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201609251

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UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Integumentary

Negative Pressure Wound Therapy Vacuum Assisted Closure (VAC) Ulta Dressing Maintenance and VAC Veraflo Instillation Therapy (4.22)

Negative Pressure Wound Therapy Vacuum Assisted Closure (VAC) Ulta Dressing Maintenance and VAC Veraflo Instillation Therapy (4.22) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Integumentary

4.22

NURSING PATIENT CARE POLICY & PROCEDURE


I. PURPOSE

To provide guidelines to maintain the integrity of the negative pressure wound therapy
(NPWT) Vacuum Assisted Closure
®
(VAC
®
)

Ulta dressing and VAC VeraFlo™
Instillation Therapy.

II. DEFINITION

NPWT is an integrated wound management therapy that creates an environment that
promotes wound healing by secondary or tertiary (delayed primary) intention by
preparing the wound bed for closure, reducing edema, promoting granulation tissue
formation and perfusion, removal of exudate and infectious material, and providing a
closed moist wound healing environment.

III. POLICY

A. A provider order is required for initiation of NPWT. The order will specify suction
settings and frequency of VAC
®
dressing changes.
B. VAC
®
dressing changes are provided by the medical team, specialty trained
Wound/Skin CNSs, Wound/Skin Nurse Clinicians, and Burn Nurses.
C. It is the responsibility of the nursing staff to:
1. Maintain the integrity of the NPWT dressing.
2. Maintain NPWT settings (pressure and intensity).
3. Change the NPWT canister as necessary.
4. Troubleshoot the NPWT.
5. Document
a. Integrity of NPWT.
b. NPWT Output.
6. If using VAC VeraFlo™ Instillation Therapy
a. Change out Normal Saline floor stock IV solution bag PRN.
b. Document instill solution volume intake on VAC flow sheet.

IV. PROCEDURE

A. Maintain the integrity of the NPWT dressing
1. Visually check the NPWT dressing every two (2) hours to ensure the foam is
firm indicating that the therapy is active.




Effective Date:
August 30, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 4.22

Original
Revision

Page
1
of 4

Title: Negative Pressure Wound Therapy
Vacuum Assisted Closure (VAC) Ulta
Dressing Maintenance and VAC VeraFlo
Instillation Therapy (Inpatient)
(Adult & Pediatric)

Page 2 of 4

2. It is recommended that NPWT never be inactive for more than a cumulative
two (2) hour period in a 24-hour period with the foam dressing in place.
a. To disconnect therapy for a short period of time (less than two hours):
i. Close clamps on the canister and dressing tubing.
ii. Turn therapy unit OFF.
iii. Disconnect the dressing tubing from the canister tubing.
iv. Cover ends of tubing with sterile gauze to protect and secure
with tape.
b. To reconnect therapy:
i. Remove protective covering from the ends of the tubing.
ii. Reconnect the dressing tubing to the canister tubing.
iii. Open both clamps on the tubing.
iv. Turn the therapy unit ON. Confirm that previous therapy settings
resume.
3. If therapy is inactive for more than a cumulative two (2) hour period in a 24-
hour period with the foam in place, contact the service (i.e., general surgery,
plastic surgery, wound and skin, etc.) that is managing the NPWT for wound
care orders.
B. Maintain the settings (pressure and intensity) of the NPWT
1. NPWT pressure and intensity settings are ordered by the provider.
2. Assure settings are maintained when visually inspecting dressing.
C. Change the NPWT canister as needed
1. Change the NPWT canister when it is full (the unit will alarm) or at least once
a week to control odor.
2. Follow standard precautions as canister/tubing may contain body fluids.
3. Turn off therapy.
4. Close the clamps on both the canister tubing and the dressing tubing.
5. Disconnect the canister tubing from the dressing tubing.
6. Cover ends of tubing to protect and secure.
7. Press the canister button to release the canister and remove it from the unit.
8. Replace with a new canister (obtain from Central Services (CS) Item Number
22041580) and connect canister tubing to the dressing tubing.
9. Open clamps on tubing and turn therapy back on.
10. Dispose of used canister in red biohazard bag.
11. Document contents in discarded canister on the Documentation Flowsheet,
I&O, Wound VAC Output record.
D. Troubleshoot the NPWT
1. NPWT Alarms and Functions:
a. Seal Check Function helps the bedside caregiver assess the degree and
location of an air leak in a loosened dressing. The bar graph and the
pitch of the audio tone will raise or lower as the rate of the leak
increases or decreases. The Seal Check button can be accessed in three
(3) ways:
i. When the ON/OFF button is turned ON, the Seal Check screen
will allow you to identify if an adequate seal is achieved at the
start of therapy.
ii. The dressing seal can be checked whenever the pump is running
by pressing Therapy, OK, and Seal Check button.

