How long does it typically take you to perform the:

1) Preparing all the material for a dressing change
2) The VAC dressing removal
3) wound cleansing and care
4) re-dressing with VAC / black sponge

I know different wounds will take different amounts of time, but I'm just looking for a rough average for each of these steps.

Peggy, Nursing Supervisor

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Peggy- Your question is complicated. I have spent 2 hours doing a vac change or as little as 15 minutes. It depends on the wound, location, how difficult it will be to insure a good seal, patient education and the experience of the person applying the vac. If your staff has little experience, you might consider contacting your KCI rep and have him/her come out to your facility an inservice your staff. They are really great at that and can give you lots of important tips. Hope this helps. Mychele George, PTA, WCC Amarillo, Texas

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You are right. The amount of time varies by wound and experience. I would allow a minimum of 20-30 minutes to accomplish this task for a simple wound.

Linda, BSN WCC

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The time it takes depends on the size and complexity of the wound. Usually it takes 20-30 minutes to do everything. If it is a new wound and quite complex with tunneling or undermining, it can take up to an hour.

Pat Collins, MSN, RN, CWOCN, APRN-BC

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Peggy I can change most VAC dressings start to finish, barring any other procedures, such as debridement, in about 20 minutes. I am known for being efficient so this may be quick according to some. I pioneered the VAC in my area and have perfomed many of them and experience will speed up the process also.

Bryan K Luster PTA, CWS

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A wound vac drsg change on a single wound, without problems with creases such as abd folds for gluteal folds takes approx 45-60min including an assessment. When bridging wounds together or on difficult wounds it should only take 60-90min with an assessment. The first time you do the dressings will take the longest but if you can schedule the same nurses to do the same dressings that time will decrease to 30-45min including an assessment. I am a certified wound care nurse and do alot of vac dressings and after 12 years most vac dressings take me 10-20 min. my email is bsn48623@netzero.com if you have any further questions.

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You are right, each wound requires it's own individual attention, some are simple and come are complex with tunneling, bridging etc. Rule of thumb that I use is one hour for each patient and it will average out.

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Hi there, I am a wound care nurse in a long term care facility. Typically it can take anywhere from ½ an hour to an hour from start to finish to remove and change a VAC dressing. Like you said, it depends on where the wound is and what stage the wound is at.
Megan Newbury, RN

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Peggy, I think it would take 25-30 minutes to do a VAC dressing change.
Dawn, RN, CWOCN
Sioux Falls

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I have found an average Home Care treatment (dressing) to complete and chart in the home I need a ½ hour per visit.

To complete an extensive treatment and chart time I would allow an hour each visit.

If there is travel time allow this on top.

Initial visits where I need to set up the file and collect the supplies for the first visit of any new client I would allow an hour and this would include the half hour visit.

It all depends how much has been completed before the actual visit.

I have been a direct service L.P.N. for over 25 years and find this is fairly consistent and fair to the care provider. BEE.
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depending on the size and location of the wound determines the time that it will take me to place a wound vac.

if it"s on the sacral/buttocks allotted time 30-45min. but if the pt. has several wounds that has to be tracked (ex.sacral/bil. hip wounds) than can take up to an hour or longer including the prep. time

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Hi Peggy Nursing Supervisor
well couldn't you ask your staff
or average their estimates in an open discussion
but lastly shouldn't you know that as a supervisor
have you not done it yourself?.
Brian Begley
RN

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My name is Sallie Ciambella, RN and I work as a wound care nurse at an LTAC. It takes me an AVERAGE of 45 minutes per patient to do everything you mentioned and to chart. As you mentioned, different wounds take different amounts of time. Some of the wounds only take about 20-30 minutes and I have one patient at this time who takes me about an hour and a half!
Hope this helps!
Sincerely,
Sallie

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Acute and Chronic Wounds by Ruth Bryant would be a great source for test questions. There are questions at the end of every chapter and you can pick and choose which areas you need to focus on. Good Luck !

