Part 1 in a series exploring topics related to negative pressure wound therapy application.

Negative Pressure Wound Therapy (NPWT), it's so simple, right? Everyone who knows anything about wound care knows how to apply it. Wait…YOU don't? No worries—we were all there at some point. In fact, for the first year or so of my wound care endeavors, I had very little insight as to how to apply NPWT. I understood the basic tenets of therapy: exudate management/removal, increased granulation tissue development, decreased frequency of dressing changes, and decreased cost of wound care, among others.

When I was just starting out in wound care, the truth was I really did not have the first clue about how to apply the NPWT dressing system. Foam, gauze, skin prep, drape, tubing, all the buttons on the unit, the different pressure settings; it was so intimidating, which was massively discouraging for me to initiate the learning process. Another obstacle was the company I worked for actually discouraged application of NPWT because the time needed to apply was generally greater than a standard dressing (the company had a "Jiffy Lube" mentality concerning clinic operations). In addition to imposed time constraints during clinic visits, the various devices/manufacturers required additional hands-on training for which it was difficult to allocate the necessary additional time.

The few times I was privy to observing another clinician applying NPWT, I attempted to mentally memorize the technique they used. To my surprise, no two people used the exact same technique when applying the therapy. Imagine my frustration, thinking I was going to hit the ground running with NPWT application after simply watching a few applications. Watch one, do one, teach one, right? Wrong. There are usually more than 10 ways to apply NPWT to a given patient/wound, if not more! There are also various indications for therapy and different dressing and device configurations that differ by manufacturer.

Finally, after about 6 months of nothing but shadowing the nurse responsible for NPWT on the inpatient wound team, I finally felt confident in my application technique and that I could safely recommend initial NPWT settings and apply the therapy when consulted on a patient.

What will help me become better at utilizing NPWT, you ask? These are the words of wisdom I would have liked to have been given at the start of my learning journey:

What You Need to Do When Applying NPWT

Know the generally accepted indications, contraindications and precautions for NPWT.

• Indications: acute, chronic, traumatic, dehisced wounds, burns, flaps, grafts, and pressure ulcers…
• Contraindications: osteomyeltitis without current antibiotic therapy, malignancy, exposed organs or blood vessels, necrotic tissue, and non-enteric or unexplored fistulas (this means not applying the therapy to or inside the fistula)…
• Precautions: coagulation therapy, patient nonadherence, and infections (even those being treated).

Cleanse the wound bed and periwound with a non-cytotoxic cleanser.

Non-viable tissue and thick exudate will hamper the growth of the healthy tissue underneath it (don't depend on the dressing medium to mechanically debride the wound bed, either). Assess the wound bed for structures such as blood vessels, tendons, cartilage, hardware, sutures, staples, tubes, or fistulas (we will cover how to work around these in another installment).

Insist on an in-service from the device manufacturer representative.

Most NPWT systems include a drainage collection device, tubing to connect it to the dressing, and a dressing medium to apply inside or over a wound. If you can apply one, you can generally figure out the premise of others (I always check the manufacturer's website for an instruction manual to ensure I'm applying the device safely if I am unable to reach the product representative before application*).

Make sure the hole cut in the drape is large enough for the suction device to fit appropriately.

Some devices have pressure feedback mechanisms in the suction pad and tubing.

Know the most commonly used default settings.

Calibrate yourself to the standard pressures, which again, vary by device, but can range from -25 to -200mmHg depending on the model. Note: Higher pressure does not equal faster healing!

Insist on pain control.

Pain management is an important aspect of applying NPWT. Soak dressing with saline, premedicate the patient or have the patient take an analgesic or as directed by the ordering provider, and utilize lidocaine topically as ordered, too.

Document the number of foam/gauze pieces placed in the wound bed.

If not removed, residual dressings can become a nidus for infection.

Talk to your patient while applying.

Teaching the patient what you're doing and how you do it can help them understand the NPWT better, especially if they or their caregiver may need to troubleshoot the device at home (an educational opportunity should never escape you!). Provide a handout, including who to contact in case of dressing or device malfunction, and request a return demonstration if applicable.

Always bring more supplies than you think you'll need.

I always keep extra on my cart or in my bag and leave it outside the room to decrease risk of contamination.

Always check systematically for leaks.

Start at the machine, then the canister, the tubing connections, the suction pad connecting the tubing to the dressing medium, and the drape covering it.

Techniques to Avoid When Applying NPWT

Do not tightly pack undermining and tunneling.

This causes contact inhibition of the tissue and will further delay healing.

Do not stretch the drape EVER, as it creates excessive stress and can damage the skin it covers.

Contour it to the periwound/surrounding landscape like you would apply paper mache to a balloon.

Don't cut foam too thin/small as this can cause over-collapse.

Over-collapse is the compression of the dressing that effectively stifles the flow of drainage through the tiny holes in the foam.

Never apply the suction pad over bare skin.

Doing so will cause tissue damage and potentially a new wound.

Never turn down an extra pair of helping hands.

Accept the offer of help when you can, even if it is the patient!

Other Helpful NPWT Application Strategies

A pretty dressing is not necessarily a more functional one.

Applying NPWT, regardless of manufacturer/device, is akin to repairing an above ground pool or an inflatable mattress: there is a good chance it's going to look like a Picasso painting when it's done.

More drape does not equal a better seal.

In fact, it can cause periwound maceration and worsen odor.

When in doubt, add more skin prep.

Skin prep can even be applied over the drape to seal any small air leaks.

Keep an eye out for blood in the NPWT pump, canister or tubing.

If frank blood is actively evacuating through system tubing and into canister, or if you find a canister full of frank blood, stop the suction and alert the patient's provider.

Know what to do if the drainage is too heavy.

If a wound is heavily draining, you may need to tuck some gauze or abdominal pads into it while drying/preparing the periwound and applying skin prep and drape. Sometimes it's a race against the clock…or the encroaching wound drainage threatening to seep under the drape and ruin your seal.

The backing to the drape will cling to your gloves for dear life.

Wrap a piece of surgical tape around your procedure table, or any other object you can wipe clean after use, and stick the backing to the tape after you've separated it from the drape. Otherwise, you'll be spending a fair amount of time trying to fling it off your hand (no one wants any flinging happening when wounds are involved).

Ostomy rings and paste are the caulk of the NPWT world.

Use these tools to your advantage when available. They perform best over clean, dry skin.

Be aware of your resources.

Colleagues in your institution with experience, product representatives/clinical liaisons, manufacturer websites, and instruction booklets attached to some devices can serve as great tools to assist the NPWT novice with safe and successful application. If available, it is always a prudent idea to conference with the local nurse liaison/device representative to brainstorm before application.

This is by no means an all inclusive instruction manual, but more of a "survival kit" of sorts to arm the novice NPWT clinician with the basic principles of therapy and the ability to troubleshoot basic applications. There are many, many more nuances in utilizing NPWT in various situations.

Don't miss the next installment, which will delve deeper into the depths of learning how to skillfully apply NPWT in various situations.

NOTE: Please use professional judgment and never apply a device to a patient if you do not feel competent and comfortable doing so. These tips are intended to reinforce the knowledge of the novice/learning clinician in the topic of NPWT as it applies to use for individual product/device indications.

About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.