Patient Centered Concerns
Pain management is important for optimal patient care. Pain is generally classed as nociceptive or neuropathic. Pain assessments should include documentation of the pain intensity, character and location at several time points, including during dressing changes and between dressing changes. As mentioned earlier, even when sensation is altered, it is important to address the need for pre-procedural analgesia.
Management of nociceptive pain can include oral medications including simple analgesia like acetaminophen or anti-inflammatories up to the judicious use of opiate medication. There are several neuropathic pain algorithms that have been published that provide guidelines for the stepwise management of neuropathic pain. In addition to these pharmacologic options, physical modalities including transcutaneous nerve stimulation, topical medications (lidocaine and others), mindfulness and cognitive behavioural therapy can be useful adjuncts for pain management (Moulin et al 2014, Mu et al 2017).
Figure 1. Algorithm for the pharmacologic management of neuropathic pain
| Gabapentinoids | ↔ | TACs | ↔ | SNRIs | ↓ | Consider adding additional agents sequentially if there is partial but inadequate paint relief† |
| ↓ | ||||||
| Tramadol | ↔ | Opioid analgesics | ||||
| ↓ | ||||||
| Cannabinoids | ||||||
| ↓ | ||||||
| Fourth-line agents* | ||||||
| SNRi – serotonin-norepinephrine reuptake inhibitors, TCA – tricyclic antidepressant *Fourth-line agents include topical lidocaine (second-line for postherpetic neuralgia) methadone, lamotrigine, lacosamide, tapentadol, and botulinum toxin. †There is limited randomized controlled trial evidence to support add-on combination therapy. Adapted from Moulin et al |
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For cases unresponsive to these measures, involvement of pain specialists and interventional pain management may be warranted.
Table 2 Simplified Pain Component &Therapeutic Action
| Simplified Pain Component | Therapeutic Action |
|---|---|
| Measurement tool | • Numeric Rating Scale, 0-10 (11-point scale; 0 = no pain, 5 = bee sting, 10 = slam the car door on your thumb; most people can live with a 3 or 4 out of 10) • Faces scale: cognitively challenged, young children, older persons |
| Neuropathic pain | • Burning, stinging, shooting, stabbing • Management strategies |
| Nociceptive pain | • Gnawing, aching, tender, throbbing • Acetaminophen, ASA, nonsteroidal anti-inflammatory drugs, narcotics (short/long acting) |
| Dressing removal | • Pull laterally to release adhesive bond and rotate like the hands of the clock before lifting up • Avoid strong adhesives (acrylates etc.) and use silicone adhesives or non adhesive dressings |
| Wound cleansing (sterile only required with immune compromise, deep postsurgical wounds) | • Use saline or (potable) water solutions at room temperature • Compresses or soaks are less traumatic than irrigation (make sure all solution is retrieved and you can visualize the base of the wound with no procedure induced bleeding or unnecessary trauma) |
| Debridement | • Topical EMLA is superior to other topical pain modalities • Use a thick layer and occlude with film type dressing for 10 to 30 minutes (shorter period for genitalia, face, folds; longer times on back or thick skin) • Can supplement topical agents with intralesional xylocaine with adrenalin (if not end artery and no other contraindication) |
| ©WoundPedia 2021 Used with permission from WoundPedia | |
Continuing with patient centered concerns, odour is often concerning for the patient and family. It is caused by anaerobic bacteria or necrotic tissue and can be distressing to patients. Management of this includes treating the cause of the offensive odour. Appropriate choices in dressings, possible debridement and addressing elevated bacteria levels may be useful. In addition, exudate can cause distress for patients and put surrounding skin at risk of breakdown. Assessment for the presence of superficial or deep infection with the use of NERDS and STONEES criteria and assessment for the contribution of edema will help in management of exudate. In order to optimize patient quality of life and coherence to the treatment plan, the patient needs to be integral to negotiation of management decisions along with their care network.
Determine Ability to Heal
Begin with the concepts of healable, non-healable and maintenance in your PI assessments. This will also help guide your local wound care strategies. Healable has adequate blood supply and the cause is corrected. Maintenance is where either patient or health system factors prevent healing. Non-healable is a wound with inadequate blood supply or a cause that cannot be corrected (see Table 5). Co-morbid conditions, including diabetes, renal failure etc., need to be optimized to facilitate healing. Adequacy of tissue perfusion is required to determine ability to heal.
Table 5. Summary of local wound care strategies
| Wound Healability Classification | Considerations | Surgical Debridement | Inflammation/Infection Management | Moisture Management |
|---|---|---|---|---|
| Healable | Provide moist environment Promote granulation |
Active | Treat inflammation/infection (topically or systemic) and antisepsis as required | Moisture balance |
| Maintenance | Decrease moisture and bacteria Prevent deterioration |
Conservative (no bleeding) | Bacterial reduction—antisepsis | Moisture reduction |
| Nonhealable | Decrease moisture and bacteria Prevent infection Enhance comfort |
Comfort removal of slough | Bacterial reduction—antisepsis | Moisture reduction |
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Adapted from Sibbald et al. Used with Permission ©WoundPedia 2021. |
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Wound status including healability classification may change between these 3 categories. For example, a patient with pressure injury may be able to quit smoking which will improve tissue perfusion and potentially take a maintenance wound to a healable wound.
Local Wound Care: Wound History
Consider the assessment of a wound. When assessing a PI, it’s important to gather additional information about the wound including:
- Location of the PI – The location of the wound may provide clues on which surfaces may be causing the pressure. For example, PIs on the ischial tuberosity’s are often caused by the surface a person is sitting on, whereas PI’s over the sacrum are often caused by surfaces the person is laying on.
- Duration of the PI – PI’s that have been chronic and ongoing are more likely to become maintenance or non-healable, and repeated trauma to the wound can decrease the tensile strength of the skin (Ireton et al., 2013).
- Previous treatments – Gathering information on previous dressings can be useful in developing a plan for the person going forward.