Dixie Lombardo RN CWS

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I understand your frustration and I did purchase the whole practice test when I only needed 1/3. In turn, the questions were ok but nothing to help study from. I have taken both the CWS and CWCN exams. The CWCN exam focus is mainly on beside care and appropriate dressings with good wound assessment knowledge. If you have a strong clinical background, you will do fine on the exam. Just think each question through and use common sense based on your professional knowledge. There is a whole study package that is available online, which I also purchased. Tuned out to be the study guide for the CWS exam with only the cover page changed. The CWCN exam is not at this level and is far, far more than what is on the CWCN exam.

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Silver nitrate sticks still come as you remember them and I use them regularly in my practice. I do not know why your physician is telling you they are no longer available. My real concern for you is not the silver nitrate sticks. My concern is what is going on that you have such lesions on your tongue. Please be concerned with that aspect and getting professional diagnosis of the real issue and don't focus any longer on what manufacturer has changed the silver nitrate sticks. Find out what it is that you are actually chemically burning with the silver nitrate and get an appropriate treatment. Just the fact that you mentioned a white ring now continues where it was resolved at one time sends red flags up for me. Perhaps it is not that the silver nitrate has changed but the cause of the area has now gained strength.

unsigned

Have you tried Cavilon No Sting Barrier Film?

Helena RN

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I've had success w/ Xenaderm. This can be cost-prohibitive for pt's without prx insurance. Regular application of a skin barrier, such as Aloe Vesta, can also be effective.
Beth CWOCN

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Try Xenaderm ointment.works well and is approved for use by Medicare – Sue, CWS
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There are a lot of good products out there, I use Multidex a lot it is cheap and effective. If you have a stage I ulcer that is not in danger of becoming chronic a good hydrogel will also work fine. Really need more info, such as co-morbidities, is the wound from pressure, shear, etc. Is it from chronic venous insufficiency. If it is not becoming chronic it should heal on its own with good wound care, just protect from infection.

Bryan K Luster PTA, CWS

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It is my understanding that Stage One wounds are intact skin!

Leslie WCC

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Unfortunately, Medicare/Medicaid won't pay for similar products. Your facility will have to decide whether to bite the bullet and pay for Granulex for Stage I breakdown, or risk stage II-IV breakdown and get the medicare coverage, and risk the fines/etc. you will encounter for getting a facility acquired pressure ulcer.
You may consider beefing up your turn schedules, along with basic skin care, such as routine back rubs with a good moisturizing lotion to help prevent stage I pressure ulcers from progressing to stage II-IV ulcers. This may require increasing your nursing assistant staff, the NA's are the keys in preventing pressure ulcers.
Bottom line, your facility will have to pay more to prevent pressure ulcers. The question is, where do they want to spend the $? Choices are pay for Granulex, hire more NA's, or pay for a facility acquired PU, which will result in a lot more consequences than a fee.
Dawn, RN, CWOCN
Sioux Falls, SD

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Mavis - Does your facility have a good skin care program in place to prevent stage I from forming? If you have a high incidence of this problem, it could be solved with a good, cost-effective skin care regimine that would be easy to follow for staff and family. Medicare/Medicaid won't pay for granulex because it isn't cost effective. Convatec has an awesome skin care program with lots of research to back it up. You might find out who your rep is by calling the 800 number or looking it up online. Hope this helps.
Mychele George, PTA, WCC

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Chronic ulcers may require methods other than topical treatments. Pneumatic gradient sequential therapy pumps assist in treating the underlying problem - poor circulation. Pneumatic pumps that milk the fluid from the legs are being used more frequently with excellent results. The idea is to stimulate the normal circulatory action through extrenal pressure. The results are quicker healing time of the ulcers, and in many cases, in the prevention of recurrence. Your physician can write a prescription for an in-home device. Most doctors recommend treatment at 40mmHg one hour twice daily.

