Pain in Pressure Ulcers

Managing the Cause of Pressure Ulcer Pain Case vignette. Ms. B is an 83-year-old female who has had a right ischial tuberosity pressure ulcer for the past 3 years that currently measures 2 cm x 3 cm x 1 cm. She lives alone, but her daughter lives nearby and helps with the grocery shopping and meal preparation. At times, her daughter finds the meals uneaten in the refrigerator. Ms. B's past medical history is significant for severe osteoarthritis, spinal stenosis, scoliosis, hypertension, and urinary incontinence. Despite mild cognitive impairment, Ms. B acknowledged that she had pain, rating it a 6 out of 10 in terms of severity. She said the pain was "because of her arthritis," and that it was particularly severe in her hips and knees. According to the orthopedic surgeon she visited, she is not a candidate for surgery. As a result of her pain, she spends most of the day in a chair watching television, as she finds it more painful to walk around. Ms. B clearly illustrates the multifactorial origin of pressure ulcers. The risk factors of immobility, loss of sensation, friction, shear, moisture, and poor nutritional status are cumulative and, in combination, place the patient at high risk for skin breakdown and delayed healing. Literature is extensive on the identification and management of the risk factors causing pressure ulcers.1,2 In this article, the focus is on the role of pain management in the prevention and treatment of pressure ulcers. The previously published paradigm for wound bed preparation3 has been adapted (see Figure 1) to provide clinicians with a framework for integrating pain management into their care plans. Treat the Cause Pressure. Ulcers develop from unrelieved pressure over bony prominences that exceeds capillary closing pressure, resulting in tissue ischemia. The ischemia itself leads to pain through inflammatory mediators. Pressure relief/reduction support surfaces not only treat the cause of the ulcers by offloading the bony prominences, but they also may aid in pain management. Seating and positioning assessments by trained professionals are an important part of pain management in people with pressure ulcers. In particular, the authors believe all institutionalized patients should be on pressure reduction foam surfaces for prevention as well as comfort. Immobility and loss of sensation. Patients at risk cannot move or cannot feel or may have both problems (see Figure 2). Pain may be an important factor in immobility and optimal pain management may reduce the risk of developing pressure ulcers. Loss of feeling. Paralysis does not mean freedom from pain. Spinal cord injury patients frequently experience persistent pain in areas that otherwise have no sensation. At least five different categories of pain potentially affect patients after spinal cord injury: 1. Pain related to mechanical instability of the spine (possibly due to incomplete healing of the fracture) 2. Mechanical compression of a nerve root at the injury site. This produces radiating pain, often unilateral but may be bilateral 3. Pain felt by the patient in the part of the body that has no "feeling." This pain is below the level of injury and is constant 4. Pain felt in the region of partial sensation - a kind of "denervation pain" 5. Overuse phenomena, not directly caused by the injury. For example, shoulder problems or carpal tunnel syndrome is frequently seen in paraplegic patients in wheelchairs who use their arms for mobility.4 Patients with spinal cord injuries also may experience spasms, which may be treated with baclofen. Spasms, especially in the lower extremities, may lead to friction and shear in the heels and cause skin breakdown. Other options include referral to a specialist in physical medicine and rehabilitation. Inability to move. Pain is a common symptom in the elderly. Among community-dwelling elderly, 25% to 50% suffer from pain5-7 and up to 80% of nursing home residents have significant pain that is undertreated.8 One in five older Americans (18%) is taking analgesic medications several times a week and 63% have taken prescription pain medications for more than 6 months.9 Although age alone is not a risk factor for increased pain (the diseases associated with aging may cause pain), age has been identified as a key risk factor for inadequate pain management.8,10 Many elderly people have diseases associated with significant pain, such as arthritis, ischemia, and cancer. Immobility related to these conditions may lead to pressure ulcer development; therefore, treating the pain that leads to immobility could potentially prevent and/or treat skin breakdown. Friction and shear. Friction occurs when one surface rubs over another and can cause surface abrasions on the skin. Shear refers to the movement of deeper tissues over bony prominences. In combination with pressure, both are significant risk factors for the development of pressure ulcers. Painful skin breakdown due to friction can be treated with appropriate moist interactive dressings. Strategies to reduce friction and shear are summarized in Table 1. Nutrition. Poor nutrition often leads to poor muscle mass and wasting of protective subcutaneous fat. Pressure ulcer healing is compromised by poor nutritional status.11-13 Nutritional demands for protein and calorie intake are greater in patients with pressure ulcers; a dietary consult is important for optimal management.14-16 In addition, patients with significant wasting tend to experience greater pain, so nutritional support is important in pain management. The use of vitamin and mineral supplements is controversial but these supplements are generally benign and often add to the patient's sense that something is being done. Deep infection. Numerous studies have shown that chronic wound exudate may have abnormally increased protease concentrations (particularly matrix metalloproteinases [MMPs]).17 The increased proteases shift the wound healing balance into a continuing chronic inflammatory phase. As discussed in the introductory article section on the pathophysiology of pain, continued inflammation and tissue injury contributes to persistent, abnormal pain sensations or chronic wound pain. Increased pain in the area of the ulcer is, therefore, one of the signs of possible deep infection. Erythema and induration greater than 2 cm, increased tenderness, and new areas of breakdown also may be signs of deep infection. Ulcers that probe to bone should be investigated for osteomyelitis. Use of appropriate systemic antibiotics will improve the associated pain as the infection resolves. Nerve damage or irritation. Pressure ulcers also may cause damage or irritation to peripheral nerves, leading to neuropathic pain, another form of chronic wound pain. The burning pain of nerve irritation may respond to tricyclic antidepressants, while the stabbing pain of nerve damage often responds better to anticonvulsants such as gabapentin. Patient-Centered Concerns A patient-centered clinician should explore both the disease and the illness experience with the patient.18 The disease consists of the physical examination, lab tests, and other objective findings, while the illness experience is the broader concept of ideas, expectations, and functional limitations related to the disease. In understanding the whole person, the disease and illness experience are examined in the context of the patient's life and stage of development. For example, one seeks to understand the impact of the illness on the patient's family system. The patient and clinician begin a negotiation process where they seek common ground, defining goals of care and the roles and responsibilities in the therapeutic relationship. People with pressure ulcers may decide that, in the context of their current situation, it is not reasonable to set "healing the ulcer" as a goal. Instead, the focus may be on controlling pain, managing exudate and odor, and improving quality of life. This may become the focus of the local wound care through choice of treatment protocols to minimize pain. Local Wound Care Debridement. In the Krasner model,19 debridement is an example of noncyclic acute wound pain. If pain is of paramount importance, autolytic or enzymatic debridement are better approaches. Sharp debridement requires advance planning for pain control using topical or injected anesthetics, premedication, and nonpharmacologic approaches to pain management as discussed in the introductory article in this document.20 Severely demented patients who are bedbound and develop pressure ulcers still feel pain with debridement, although they may not be able to communicate this. Using pain assessment scales or watching for nonverbal clues to pain, such as agitation or facial grimacing, is important. As previously discussed, patients with paralysis may experience pain with debridement. Any unpleasant experience should be discussed with each patient, as sensations differ between individuals. Patients with high spinal cord paralysis will require local anesthetic before debridement to prevent autonomic dysreflexia. Severe muscle spasms with pervious interventions are a clue to possible autonomic dysreflexia. Moisture balance. Any nurse worth her salt allows patients to remove their own dressings. - H. Orsted, 2002 Dressing removal is frequently cited by patients as the time they experience the greatest amount of pain.21-26 Pain at dressing change can be minimized by adopting strategies to reduce pain and trauma, as well as carefully choosing dressings with pain-reducing characteristics. Some strategies to avoid pain with dressing changes include soaking old dressings with saline or even 4% topical lidocaine before removal or using nonadhesive/nonadherent dressings, but the use of atraumatic dressing products (eg, soft silicones) is a more modern practice. Many patients fear pain with dressing removal, so talking to the patient about any fears or concerns before the event is crucial. Having a plan for pain management in place before dressing changes, including patient initiated breaks or "time-outs" during the procedure, can help alleviate discomfort and anxiety. When the patient says "Stop," the clinician must cease the intervention immediately if trust is to be gained. In addition, pain medications can be given an hour before dressing removal if pain is anticipated. Using dressings that provide pain-free removal as well as non-adherence is also beneficial. Gauze dressings can stick to the wound and cause pain. Soft silicone products have been recommended to help minimize pain and trauma on dressing removal.21,27 Hydrogels and alginates also may minimize pain in appropriate patients with mild to moderate exudate. As occurs with debridement, spinal cord injury patients also may experience pain and/or discomfort with dressing changes. These issues should be addressed with this patient population as well. Superficial bacteria/inflammation. Chronic pressure ulcers exist on a continuum from contaminated to infected. In contaminated wounds, the bacteria are on the surface and host resistance is greater than the bacterial numbers and virulence. In infected wounds, the bacterial numbers and virulence have overwhelmed the host abilities to contain them, deeper tissues are invaded, and chronic inflammation is established. As wounds move from contaminated to infected, the clinician may observe subtle signs of impending infection, including friable exuberant granulation tissue, abnormally red color, increased exudate and odor, and stalling of healing. Patients may say the wound is painful. Healable wounds with increased bacterial burden may benefit from topical antimicrobial treatment. Silver sulfadiazine has broad spectrum of activity, is rarely associated with bacterial resistance, and has proven useful in this context. Several modern dressings have incorporated silver into a variety of formats, including hydrofiber, alginate, and foam. These dressings allow for the combination of dressing functions and maintenance of bacterial balance. Iodine has broad antiseptic properties and is now available in a slow-release format that is nontoxic to granulating tissue. Nonhealable wounds may require the use of full-strength topical antiseptic. Conclusion to the Case Vignette Ms. B was started on acetaminophen (1,000 mg every 6 hours) around the clock. She found this only of slight benefit, because she continued to experience pain. Codeine (30 mg prn) was prescribed in addition to the acetaminophen. Lactulose (30 mL po OD) also was prescribed as a prophylactic measure to prevent constipation. Over the course of several weeks, the dose of codeine was increased, and eventually the codeine was switched to long-acting morphine, starting at a dose of 15 mg q 12h, with morphine 2.5 mg prn for breakthrough pain. Ms. B continued to take the acetaminophen regularly. She still needed several breakthrough doses a day, so she was gradually increased to long-acting morphine (45 mg every 12 hours). She no longer required any breakthrough doses, but complained that she didn't like taking the pills. She subsequently was switched to transdermal fentanyl (25µg/day) to be changed every third day. By this time, Ms. B's functional status was dramatically improving. Although she had never been depressed, she stated that she was able to have fun again, shopping and socializing with her friends. She even began going to a seniors exercise program at the local community center. Her ulcer also was improving dramatically, and because she was able to walk and perform her activities of daily living, she was no longer confined to bed or chair. Her appetite improved, and she gained some weight. At one point, her nurse noted that the wound was friable, and Ms. B was complaining of pain in the ulcer. Odor and exudate had increased. A swab grew beta-hemolytic Streptococcus. Ms. B was given a course of oral antibiotics and a silver-containing dressing. Her symptoms resolved and she re-commenced healing. At her most recent doctor's appointment, Ms. B stated that although she has occasional pain, she is much more independent with all her activities of daily living and that her quality of life has markedly improved. Conclusion The treatment of pressure ulcer-related pain requires a systematic approach to the cause, patient-centered concerns, and local wound care. The pain associated with pressure ulcer patients can be caused by pressure, infection, or other factors along with local wound care problems. A successful approach to treatment must include the patient in the decision process. - OWM

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