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Innovative Wound Management Services
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Catherine Eager, BSN, RNC, ETN, CWS · Nancy Turpin, MSN, GNP,CWS |
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| Articles in this Issue: | ||
| Methods for Relieving Pain during Dressing Changes | ||
| Pain Management for Lower Extremity Wounds | ||
| Comparison of Two Foams | ||
| Links to Pain Management Resources | ||
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Sensory processing of painful stimuli does not change as we age. There is widespread belief among clinicians that pain tolerance decreases with age and that the elderly tend to increase their complaints over minor painful experiences. In fact, the elderly may experience more pain than younger people, although they may be less likely to complain about it. As a result, the elderly receive poor pain management. The goal of the clinician should be to listen to the patient and address his/her pain. Understanding the physiology assists in administering and implementing pain relief measures. In the elderly
Some practical measures can reduce pain during dressing changes making the experience tolerable.
Consider the patient holistically. Failure to treat pain effectively is no longer acceptable and should be considered a prime indicator of poor quality medical care.
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Chronic leg ulcers are caused by a variety of disease processes. Venous insufficiency is the causative factor in 70-90% of lower extremity ulcers. The remainder are primarily caused by diabetes and arterial atherosclerotic disease. Effective pain management for lower extremity ulcers of these three types must be based upon recognition of the specific causative disease process: each produces pain of a different type. The sensation and description of the pain are as important as the intensity of the pain present. Narcotic “big guns” are frequently NOT the best answer for the wound care client, who is most often an elderly individual with concomitant disease states and multiple routine medications. Many venous ulcerations are painless or minimally uncomfortable. PRN Tylenol is then sufficient for discomfort. Ibuprofen and other NSAID’s should be avoided due to enhanced bleeding tendency in wound tissue. Deeper venous wounds, especially if infected, may be more painful. In these cases, pain is frequently best relieved by measures other than medication! Mild compression wraps to the lower legs, combined with rest with feet elevated to heart level and consistent warmth provide relief. If a wound is infected, the addition of appropriate antibiotic therapy makes a significant impact on pain within 24-48 hours. “Appropriate antibiotic therapy” includes coverage for both aerobic and anaerobic organisms. Experience has shown that a combination of lower doses of Levaquin and Clindamycin is very effective, and should be continued until signs of infection are gone and some progress in healing is apparent. Both the initial aspiration culture and the follow-up culture should be done to ensure treatment effectiveness as well as to identify resistant organisms - such as MRSA (methicillin-resistant Staph. Aureus) - that require specific antibiotics for much longer courses. Venous ulcer pain not relieved by the above measures is often effectively treated by Extra Strength Tylenol taken routinely (two tablets 3 times a day), or by Ultram 50-100 mg. 2-3 times a day. As the wound shows evidence of regenerating tissue (often 1-2 weeks with expert wound care), the pain reduces or even disappears. Long-term need for analgesics is very infrequent, unless the wound healing course is interrupted or complicated. Lower extremity ulcers caused by diabetic microcirculatory compromise and other neuropathic changes require a somewhat different pain management approach. Generalized neuropathic discomfort is often made more pronounced by the development of skin lesions and wounds. Clients describe this pain as “constant burning” or “severe aching” which is an intensified version of chronic neuropathic (degenerating nerve) pain. Even if lower legs and feet are insensate due to longstanding diabetes, some clients will still experience a non-specific sensation of pain (varying degrees) related to skin breakdown. Narcotics, sedatives, anti-anxiety agents, or sleep aids do not relieve this type of pain effectively. Drugs that reduce nerve irritability such as Neurontin (classified as an anti-convulsant), and the synthetic centrally acting analgesic Ultram are much more effective than high side-effect narcotics. Arterial ulcers present a challenging, more complex pain problem. The skin breakdown caused by arterial atherosclerosis can best be termed a tissue “infarct,” i.e., the death of skin layers due to lack of oxygen. These are the most difficult lower leg and foot ulcers to treat due to significant necrosis occurring rapidly, often down to the bone. The ulcers are always very painful. The main objective for effective pain management is to first attempt measures that may improve (at least temporarily) the delivery of oxygenated blood to the site. ASA 325 mg. per day (one adult tablet) can sufficiently thin blood to improve flow to the compromised area. ASA daily therapy in combination with Trental 400 mg. one capsule per day titrated to an eventual 400mg. 2-3 times a day provides optimal possibility for improved circulation. The powerful blood thinner Coumadin may be used in cases of severe arterial narrowing, but can prove deleterious to topical treatment of an open wound. If these measures do not produce adequate pain relief, then narcotics such as hydrocodone and morphine preparations are usually required, either alone or in combination with the ASA/Trental regime. In many cases of arterial lower extremity compromise causing infarcted tissue, the condition is advanced to the point that the only real answer is surgical revascularization, assuming the client is a candidate for this procedure. Arterial ulcers with necrosis and/or gangrene caused by diabetic vascular complications account for the vast majority of toe, foot, and below-the-knee amputations. Peripheral vascular disease (PVD), especially with a marked arterial component, also accounts for many below-the-knee amputations. PVD of this severity is often caused by the vascular effects of long-term cigarette smoking, chronic hyperlipidemia, and/or uncontrolled hypertension.