Dayna

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I don't know how you are managing the wounds. However, sometimes the chronic nature of the problem results in a situation where the whole local area is subjected to various chemicals and the ultimate result is slow healing or even worsening.
One should revert to washing the part gently with an ordinary mild (non-medicated) soap and plenty of tap water. Thereafter cover the raw areas with gauze soaked in normal saline or ringer lactate and squeezed. A moisturizer can be applied to the surrounding skin if it tolerates it or else just nothing. Then apply the compression. Before going to bed remove the outer layers of gauze gently. Let the adherent ones remain. Wet thoroughly with tap water and ease off the gauze without damaging the ulcers which are trying to heal. Wash once again with soap and repeat the earlier dressing.
Kumkum

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Unfortenately the cause of your wound is overload of edema which can only be controlled by compression. These wounds are fairly easy to heal. I like to use a silver impregnated dressing like Silverlon, and then wrap with an Unna Boot and Coban if you are active and do ambulate, if you are fairly inactive I would use a 4 stage compression wrap. After the wounds are healed if you would begin to wear a compression stocking you may prevent any wounds from forming, although it depends on the severity of your venous disease. There is no magic cure, you need to understand the valves in your venous system and why compression is the answer and then you must be compliant or this problem will get worse.

Bryan K Luster PTA, CWS

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My whole focus for my practice is problem healing wounds and I hear stories the same as yours all the time. I understand your frustration and could help you but the problem is I am in Missouri and not Florida. Sounds like you have pieces of information but have not had anyone to put the puzzle together for you so you can understand and treat what is going on with your legs. My first focus in treating chronic wounds is to educate the person and any care givers involved so that everyone is on the same page working together instead of jumping all over the page. Don't jump to leaches or extreme treatments. Go back and understand what the problem really is. I recommend going to the CWS web site and looking for who is available in your area. (CWS= Certified Wound Specialist and their web site has an area to put in to find one near you.) So much of wound care is actually seeing the wound and just giving you more generic information online will only add to your frustration. There are simple and advanced diagnostic tests available and the guess work will be removed and then the treatment can be set up to get you on your way to healing and staying healed.

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Hi,

I am currently involved in a gene therapy study to heal venous ulcers at the University of Pennsylvania in PHiladelphia PA.
If interested please call 215-898=5211.
Thanks
linda weinberg, DNSc, CRNP, RN

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Please see a vascular surgeon who deals with venous diseases. KT - Vascular surgeon

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My name is Kim. I work in long term care facility and have inherited all wound care in my facility. What I have found that works wonder is using Cellerate powder if wounds are wet and Cellerate gel if wounds are dry. If they are in transition then mix the 2 products together. Apply adaptic dressing and cover with 4x4. Dressings only need to be changed twice a week. I have seen dramatic changes in 1 week. Most of my wounds are healed in about 2 to 3 weeks.

Kim RN, ADON

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That mesh could be several things. I suggest you find a local wound specialist to see her and decide what will be best to help her heal. It's impossible to make good recommendations without more information.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
 

I am in a very similar situation with my Mom and would like to know how your mothers status is now? Did she have the surgery? Is the wound Healing?

My mom is a T4 parapalegic and has a 2x2 wound on her coccyx as well. They also want her to have the surgery but is fighting bone and blood infection now and cant undergo surgery.

Cheryl Noori

Meoowme@aol.com

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There are several reasons her wound may be no longer improving including: inadequate pressure relief (the same thing that caused this wound), infection - of the soft tissue itself or the underlying bone (osteomyleitis); poor nutrition (what are her albumin & pre-albumin levels which demonstrate protein stores?), poor VAC technique/seal ie-is the dressing maintained the entire time between dressing changes & is the foam placed properly?

The VAC does have different levels of pressure & bumping her to the next level may be helpful to futher challenge her cells. Also, there is an intermittent setting which research shows is more effective, however her seal may be more difficult to maintain with that on/off cycle.

People have had colostomies to prevent contamination of wounds in these areas to allow healing. All of the underlying factors (listed above) must be addressed also.

Monica

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I understand your concerns, but with my experience with chronic wounds the nutritional status is so important, it is the building blocks of aminio acids. The elderly patients do not seem to heal nearly as fast as someone who can eat 2000 to 3000 calorie diet. You can add protein powders, puree the foods add a supplement. First, the wound needs to have several things in place in order to heal and that is, rule out an infection by a punch biopsy. a baseline Albumin level and the most important pressure relieved off the area. As long as the area is deprived of circulation. That's where the Vac has been useful. The incontinence is an important factor and a colostomy will help with fecal matter entering the wound. The other thing you could ask he medical doctor is about hypobaric pressure. I have seen some really awful wounds heal from this method saving the patient from an amputation. I hope this gave you some insight on things to consider.

