Nursing Practice Innovation


Malmsjö et al, 2009b), scar tissue depth (Fraccalvieri et al, 2011a), and effect on microvascularity (Malmsjö et al, 2009a). Little difference has been demonstrated between the two, although patient-reported pain on dressing change has been consist- ently significantly lower with gauze (Doraf- shar et al, 2012; Fraccalvieri et al, 2011b). The use of gauze also requires fewer dressing changes and, without the need to sculpt the foam, less nursing time at dressing change (Dorafshar et al, 2012).


Patient selection Patients whose wounds are suitable for NPWT need to be assessed for their ability to live with the device. The following fac- tors should be considered: » Level of mobility and risk of tripping – drain tubes can create a trip hazard for those with reduced mobility, who may also find the larger pumps too cumbersome;


» Level of cognitive ability and risk of pulling the dressing or tubes off;


» Mental health status and ability and willingness to adhere to the treatment regimen – which involves wearing the pump at all times and having two or three dressing changes a week, and to care for the pump;


» Position of wound or wounds and the ability to obtain and maintain a seal;


» Pain at dressing changes – some patients may need nitrous oxide for pain relief, or if this is ineffective or unavailable (for example in community settings) it may be necessary to discontinue NPWT.


Dressing application The application of NPWT dressings is not difficult but it requires an understanding of how the therapy works and training in the use of the specific device. Staff undertaking dressing changes should have the appropriate knowledge and training – poor dressing technique can lead to wound complications or breaches in the seal. The wound is filled with gauze or foam, depending on the device used, then a drain is applied to facilitate the application of negative pressure and remove wound exu- date. Drains are either inserted into the wound filler or on top, again depending on the device. Any areas of undermining, tracks or sinuses must be fully explored and filled to ensure negative pressure is achieved at these deepest areas. Practi- tioners applying NPWT must ensure that: » Healthy skin is not damaged by contact with foam, gauze or drains;


» Exposed tissues such as tendon or bone are not damaged;


» Dressing materials are not left to embed into granulation tissue;


» Drains do not cause pressure damage; » Patients and staff are familiar with the functionality of the pump;


» Foam/gauze does not come into contact with intact skin;


» Intact skin is lined with film dressing if foam needs to extend onto it, for example with small wounds or when bridging more than one wound;


» When more than one piece of foam or gauze are used no gaps are left between the pieces;


» An airtight seal is created using film dressing (Chariker et al, 1989) – this may require adhesive gel provided by the manufacturer or stoma paste to help facilitate a seal in awkward areas of the body (Fig 1);


» For drains secured on top of the dressing, if the drain port is larger than the wound, it must not extend beyond the dressing margin onto skin, to prevent pressure damage. The use of a low-adherent liner dressing


became standard practice when using foam because it prevented the foam adhering to the wound bed. However, Jones et al (2005) demonstrated that liner dressings can reduce the level of pressure delivered to the wound bed. They are unnecessary unless bowel, tendon or bone is being protected or dressing adherence causes painful dressing changes. Care must be taken to ensure that all liner is


18 Nursing Times 04.09.12 / Vol 108 No 36 / www.nursingtimes.net


BOX 1. CONTRAINDICATIONS AND CAUTIONS


Contraindications ● Wounds involving untreated osteomyelitis ● Wounds exposing blood vessels or organs or with an unexplored fistula ● Wounds including open joint capsules ● Skin malignancy and excised skin malignancy – except for palliative care ● Wounds with necrotic tissue


Cautions ● Wounds with visible fistula ● Wounds with exposed bone or tendon ● Clotting disorder (risk of bleeding) ● Compromised micro-vascular blood flow to wound Source: European Wound Management Association (2007)


removed at dressing change, as there has been a reported case of liner dressing growing into the wound and scar tissue (Tan et al, 2009). Cutting gauze or foam should be carried out away from the wound as this can leave fragments in the wound, which can become embedded in healing granulation tissue. Carving foam is a skilled procedure as it


involves creating a shape that fits into the wound contours. If more than one piece of foam is used it is important to document how many so they can be counted out at dressing change. The wound bed should be thoroughly examined for flecks of foam or threads of gauze at dressing change so that these can be removed. It is also necessary to secure drains at


the exit point of the dressing to help obtain a seal and to prevent skin damage due to pressure at the exit point.


The use of NPWT in community settings The introduction of NPWT in community settings means patients with chronic and complex wounds can be treated at home, and also facilitates early discharge. The pathway illustrated in Fig 2 is an example of a community provider offering NPWT through community-based integrated care teams (ICT) after patients are discharged from hospital. The teams include nurses, an assessment team and matrons and liaison nurses based within the local acute hospital. The provider purchased 18 NPWT devices, nine of which are kept in ICT bases; the remainder are kept at the hos- pital and used to initiate therapy before patients are discharged. After discharge patients receive one of the community- based devices and the hospital-based one is returned. The pathway was designed to ensure


that patients with NPWT initiated in hos- pital can be discharged home and receive equitable care. However, it is extremely


Fig 1. Stoma paste around wound edge


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