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This report, the results of which were presented as a poster at the 14th Annual Symposium on Advanced Wound Care & Medical Research Forum on Wound Repair, is a retrospective review of data collected on patients seen at our outpatient wound clinic. It compares two groups of patients suffering from stage III and IV ulcers. The goal of the data review was to compare the times to healing, the time between dressing changes, and the peri-wound issues of two foam dressings: a soft-silicon coated polyurethane foam dressing1 and a hydrophilic polyurethane dressing2. We reviewed data on 87 wounds treated with a soft-silicon coated polyurethane foam dressing1 and 86 wounds treated with a hydrophilic polyurethane dressing. Method. Only data for healed stage III and stage IV ulcers were reviewed. Patients were differentiated by type of wound, stage of ulcer, age and gender. A standardized documentation tool was used to track the number of times each foam was used, the average time between dressing changes, time-to-healing and peri-wound status. Data was then collected and analyzed in a computer program developed for our clinic.
Results. 1. The soft-silicon coated polyurethane foam dressing1 showed faster healing rates than the hydrophilic polyurethane dressing. 2. The soft-silicon coated polyurethane foam dressing1 demonstrated longer wear times than the hydrophilic polyurethane dressing. 3. Patients treated with the soft-silicon coated polyurethane foam dressing1 had fewer peri-wound issues than those using the hydrophilic polyurethane dressing.
Conclusion. Irritation and inflammation of the peri-wound surface interfere with the phases of healing by increasing the inflammatory response and delaying epithelial activity. To maximize the healing time of wounds, it is necessary to care for the peri-wound surface. Maintenance of the peri-wound increases patient comfort and length of time the dressing was tolerated. Of the 87 wounds treated with a soft-silicone coated polyurethane foam dressing, six had incidents of dermatitis. Among the 86 wounds treated with the hydrophilic polyurethane dressing, there were eleven documented cases of dermatitis. The soft-silicone coated polyurethane foam dressing could be left on for an average of 5-7 days. The hydrophilic polyurethane foam dressing could be left an average of 3-5 days. These general findings and the experiences of the clinicians and patients would seem to indicate that the soft-silicone coated polyurethane foam dressing has a greater ability to effectively absorb exudate over an extended wear time without causing dermatitis or peri wound breakdown. 1Mepilex, Mölnlycke Health Care, Eddystone, PA
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Sources: Banks V, Harding EF, Harding K, Bale S. Evaluation of
a new polyurethane foam dressing. J Wound Care 1997; 6:463-6.
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For More Information About Pain Management:
Agency for Healthcare Research and Quality American Pain Society Nursing Research and Education/
City of Hope Pain Resource Center Joint Commission on Accreditation of Healthcare Organizations (JCAHO) | ||
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Innovative Wound Management Services is a division of Wound Care Protocols, Inc. The contents of the Innovative Wound Management Services Newsletter are not intended to provide personal medical advice, which should be obtained from a qualified health professional. The contents of the Innovative Wound Management Services Newsletter do not necessary reflect the views or opinions of the sponsor who has provided an unrestricted educational grant. The use of information from the Innovative Wound Management Services Newsletter for commercial purposes is prohibited without written permission from Innovative Wound Management Services. |
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