Deborah Taft, RN, WCC

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Please do not get hung up on wound measurement only.
Whatever method you use please write down how you measured so that the next time you or some one else will use the same method. Serial photographs would be of more help. Good luck

KT, Vascular surgeon

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Actually nutrition is one of the key components in wound healing. The underlying cause of this wound also needs to be addressed, she needs to probably be on hourly positioning changes. And the infection is a problem if they are unable to place the VAC without letting feces get into the wound. I think with nutritional supplementation and removing the pressure/shear the VAC is a good choice of product. Prevention of these types of ulcers is extremely important but once they occur, and it is more often than it should be, they can be challenging. Probably needs some sort of silver dressing under the VAC sponge to combat the microbial colonization.

Bryan K Luster PTA, CWS

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I am a wound care nures in nursing home I deal with a lot of wound vacs nutrition plays a big role in the healing of ulcers has she had a protein and prealbumin level done lately if the protein is low she will need alot of protein there are supplements high in protien and there is protein powder that can be added to her daily regimen.

robin

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Wounds sometimes plateau, I always tell my patients that it is like being on a diet and you loose weight then nothing and all you have to do is change one little thing to jump start the progress. With the vac I sometimes increase the neg. pressure by 25mmhg for a week or two or if the patient prefers I will put the vac on hold and switch to a daily wet to dry dressing for a week then go back to the vac with 125mmhg cont. suction. As far as the high protein diet everything you have said is true. I had a 94 year old patient with poor nutrition and found out she had a real sweet tooth, family began making high protein cookies and snacks and she began to eat these like crazy. After about 2 weeks of these she said she hadn't been eating real food because her teeth didn't fit right and had them fixed and is now eating more than enough protein. By the way her wound was larger than your mom's but was on the vac eleven months. Pressure ulcers don't take long to develop but take along time to heal. Is your mom on a specialty been to prevent pressure? The colostomy is another question, Is she alert, have they tried a bowel regime? If she is alert the colostomy may cause depression where as if they gave her an enema every 2-3 days to clean her out the incont. episodes would be less. Bonnie RN, CWCN bsn48623@netzero.com

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Hi there, basically the “malnourished” explanation is correct, he just didn’t explain it well enough to you. Wounds need a number of things to heal-one of them is zinc, vitamin c, and protein. If she is not getting adequate amounts of these things, she is not likely to heal. Increasing these things in her diet will help to kick start the body. If there has been no progress with the VAC, it needs to come off. Use other types of dressings in its place. We often will use a silver dressing such as acticoat, or aquacel silver if the wound is draining moderate amounts. There are lots of options if you are concerned about the ostomy

check them out on line!

Megan Newbury, RN

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Kansas,
Is she incontinent of stool that gets into the wound on a regular basis? If so, a colostomy is definitely indicated.
Has the Dr. been monitoring labwork that indicated nutritional status? This would be albumin, and more importantly prealbumin. If these labs are in normal limits, her nutritional status is not a concern.
I would not discontinue the use of the VAC until continence and nutritional status is established. KCI has studies that claim that the VAC on intermittant suction works better, but most of my patients can't tolerate intermittant because of pain control issues. I think it would definitely be wise to try the VAC on intermittant suction.
You also need to make sure that she is on an appropriate bed/chair cushion that will decrease pressure to the wounded area.
Dawn, RN, CWOCN
Sioux Falls, SD

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Hi my name is Kim. I am a nurse working in long term care. I have seen wounds do that. From my experience they( wounds) build up like a tolerance to treatment. So, changing treatments around helps. Ask the doctor about trying a product called Cellerate. I have found it is a miracle product.

Kim RN ADON

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First of all, I am so sorry about your moms condition.

my heart goes out to you and your family.

My name is Sallie Ciambella, RN and I am a wound care nurse at an LTAC. I have had many wounds that have been like you described your mom's wound. The doctor is right - a person doesn't have enough protein, the wound won't heal no matter what you do to take care of it. We regularly do lab work on our patients to check and see if their  albumin or pre albumin levels are adequate to heal a wound. I know it is a tough decision to make as to your mom's care. Sometimes a feeding tube is necessary to heal a wound, and many families really have a hard time with that decision.

