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CHAPTER 32 Skin Integrity & Wound Healing
from the soiled dressing. If other signs of infection are present (i.e., fever, tenderness, redness, swelling, purulent drainage), notify the health- care provider. ■ Suction cannot be maintained? Identify why the seal cannot be main- tained. If the wound is near the coccyx and gluteal fold, use a dollop of paste to help fill in the crack and maintain a seal. If the skin around the wound is moist, adhesive drape will not adhere to skin. Use a skin prep product or drape to protect the skin. If the tube is pulling away from the dressing or tension is being placed on the tube, anchor it with additional drape or tape several centimeters from the dressing or wound. ■ The canister is filling with blood? Immediately discontinue negative pressure therapy. The gauze or foam dressing will not stop the bleeding, so take measures to control bleed- ing (i.e., hold pressure on wound). Do not remove dressing until the treating healthcare provider is consulted.
■ After 2 weeks, I see that the wound is not improving?
■ Dressing does not collapse or the alarm sounds? a. Press firmly around the transpar- ent dressing to seal. b. Verify the machine is turned on, all clamps are open, and tubing is not kinked. c. Check tubing and drape for leaks. Listen for leaks with a stethoscope or by moving your hand around the wound margins while applying slight pressure. d.Additional small pieces of trans- parent dressing may be used to seal around hardware, skinfold, or creases. e.Do not place multiple layers of drape or adhesive dressing. Several layers may decrease the dress- ing’s moisture vapor transmission rate, increasing the risk of maceration. f. Never leave foam in place without an adequate seal for more than 2 hours. If an adequate seal cannot be achieved in that time, remove the foam, and apply a saline- moistened gauze dressing.
Consult with the healthcare provider or a wound care specialist. Aver- age length of therapy is usually 4 to 6 weeks.Therapy should be discontin- ued if the wound shows no improve- ment in 1 to 2 consecutive weeks, the patient is unwilling or unable to follow the medical plan, or the goal of ther- apy has been met. The longer a wound is open, the longer it takes to heal and places the patient at risk for complications. A steady decrease in wound size should be seen every week. If NPWT is not effective, alternative wound care should be evaluated. ■ I cannot find or remove a piece of foam? Notify the healthcare provider, as this may necessitate surgery. The retained material in the wound could likely create an inflammatory response. ■ There is a foul odor when the dressing is removed? Clean the wound with normal saline to ensure odor is not emanating
Evaluation ■ Note the patient’s response to the procedure. ■ Continue to monitor wound healing and changes in peri- wound tissues. ■ Monitor dressing every 2 hours to ensure it is firm and collapsed in the wound bed while therapy is on. ■ Monitor the seal of the dressing and pressure settings. ■ Monitor for brisk or bright bleeding, evisceration or dehis- cence, and symptoms of infection.These must be reported to the healthcare provider. Home Care ■ Refer the patient to a home health agency for wound care. ■ In limited circumstances, some patients or caregivers may be able to perform dressing changes. Determine their ability to perform dressing changes; teach and demonstrate as needed. ■ Instruct the patient or family to visually check the dress- ing every 2 hours to ensure it is firm and collapsed in the wound bed.
■ Review safety labeling, alarms, and pump instructions. ■ Review conditions in which to seek medical care: bleeding, infection, unresolved alarms, or loss of suction. ■ Review proper disposal of contaminated supplies.
Documentation Document the following information: ■ Date and time of dressing change
■ Wound assessment: location of the wound, size (length, width, diameter), undermining or tunneling, amount and character of drainage, odor, wound bed includ- ing type and percentage of tissue seen, and periwound appearance ■ Evaluation of therapy with evidence of healing ■ Treatment selected: type of NPWT, type of gauze or foam, number of pieces placed in the wound ■ Treatment settings: pressures, intermittent vs. continuous, or variable pressures ■ Patient response to dressing change
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