Don't be so hard on yourself. You were doing a difficult drsg with no support or guideance. I've done several VAC drsgs and have never used Miradex powder ( don't even know what that is!) so the pt should be fine.

I think you need to go to your supervisor/manager/whatever and ask for an inservice about VAC drsgs. Once you learn how to do one, you will feel better. You also need to tell familes like the granddaughter to back off and let you work!

And I doubt you will be fired simply because you had difficulty with a new procedure!

[UM Review RN, ASN, RN]

I know my problems are meaningless to you all but that doesn't make them go away. Please help with some words of encouragement.

Wha???

Anyhow, back to the problem:

I really feel for you HHNs. I'd have to carry a laptop and have Internet access in order to use that for a resource, because no way would I remember all you have to know.

I was just taught the Wound Vac, and I don't recall the Mirapex powder either, so I would've done it the same way, MM.

Here's the Wound Vac link, and as you can see from the illustrations at the end, regarding open ab wounds, no Mirapex is used:

http://www.kci1.com/29-A-141_AbFoam_Brochure_2-05.pdf

Here's the main KCI link:

http://www.kci1.com/87.asp

[Tweety, BSN, RN]

Wound vacs can be a challenge, but the more you do them, the easier it gets. It is a quite painful experience for the poor patients. Patients often scream and carry on. Some are more dramatic than others, depending on their coping skills. I did one last week and the patient starting sobbing (with 10 mg of Valium, two percocets, 6 mg morphine and 25 mg Phenergan), when I was cutting off the outer dressing. "Sweetness I haven't really touched you yet").

Sometimes when patients have had it done over and over again I usually try to get some input from them as to how it's been done and how they want it done because some patients can be very anal retentative about their wound vacs. They don't realize there's more than one way to do things.

We don't use Miradex (don't know what it is either) so I'm sure your lady will be alright. Sounds like you did a great job.

[vanillaskye]

Just feeling your pain motorcycle mama. Like you, I am somewhat new to the vac. But I get more comfortable doing them as time has gone by. I had a patient recently where the black foam was stuck to the wound bed and the patient had to get it debrided out. The vac was in a very awkward spot-almost impossible to get a good seal and it was hurting her. The local ER sent the patient home without any treament. I just kept calling until I found a Dr. that would really look at the wound. The patient by that time had developed an abscess between the wound and the outer area of skin. And yes, she is diabetic.

As for the family members that hover like buzzards, sometimes you have to clear yourself a space. Tell them that you need to concentrate on what you're doing and that you'll answer questions before or after, but not during. Sometimes there is no greater relief than leaving a patient's home.

Good Luck in what you're doing.

[DONN]

I am on the Vac team at work and we seldom, if ever, apply the powder. The vac dressings can be somewhat intimidating to the first time user but it sounds like you did a good job. Its highly unlikely you would be fired over this IMO. Let yourself off the hook, its the weekend so now go out and enjoy.....

[PumpkinButt]

If there's no drainage, then a wound vac isn't indicated. The foam was growing into granulated tissue, which is why it was so difficult to remove. I had a pt come from the hospital once with a chunk of foam shoved way into a tunnel but it hadn't touched another piece of foam for awhile, so the tissue was growing into it. I sent him out that day to have it cut out. He ended up with an abcess because of it.

I use a stingless skin prep around the edges of the wound to protect the good tissue, and I always lay down thin strips of transpore over that to protect even further. I also use an adhesive remover to get the top opsite off. Just rub it over the top and it literally goos off in your hand. It's the best stuff!

There's quite a bit of info in the wound forum here that I posted about wound vacs with some tips and tricks as well. Good luck with your next change!

PB

[traumaRUs, MSN, APRN]

We get patients from the NH with wound-vacs sometimes and I don't touch them - have no clue what to do with them! I think you did just fine!

[CoffeeRTC, BSN, RN]

Yeah...what pumpkin butt said. Wound vacs are only indicated if there is alot of drainage. If the dressing was working before there should have been drainage collected. When the drainage stops they are d/c'd.

The biggest thing to remember is to fill the cavity, do not place the tubing directly in the wound bed and make sure the seal on the wound is air tight.

I've never used the powder either.

You did fine.

[donsterRN, ASN, BSN]

I think you did an amazing job in a very tough situation.

But don't you ever think that your problems are meaningless to the rest of us. You well know what a great, caring group of people there are on these boaards. OK?

[StNeotser, ASN, RN]

I only ever had one patient with one of these and she was an inpatient. the wound was on her heel and we had to change the dressing two times a shift because she kept moving. Before doing it myself, the wound care nurse gave me a demonstration and did it with anyone who asked so we were lucky.

Never did apply miradex powder. It's an incredibly difficult thing to do if you haven't done it before so I really wouldn't worry. I just got so much practice with this lady that I became an expert.

[UM Review RN, ASN, RN]

A-hem. Just want to add a couple of things I learned while reading this thread.

This is Multidex Gel . It also has a powder form. Is that perhaps what was used on the wound, MM? Because I did a search and found that

Mirapex is a Parkinson's drug, http://www.mirapex.com/pd/hcpControllers/Controller.jpf and Miradex appears to be an Internet shopping center of some sort. http://miradex.stores.yahoo.net/index.html