I hope this helps. If you would like another physician's opinion, I would get a consult from a plastic surgeon. Many times once a wound is clean and granulating in, they can graft the wound if the patient is well nourished. (if their protein levels are adequate and they have enough muscle mass)  It would be good to get the opinion of another physician anyway, and he would tell you if she was a candidate or not, or if it would ever be possible to do it.

Good luck with your mom, and with you and your siblings decisions.

Sincerely,

Sallie

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re. Kansas
Your concern for your mother's condition is heartfelt.
The VAC is a very effective modality for many wounds. A pressure ulcer such as this is very complex, many different issues come to play to delay healing in the chronic wound, and nutrition often has a significant role. Certainly her nutrition should be optimal in order to heal this wound. In addition, if the fecal material is gaining access to the wound, this would delay the wound healing as well, and often increase the wound complications. The wound should
be cultured for the presence of an infection-this of course would also delay wound healing.
First, have they tried to create a barrier to prevent feces access to the wound? The enterostomal paste is a very effective barrier for this purpose. Also, it has been shown that intermittent VAC therapy is more effective in
increasing circulation to the wound bed. Your recommendation was well founded.
The treating clinicians may also introduce Panafil to the wound bed, followed
by the VAC sponge. We have had great success with this combination in
hastening wound healing. In addition, electrical stimulation is another excellent modality for chronic wounds. If the above is not effective, I would recommend a qualified PT evaluate the wound for possible use of electric stimulation.
Good luck!
Sandy T. PT, MS, CWS
 

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Both methods are valid, and each has pros and cons. The Sussman and Bates-Jensen book goes into a description of both methods. The key thing is that you pick one and have everyone do it that way for consistency.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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William,
According to the National Alliance of Wound Care and standard testing and current teachings for wound care, length is always measured from 12:00 to 6:00 (12:00 should always be oriented to the patient's head) and width is from 3:00 to 9:00 (laterally). This is has always been an area of misunderstanding in wound care, but standard of practice and wound care courses teach the above measurements to be accurate. remember, it is possible to have a bigger width measurement than a length measurement. The imporant thing to remember is everyone must measure the same to document progress and validate wound care to insurance. Hope this helps
Mychele George, PTA, WCC

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HI

I KNOW WHAT YOU ARE SAYING BUT, TO PROVIDE CONTINUITY FOR YOU DOCUMENTATION THE MEASUREMENTS SHOULD BE:
LENGTH-HEAD TO TOE
WIDTH-SIDE TO SIDE.

I KNOW THIS IS NOT WHAT YOU WANTED TO HEAR BUT THAT IS THE WAY WOUND EDUCATORS TEACH AND IF YOU HAVE A WOUND THAT IS MEASURED INCORRECTLY, EVERY
NURSE THAT HAS SEEN THAT PATIENT WILL DOCUMENT DIFFERENTLY AND YOU WILL GET
NAILED!
SORRY AGAIN,

TAMI

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Hello William,

We have this discussion all the time and our policy says the head to toe is the length and width is horizontial side to side. I use to always think the longest points were the length, but as long everyone measures the head to toe way then we are all on the same page across the board.

Deborah Taft, RN, WCC

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Boy do i agree with you
logic over plane old rule for the sake of a rule.
Brian Begley
RN

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You are correct. Measuring the greatest length and width, no matter the axis, gives the most reliable, meaningful, and reproducible data.
Dee

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The correct way of measurement is using a clock method with the head being 12 and the feet being 6. The length of the wound will be from 12 to 6. The width will be from 3 to 6. This is the standard and correct way to measure the wound. Linda K RN, BSN
 

Coreen
 

I would not use gauze when VAC is being used. If it is infected it needs frequent changes, good debridement and perhaps use of antibiotic.
KT - Vascular Surgeon

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Hey, If the wound is deep there is moist white foam called granulfoam you can use especially if you have a tunnel. KCI sells this product and when you use it and change the dressing remember measure the material and inch or so shorter to give the wound a chance to fill in. You can only use gauze around the tubing if using a Blue Sky machine and this gauze has clorahexaden to help with bacteria since this dressing is changed two times a week.

Deborah Taft, RN,WCC

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No - you don't want to continue gauze packing if using the KCI Wound VAC system, the foam provides the packing. See the KCI website http://www.kci1.com/82.asp for how it works and/or contact a KCI rep.

Some of the other negative pressure systems do use a gauze packing - it is a treated gauze, not the plain gauze you were likely using.

Patti Kuvik, RN
Bayada Nurses

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I would not use gauze when VAC is being used. If it is infected it needs frequent changes, good debridement and perhaps use of antibiotic.

unsigned

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If the sponge of the VAC fills the wound no other packing is necessary, if there are tunnels or fistulas make sure they don not enter a body cavity first, and talk to your representative where you get your VAC and see what they have. If it is a small opening tunnelling wound take a look at Graft Jacket Express, it is a caulk like material that I have had good outcomes with tunnelling wounds.

Bryan K Luster PTA, CWS

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it only needs the wound vac dressing

Robin

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If you are packing the wound with the wound VAC foam, you do not need any other gauze, the wound VAC foam is sufficient.
Dawn, RN, CWOCN
Sioux Falls

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Coreen
The vac sponge always takes place of the packing. You don't have to use anything else unless you have problems removing the sponge and causing excessive bleeding or patient discomfort. You can use xeroform gauze or mepitel silicone mesh sheets over tendons and to protect fragile granulation tissue. Neither of these will interfere with healing and both help control pain when removing the vac. Good luck. Hope this helps.
Mychele George, PTA, WCC

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no you don't have to use gauze for packing. use the versafoam packing (white foam) with the wound vac.
stephanie royster rn,wcc
noland health serevices

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No. Just pack the wound with the foam that was ordered from the prescriber. If you need assistance with the vac and application the manufacturer will send someone to inservice the staff.

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No details have been provided as regards the site, cause and depth of the "wound".
A cavity may be loosely packed or even just a gauze wick be placed to prevent locculation of the deeper part by strands of healing tissue. If it is a wide based cavity with a wide mouth, the chances of locculation are less. Packing an infected wound tightly can impede drainage and worsen the situation.
In the application of VAC the purpose of the sponge pack is to evenly distribute the negative pressure to the raw surface.
Kumkum

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Allison

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Considering that the pressure sore is not infected and not pouring out significant exudate, maybe now the presence of the sponge is preventing the walls of the cavity from meeting and thereby the process of healing has stalled.
Maybe it is time to revert to an ordinary dressing keeping a narrow corrugated drain up to the depths and gradually shortening it as the situation demands.
Kumkum

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Hi,

We have treated similar wound/pressure ulcer similar to this about 2.5x 3.5 cm deep. Remove necrotic tissues and slough using intrasite or solosite in gauze packing in daily dressing till gauze is free from puss. It may take several weeks or few months.
Then change the packing to normal saline and gauze.
Frequency of packing / dressing depends on condition of the wound (lesser as the wound healed up). Other things needed good blood circulation on affected area (avoid applying pressure), Vit. C and good dietary intake. It works in residents in our nursing home, hope it will help your case.

R. Mateo RN-1

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The sponge should be cut to fit the wound and not overlap the periwound. Sometimes I double the sponge if it is a deep wound but there may be other causes of the wound not healing, is the area innervated, infected, or maybe compromised by small amounts of bacteria, are you keeping pressure off the area, etc.

Bryan K Luster PTA, CWS

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your tissue is still getting the suction from the vac

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Allison,
are you confined to a wheelchair? If so, have you had any pressure mapping done to see if continued pressure over the area is the issue? It is not always necessary to pack the sponge completely into the wound to facilitate closure. It could be the vac settings aren't optimal. Have they tried a sponge with silver impregnated into it? How often are the dressings being changed? What about blood work to check your albumin and pre-albumin and protein levels? These are all very important things to consider with chronic wounds that won't heal. Have you looked into hyperbaric treatments? Sounds like you need to sit down with the dr and have a heart to heart about other options and methods of treatment. You might also mention packing the wound with Aquacel Ag. It doesn't sound like the wound is extremely large and Aquacel Ag promotes healthy tissue formation while fighting infection and contamination. Have they tried using a pulsivac treatment with you? Then packing with Aquacel Ag and covering it with a special foam to catch the drainage. Hope this helps. Good luck. Mychele George, PTA, WCC