Enterostomal Therapy Wound Vac [ ] General DATE/TIME PROVIDER INITIALS PHYSICIAN ORDERS
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1 Enterostomal Therapy Wound Vac Height Weight Allergies Please consider the following contraindications to wound vac therapy: Untreated osteomyelitis, necrotic tissue greater than 20%, malignancy in the wound, nonenteric and unexplored fistuals, active uncontrolled bleeding. General Notify Provider [X] Notify provider, Until discontinued, Starting today Pulse greater than: Respiratory rate less than: Respiratory rate greater than: Temperature greater than (celsius): Urine output less than (ml/hr): Systolic BP greater than: Systolic BP less than: Diastolic BP greater than: Diastolic BP less than: Other: Re-evaluate wound vac therapy and contact provider. For uncontrolled pain, increased necrotic tissue, frequent loss of suction or excessive bleeding. Nursing Intervention [X] Nursing communication, Until discontinued, Starting today, Resource and/or Primary Nurse: See Troubleshooting/intervention instruction sheet. Patient should not be off suction for more than 2 hours in each 24 hour period. If suction off for more than 2 hours, or if unable to obtain a seal, then remove all tape/drape and foam/packing from the wound. Fill the wound loosely with 0.9% sodium chloride (Normal Saline) moistened gauze, moist to damp dressing. Change dressing every 8 hours until Enterostomal Therapy Nurse can reassess patient. Page 1 of 5
2 Nursing Intervention - VAC dressing change Standard/Uncomplicated [X] Nursing communication, Until discontinued, Starting today, Change VAC dressing. Cleanse wound with 0.9% sodium chloride (Normal Saline) or sterile water. Shave periwound skin if excessive hair present. Use no-sting barrier wipe under drape and to periwound skin as needed. Protect periwound skin with drape and/or hydrocolloid dressing. Pack wound with black foam. Use white foam for any tunnels present or if complex undermining. Continuous suction to be set at 125 mmhg when black or silver foam used and 150 mmhg when white foam used. Frequency of dressing changes to be 2-3 times per week. Nursing Intervention Special Consideration - Painful Wound [ ] Nursing communication, Until discontinued, Starting today Volume (cc's): Instill 0.9% sodium chloride (Normal Saline) foam minutes prior to removal. [ ] Instill Lidocaine 1% injectable into foam minutes, Until discontinued, Starting today prior to removal [ ] Nursing communication, Until discontinued, Starting today, Use non-adherent contact layer under the foam. [ ] Nursing communication, Until discontinued, Starting today, Use white foam. [ ] Nursing communication, Until discontinued, Starting today, May titrate continuous suction down by 25 mmhg increments. Nursing Intervention Special Consideration - Denuded Peri-Wound Skin [ ] Nursing communication, Until discontinued, Starting today, Crust with stomahesive powder and no-sting barrier wipe up to 3 times before applying drape. [ ] Nursing communication, Until discontinued, Starting today, Apply hydrocolloid dressing. [ ] Nursing communication, Until discontinued, Starting today, Apply alginate dressing. Nursing Intervention Special Consideration - Peri-wound Fungal Rash [ ] Nursing communication, Until discontinued, Starting today, Crust first layer with miconazole nitrate (Mitrazol) 2% powder and no-sting barrier wipe before applying drape. [ ] Nursing communication, Until discontinued, Starting today, Crust first layer with Arglaes powder and no-sting barrier wipe before applying drape. [ ] Nursing communication, Until discontinued, Starting today, Stomahesive powder and no-sting barrier wipe before applying drape, if indicated. Page 2 of 5
3 Nursing Intervention Special Consideration - Infected Wounds [ ] Nursing communication, Until discontinued, Starting today, Silver foam to be used for 2 weeks. [ ] Nursing communication, Until discontinued, Starting today, If silver foam not available then dust wound with Arglaes powder and use black foam. [ ] Nursing communication, Until discontinued, Starting today, VAC instill may be used per provider order following KCl protocols (see KCl clinical guidelines). Nursing Intervention Special Consideration - Necrosis [ ] Nursing communication, Until discontinued, Starting today, Conservative sharp debridement as needed with dressing changes. [ ] Nursing communication, Until discontinued, Starting today, Apply approved debriding agent to the slough prior to packing with black or white foam only. Nursing Intervention Special Consideration - Eschar [ ] Nursing communication, Until discontinued, Starting today, Debride prior to dressing application. VAC foam is NOT to be placed over eschar. Nursing Intervention Special Consideration - Exposed Bone, Tendon, Blood vessels, or Organs [ ] Nursing communication, Until discontinued, Starting today, Protect organs, nerves, biologic mesh/grafts, and/or blood vessels with several layers of fine, meshed, non-adherent contact layer. [ ] Nursing communication, Until discontinued, Starting today, Protect bone and / or tendon with 1-2 layers of fine, meshed, non-adherent contact layer. Nursing Intervention Special Consideration - Minor Bleeding [ ] Nursing communication, Until discontinued, Starting today, Use a contact layer over the area before placing the foam once the bleeding has stopped. Nursing Intervention Special Consideration - Other [ ] Nursing communication, Until discontinued, Starting today, Medihoney 1/8" thick layer applied to wound bed prior to application of VAC foam. Page 3 of 5
4 Ancillary Consults [ ] Inpatient consult to Dietary Reason for Consult? Labs Chemistry [ ] Hemoglobin A1c Once, Starting today [ ] Prealbumin Once, Starting today [ ] Albumin Once, Starting today Microbiology [ ] Aerobic gram stain and culture Once, Starting today [ ] Anaerobic culture Once, Starting today Medications Medications [ ] lidocaine (XYLOCAINE-MPF) local injection 1% Other, As needed, Pain Apply topically PRN pain management with each dressing change Dose Required [ ] miconazole (MICOTIN) powder 2%, As needed, fungal skin rash Apply powder to affected area PRN fungal skin rash with each dressing change [ ] collagenase (SANTYL) 250 unit/g Ointment 1 application, Topical, As needed, necrotic tissue Apply ointment to necrotic tissue PRN with each dressing change. DO NOT use with any silver products [ ] silver nitrate applicators 1 application, Topical, As needed, bleeding, epibole, and/or hypergranulation Apply stick PRN to control bleeding, epibole and/or hypergranulation. Only to be use by Provider or Enterostomal Therapy Nurse [ ] sodium chloride 0.9 % (PF) injection 10 ml, Topical, As needed, line care Fill wound loosely with Normal Saline moistened gauze, moist to damp dressing [ ] sodium chloride 0.9 % (PF) injection 10 ml, Topical, As needed, line care Cleanse wound with normal saline or sterile water Page 4 of 5
5 [ ] sodium chloride 0.9 % (PF) injection 10 ml, Topical, As needed, line care For painful wound, instill Normal Saline into foam minutes prior to removal [ ] lidocaine (XYLOCAINE-MPF) local injection 1% Other, As needed, Pain For painful wound, instill Lidocaine into foam minutes prior to removal Dose: Required Date / Time Print Provider Name Provider Signature Date/Time RN Signature Acknowledgement Page 5 of 5
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