Addressing the Pain: A Pain Management Protocol for Wound Care

   Robert Kirsner’s recent discussion¹ of the work of the European Wound Management Association (EWMA) position paper,² which cites pain as an important aspect of wound care, is on target. Acknowledgment of the need for attention to patient level of comfort has been coming from many directions.

When the Agency for Health Care Policy and Research (AHCPR), now the Agency for Health Care Research and Quality (AHRQ), gathered experts throughout the country to develop its Clinical Practice guidelines,^3,4 wound pain was recognized as having a significant impact of quality of life. The National Pressure Ulcer Advisory Panel has noted that pressure ulcers are “a significant and increasing source of considerable human suffering.”⁵

   In addition, the Joint Commission for Accreditation of Health Care Organizations (JCAHO) has woven pain management into numerous standards for which care providers in a variety of settings are responsible.⁶ The Joint Commission, along with several other agencies, has provided educational sessions on the topic in numerous sites for healthcare providers across the country.

   Perhaps the strongest motivator for addressing the pain patients experience is moral imperative. Gallagher wrote, “This means deciding the best course of action for those in our care.”⁷

   As clinicians assume responsibility for wound management, they are obligated by non-maleficence, or to “do no harm.” Studies by Phillips, Stanton, Provan and Lew⁸ have shown that more than 67% of patients with lower leg ulcers report severe pain. More than 60% of patients with venous ulcers have been reported to have trouble sleeping because of ulcer pain, according to studies by Hofman, Ryan, Arnold, et al.⁹ McDowell¹⁰ cites emotional pain as another aspect of wound care to be considered. She discusses the feelings of a cancer patient with a fungating tumor who must cope with “a constant visual reminder of the underlying disease and an altered body image.”

   One way to facilitate the care provider’s consideration of pain management in the context of wound care is the development of an organizational protocol. Nanticoke Health Services (NHS) Pain Management Protocol for Wound Care (see Figure 1 in journal) was developed by the authors in an effort to stimulate awareness of pain management among healthcare providers within the organization. Although a detailed description of parameters to be considered for assessment is not included in this protocol, reference is made to the organization’s Pain Assessment Tools procedure. This document contains specific guidelines for assessment of all types of pain. An initial, thorough pain assessment, which includes inquiry about the location, intensity, quality, duration, pain precipitators and relievers, is a vital part of a wound care provider’s role.

   Using a standard pain scale to describe intensity enhances the overall effectiveness of the individual’s pain management plan of care by providing a reliable means to evaluate interventions. Patients who are able to communicate verbally are asked to rate their pain using a Visual Analogue or 0-10 Numerical Rating Scale. Pediatric and geriatric populations may respond well to the Wong-Baker Scale,¹¹ a series of faces that express increasing levels of distress. Freeman, Smyth, Dallam, and Jackson¹² have published research on the reliability of the Visual Analogue and Faces Rating Scales in measuring pressure ulcer pain. Even patients who are cognitively impaired, have an altered mental status, or are otherwise unable to communicate about their pain can be assessed for pain using behavioral observation skills. For children, the FLACC Scale documents observations of the face, legs, activity, cry, and consolability; the Children’s Hospital of Eastern Ontario Pain Scale is another behavioral rating scale.¹³ Also included in the assessment portion of the Nanticoke protocol is Krasner’s model of wound pain,¹⁴ which distinguishes acute non-cyclic, acute cyclic, and chronic wound pain. Identifying which type or combination of types of pain the patient is experiencing helps guide appropriate interventions for pain management.

   The NHS Pain Management Protocol, referenced in the treatment/management portion of the wound pain protocol, includes the World Health Organization’s analgesic ladder¹⁵ for starting and combining analgesics in the pharmacologic management of mild to severe pain. Special considerations also are included in the Nanticoke protocol for patients with chronic conditions that lead to chronic pain. For example, neuropathic or phantom pain may be experienced after limb amputation — the burning or paresthesia experienced arises from injury to the nerve fibers at the stump. Educating the patient concerning this phenomenon is a significant part of the clinician’s role.

   Specific dressing and wound management options are suggested to address the cyclic acute pain associated with dressing changes. Therapeutic products that limit the frequency of changes, protect exposed nerve endings and periwound skin, and minimize trauma associated with removal should be selected. Analgesics should be offered when pain is anticipated. Non-pharmacologic interventions incorporated into the period before, during, and after wound treatments should be adapted to the patient’s developmental level. These include positioning, using pressure-reducing support surfaces, reducing anxiety by establishing a sense of patient control and encouraging deep breathing, imagery, and other diversionary tactics. Educating the patient and significant others about pain management and wound treatment plans is vital to successful outcomes.

   Thorough documentation of the treatment plan, administration, and patient’s response will help ensure good communication among all members of the healthcare team.

   Senecal¹⁶ notes that “concerns about addiction, limited knowledge of the pathophysiology of pain, and the pharmacokinetics of analgesics contribute to substandard pain management of patients who require wound dressing changes.”¹⁶ Specialists in wound care have a duty to maintain a current knowledge base regarding methodologies of optimal pain management for their patients. Developing procedures and protocols to guide pain management during wound care is an essential first step in facilitating positive patient outcomes.

1. Kirsner R. New approaches to a timeless dilemma. Ostomy/Wound Management. 2003;49(1):12–14.

2. Wulf H, Baron R. The theory of pain. In: European Wound Management Society. Position Document: Pain at Wound Dressing Changes. London, UK: Medical Education Partnership Ltd; 2002.

3. Bergstrom N, Bennett MA, Carlson CE, et al. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. Rockville, Md: US Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1994. AHCPR Publication 95-0652.

4. Acute Pain Management Guideline Panel. Clinical Practice Guidelines Number 3: Acute Pain Management: Operative or Medical Procedures and Trauma. Rockville, Md: US Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; AHCPR Publication 92-0032.

5. National Pressure Advisory Panel. Pressure ulcers prevalence, cost and risk assessment. Decubitus. 1989;2:24–28.

6. Joint Commission on Accreditation of Health Care Organizations. Joint Commission Offers Pain Health Summits, 2002. Available at: www.jcaho.org. Accessed February 1, 2003.

7. Gallagher S. Ethical dilemmas in pain management. Ostomy/Wound Management. 1998;44(9):18–23.

8. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychological implications. J Am Acad Dermatol. 1994;31:49–53.

9. Hofman D, Ryan TJ, Arnold F, et al. Pain in venous leg ulcers. Journal of Wound Care. 1997;6(5):222–224.

10. McDowell K. Wounds and pain management. Nursing Standard. 2000;14(23):47.

11. Wong DL, Hockenberry-Eaton M, Wilson et al, eds. Wong’s Essentials of Nursing, 6th ed. St. Louis, Mo.: Mosby;2001.

12. Freeman K, Smyth C, Dallam L, Jackson B. Pain measurement scales: a comparison of the visual analogue and faces rating scales in measuring pressure ulcer pain. JWOCN. 2001;28(6):290–296.

13. Finley PJ, McGrath PJ. Measurement of Pain in Infants and Children. Seattle, Wash: IASP Press; 1998.

14. Krasner D. The chronic wound pain experience: a conceptual model. Ostomy/Wound Management. 1995;41:20–25.

15. World Health Organization (WHO). Cancer Pain Relief, 2nd ed. Geneva, Switzerland: WHO; 1996.

16. Senecal SJ. Pain management of wound care. Nurs Clin North Am. 1999;34 (4):847–860.