BSamantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN
Part 2 in a series exploring topics related to negative pressure wound therapy application. For Part 1, click here.
In my previous blog installment, we touched on some foundational elements of negative pressure wound therapy (NPWT). So, now that we are armed with the basics of NPWT application, we need to talk about how to document it! It would seem logical to simply 'write down what was done'. But, in learning the particulars of application, we discover the colossal importance of what may be considered minutia.
Negative Pressure Wound Therapy Documentation Requirements
As you can imagine, documentation of NPWT application builds on the competency of basic wound assessment skills, including:
- Wound bed and periwound characteristics, exudate type/color/consistency;
- Measurements (especially key in the outpatient setting where continued use of NPWT must be justified by a decrease in wound length/width);
- Current progress in plan of care and how patient is tolerating therapy;
- Wound etiology (if known and diagnosis is documented by a provider);
- And related preventative/treatment measures (nutritional support, offloading, regular debridement of non-viable tissue).
Following are key details to include in your NPWT documentation:
Note (if consistent care is provided among clinicians) if any wound contraction, granulation, or other signs of healing are observed. Conversely, document if any epibole is beginning to form, or if the wound does not appear to be granulating or contracting. Of particular importance, document any significant change in exudate that may require prompt provider re-evaluation of therapy.
Document what you remove, including the number of pieces of foam or gauze, contact layers, and other dressing mediums* if applicable. When this practice becomes habit, it will minimize the chance of material being left behind in the wound to become a potential nidus for infection. (*Off label use of other dressings in combination with NPWT is cautioned, as some may prevent the system from working—see previous blog for more information on this subject.)
Include unit settings in documentation, inclusive of pressure and variability setting (continuous, intermittent/dynamic), checking against current orders each time. At times, patients, family members, or other clinicians may alter settings without knowledge of how it may affect therapy. This can play an important role in overall assessment of the patient's plan of care; if expected improvement in wound status is not achieved, a review of the documentation may reflect that therapy settings were frequently inconsistent with orders.
Describe the manner in which the periwound and surrounding skin is protected, along with any noted skin reactions or potential sensitivities to products. For example, why should you use no-sting barrier when a regular barrier is fine and there is no breakdown?
Document what you apply to the wound, just as you document what is removed, including pieces of foam/gauze, different types of foam, and other necessary components (e.g. any protective layers for vulnerable/exposed tissue structures). It is helpful to document the rationale for arranging pieces of foam, gauze, or other dressing mediums in specific ways (i.e. purposeful delayed closure, attempted drainage of a sinus tract, barrier over an area of suspected fistula or intent to promote closure of certain area of wound). Write the number of foam pieces and date on the stickers provided with dressing kits in accordance with facility policy.
Document how patient tolerated procedure and what type of pain control was utilized for patient comfort.
Record the amount of exudate in the exudate collection chamber/canister, and whether it was changed. Some facilities ask that it be documented in the intake/output or 'drain' portion of the medical record, so be sure to check the facility policy.
Document the size/type of the dressing kit utilized, along with any other notable items (skin prep or other adhesive products, etc.) so that other clinicians accessing the note can bring appropriate supplies.
Note the amount of time it takes to apply the therapy. I see this often omitted, but it can be an integral part of transitioning care to other settings. In the event a SNF or home health agency will be assuming care, this will assist case management and social work to provide an accurate representation of the labor involved.
If a provider was present during the dressing change and the plan of care is discussed, or leads to any therapy changes, make note. This is helpful to record provider involvement, in lieu of an order for a change in therapy with no "paper trail".
As clinicians, we understand the importance of accurate documentation in any health care setting. However, for patients receiving NPWT, it becomes a crucial component of care for post-acute settings, and can 'make or break' the patients' ability to have access to NPWT. For example, as discussed in a previous installment about billing in the HOPD, the LCD and specific payor policies will outline the requirements to qualify a patient for therapy, and to substantiate continued medical necessity. Thorough documentation is also vital in situations where an amount of supplies above the approved amount is required (large wounds, dressing changes more frequent than average, etc).
Telling the Story: An Example of NPWT Documentation
I always enjoy reading other clinicians' documentation and noting what I like, or what I feel that mine personally lacks for completeness. Good documentation should tell a story! Here's an example:
"NPWT dressing change to sacral/coccygeal pressure ulcer per current orders of -150mmHg continuous. Therapy was switched off and patient/unit side tubing clamped. The dressing was instilled with NS and left to soak for 10 minutes. John, RN with wound team at bedside for turn/position assist. Coordinated with provider to view wound. Previous dressing removed (1 PC white foam and 1 PC black foam removed, consistent with drape marking and previous clinician note). Upon inspection of the wound bed, there was 50% red granulation tissue/40% pale pink tissue/10% yellow slough. Measurements are 4.8cmx5.3cmx4.5cm with undermining of 4.0cm at 10 o'clock, which are reduced from measurements two days prior. No malodor or purulence noted. Periwound skin mildly macerated with small area of breakdown at 4 o'clock. Inferior wound edges flat, superior slightly rolled. No erythema or induration noted. Wound cleansed with NS and 4x4's, then the periwound was prepped with 3m no sting barrier and adhesive drape, with stoma paste to inferior gluteal cleft for occlusive seal. One piece of small white foam was cut into a rectangular shape and fitted into the undermining at 10 o'clock only per Jane Smith, PA who is present at bedside during assessment. A pre-cut coiled dressing was used to fit the contours of the wound bed and ensure contact with the base of the wound to encourage granulation tissue formation, as well as maintain contact with the white foam for best drainage of exudate and conduction of pressure. Drape was applied over the foam and the suction pad was bridged to the left hip with a sufficiently large strip of black foam skin protected by drape. (1 PC white, 1 PC black and date were written on the dressing). The unit was set to -150mmHg continuous per order, and good seal was achieved. Old canister had 150mL serosanguineous exudate, which was exchanged for a new canister and dated. Pt tolerated procedure well, premedication with IV morphine and hydroxyzine provided by primary RN. Total time for dressing change was 35 minutes, including pre-soak with NS. Nutritional support for wound healing per dietary recommendations/consultation. Low air loss mattress plus climate control overlay continued. Staff will continue turning and repositioning schedule, and patient/caregiver understand to avoid sitting up over 30 degrees in bed except for meals."
-Sarah, RN, CWCN
What are some things you feel are required to develop thorough NPWT documentation? I would love to see any comments below. Thank you again for reading, and I'll leave you with this quote:
"A reader lives a thousand lives before he dies, the man who never reads lives only one." –George R.R. Martin
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.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.