Page 3 of 4

iii. During a leak alarm, the Seal Check button will appear. Seal
Check gives both a visual indicator of the degree of air loss from
the dressing and an audible alarm to notify the nurse there is a
dressing leak. Do not disable the Seal Audio.
b. Therapy Inactive alarm indicates the unit is turned ON but the
therapy has not been started. Push the ON/OFF button and assure the
green crescent is present.
c. Canister Full alarm indicates the canister should be replaced.
d. Battery Critical or Battery Low indicates the internal pump battery
is low. Plug the external power cord into an electrical outlet.
e. Leak Alarm indicates that therapy is interrupted due to a leak in the
system. Pushing the Audio Pause button will pause the alarm tone for
up to two (2) minutes. A leak can also be noted by a hissing sound
heard at the site of the leak on the dressing.
i. If the sound is heard, move hand slowly to the dressing, applying
light pressure until foam compresses and sound ceases.
ii. Apply NPWT drape to identified area to seal leak.
f. Blockage Alert indicates that a blockage exists between the NPWT
unit and the patient. Ensure that tubing clamps are open and that
tubing is not kinked or collapsed.
g. Canister Not Engaged indicates the canister is not properly installed.
Ensure the canister is properly seated in the side of the NPWT unit.
2. If unable to correct alarm contact the service (i.e., general surgery, plastic
surgery, wound and skin, etc.) that is managing the NPWT.
E. Additional troubleshooting required with VAC VeraFlo™ instillation therapy
1. Alarms and function
a. VAC VeraFlo™ Therapy Pressure Deviation Alarm. Alarm indicates
the wound site positive pressure has exceeded its allowable limits
i. Ensure clamps are open on V.A.C.VERAT.R.A.C.™ Pad or
VAC VERAT.R.A.C. DUO set tubing are open.
ii. Ensure clamps on VAC VERALINK™ cassette tubing are open
iii. Ensure tubing is not kinked, crimped, or blocked in any way
iv. Ensure the VAC VERALINK™ is fully engaged and latched
b. VAC VeraFlo™ Therapy Blockage Alarm. Alarm indicates a blockage
exists between the patient and VAC machine.
i. Ensure clamps are open on V.A.C.VERAT.R.A.C.™ Pad or
VAC VERAT.R.A.C. DUO ™ set tubing are open
ii. Ensure clamps on V.A.C VERALINK™ cassette tubing are open
iii. Ensure tubing is not kinked, crimped, or blocked in any way
iv. Ensure the VAC VERALINK™ is fully engaged and latched
c. VAC VERALINK™ Not Engaged. Alarm indicates that he canister is
not properly installed.
i. Remove VAC VERALINK™ Cassette from therapy unit
ii. Ensure cassette’s pivot connection is securely engaged
iii. Re-attach cassette, ensuring it is fully engaged and latched
iv. If alarm continues, install a new cassette
d. Solution Bag/Bottle Empty Alarm. Alarm indicates there is no
instillation fluid in the bag/bottle.
i. Remove empty bag/bottle

Page 4 of 4

ii. Attach new solution bag/bottle and place on solution container
hanger arm
iii. If bag/bottle is visibly full, ensure that bag/bottle is fully spiked
e. Canister Full Alarm. Alarm indicates the canister is full and should be
replaced.
i. Replace the canister and hit reset to return to home screen

V. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 13.08, Hand Hygiene
B. V.A.C. Ulta Care Troubleshooting Guide (found on U-Connect)
C. VAC Veraflo Troubleshooting Guide (found on U-Connect)

VI. REFERENCES

A. KCI Licensing, Inc. (2013). V.A.C. Ulta User Manual. Available at:
www.acelity.com (formerly kci1.com) or vaculta.com

VII. REVIEWED BY

Clinical Nurse Specialists, Wound & Skin
Nursing Patient Care Policy and Procedure Committee, August 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer