Skin Matters: Pain from Skin and Wound Conditions: Part 1

  Patients across the continuum of care often experience pain due to skin or wound conditions. Clinicians sometimes view the causative condition as minimal or commonplace; for patients, however, pain is often perceived as problematic, severe, or having an enormous impact on their healthcare-related quality of life.^1-3 Common sources of skin and wound pain are listed in Table 1.

Case Vignette

  Ms. J was a 74-year-old woman admitted to an acute care hospital as the result of a cerebral vascular accident, status post left. Her stroke resulted in severe right-side weakness, immobility, and bed-bound status. Although she was continent before admission, Ms. J was rendered doubly incontinent, requiring incontinence briefs. Subsequently, she developed severe dermatitis with some erosion of both buttocks. Ms. J rated her buttock pain as 7 out of 10 and says the worst pain occurred when the nurses cleaned her following an incontinent episode.

Using the ABCD Guide for Skin and Wound Pain Management

  The ABCD Guide, developed by Fogh et al⁴ (see Figure 1), can help organize the management of painful skin and wound conditions. Although created for the launch of Biatain-IBU (Coloplast Corp., Marietta, Ga) in Europe and Canada, (the product is not yet available in the US), the Guide is applicable to all types of painful skin and wound conditions.

  A. Assess the pain. Skin and wound pain can be nociceptive, neuropathic, or both. It can be procedural or non-procedural related. Chronic wound pain also can be described as acute non-cyclic, acute cyclic, or chronic.⁵ Since 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated that pain be assessed and measured and has suggested that it be considered the fifth vital sign.⁶ Often with skin conditions, an itch-scratch-itch-scratch cycle exists that, if not addressed, can lead to painful skin breakdown. Early recognition and assessment of underlying etiologies is essential for prevention and early intervention strategies. Hence, the first step is to ask a series of questions, including, “Does your wound pain interfere with your sleep, mobility, or appetite?”

  B. Be aware of the cause and treat it. Pain treatment requires an individualized plan based on the assessment. Common causes of skin-related pain, such as infection and uncontrolled edema, may require a series of interventions.

  Treatments chosen to address underlying causes or conditions should take pain reduction/relief into consideration. For example, for an infected skin tear, a pain-relieving cleanser and topical treatment (eg, wound cleanser and hydrogel) should be selected rather than products that are likely to exacerbate pain (such as Dakin’s solution and povidone-iodine ointment). If pain is secondary to a superinfection such as incontinence dermatitis with Candida, an all-in-one product (moisture barrier with antifungal) that minimizes procedural pain and effectively addresses underlying etiologies should be used.

  C. Consider local treatment. Many local strategies can be used to address skin and wound-related pain. Topical analgesics and anti-inflammatory agents (over-the-counter and prescription) can be useful in addressing pain. Additionally, moisturizing lotions, creams, and ointments can be used depending on the etiology of the wound/condition. Barriers, including petrolatum and zinc oxide-based products, are often important adjunctive products when exudate or incontinence must be considered.

  D. Do we need a systemic approach? Often the pain from skin and wound conditions is so severe or persistent that systemic treatments are necessary to complement the local or topical treatments. The facility pain team and nurse specialist are reliable resources. In addition, a comprehensive pocket guide, “Assessing and Managing Painful Chronic Wounds: A Pocket Guide” is available at: https://www.biatain-ibu.coloplast.com.

Case Vignette Wrap-Up

  Ms. J’s nurse determined her pain was primarily procedural due to incontinence clean-ups on severely denuded and irritated skin and she initiated a multifaceted approach. To minimize the pain caused by the friction from wiping denuded skin, the nurse used a no-rinse incontinence spray or foam cleanser to preserve skin integrity. To prevent urine and stool from contacting irritated and denuded skin, a thick layer of moisture barrier ointment (one that is clear and allows for visible inspection of the area during the healing process) was applied. To address persistent pain from the inflammatory process, the physician was asked to prescribe a systemic analgesic/anti-inflammatory agent to be administered around the clock. The plan was communicated both to Ms. J and her nursing colleagues, emphasizing the complexity of the problem and the benefits of implementing the ABCD approach. Within a week, the denuded skin had re-epithelialized, the redness and pain were gone, and a prevention plan was in place.

  Part 2 will focus on chronic wounds.
 

The Skin Matters series is made possible through the support of the Skin Health Division of Coloplast Corp., Marietta, Ga. 

This article was not subject to the Ostomy Wound Management peer-review process.

1. Krasner DL, Shapshak D, Hopf HW. Managing wound pain. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds, 3rd ed. St. Louis, Mo: Mosby;2007;539–565.

2. Nix D. Prevention and treatment of perineal skin breakdown due to incontinence. Ostomy Wound Manage. 2006:52(4):26–28.

3. Norman RA. Xerosis and pruritus in elderly patients, part 2. Ostomy Wound Manage. 2006;52(3):18–20.

4. Fogh K, Glynn C, Junger M, et al. The Persistent Pain Management Guide. Available at: www.biatain-ibu.coloplast.com Accessed August 6, 2006.

5. Krasner DL. Caring for the person experiencing chronic wound pain. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, Pa: HMP Communications, 2001:79–89.

6. www.jcaho.org Accessed August 6, 2006.