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Wound Care and Pain Management: From a Pharmacy Viewpoint

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Michelle Anderson

on 8 June 2011

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Transcript of Wound Care and Pain Management: From a Pharmacy Viewpoint

Healing ...and patients describe
the pain as being the "worst thing" of having a wound. Wound Related Pain Management Pain Control Patient Centered Care Wound pain is complex
and specific to each
person ...and don't forget:
as health care professionals, we all have a pivotal
role in providing
effective wound management Look to the Pharmacist for consultation on
wound
care
ideas! Wound Care
and
Pain Management: From a Pharmacy Viewpoint Causes of Pain and Assessment Modalities of Pain Treatment Wound Healing Dressing Changes Why control Pain? Quality of Life
Wound Healing
Physiologic Effects
Increased Pain Perception Personal and subjective, but even with differences
in perception of wellbeing, it is clear that pain will have a negative impact. Pain activates the stress response which may impair wound healing. Pain can have detrimental effects on many organ systems in the body. Increased sensitivity in the wound bed or pain in uninjured surrounding areas.
Hyperalgesia- a small stimulus is perceived as painful If painful stimuli continue, such as in dressing changes, the patient may complain that any sensory stimulus, registers as pain.
Allodynia- pain that is caused by stimuli that are not usually painful Barbul Adrian, Efron David T, "Chapter 9. Wound Healing" (Chapter). Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE: Schwartz's Principles of Surgery, 9e: http://www.accessmedicine.com/content.aspx?aID=5013857.

Gomella LG, Haist SA, "Chapter 14. Pain Management" (Chapter). Gomella LG, Haist SA: Clinician's Pocket Reference: The Scut Monkey, 11e: http://www.accessmedicine.com/content.aspx?aID=2694871.

Woo KY, Harding K, Price P, Sibbald RG. Minimising wound related pain at dressing change: evidence-informed practice. Int Wound J 2008;5:144-157.

Christensen John F, "Chapter 31. Stress & Disease" (Chapter). Feldman MD, Christensen JF: Behavioral Medicine: A Guide for Clinical Practice, 3e: http://www.accessmedicine.com/content.aspx?aID=6442693.


Gomella LG, Haist SA, "Chapter 14. Pain Management" (Chapter). Gomella LG, Haist SA: Clinician's Pocket Reference: The Scut Monkey, 11e: http://www.accessmedicine.com/content.aspx?aID=2694871.

Lloyd Jones M (2004) Minimising pain at dressing changes. Nursing Standard. 18, 24, 65-70. Date of acceptance: December 18 2003.

Benbow M. A practical guide to reducing pain in patients with wounds. Br J Nurs. 2009 Jun 11-24:18(11):S20, S22, S24 passim Hollinworth H (2005) The management of patient's pain in wound care. Nursing Standard. 20,7,65-73. Date of acceptance: September 14 2005.

Mudge E, Orsted H. Wound Infection and Pain Management Made Easy. Wounds International 2010; 1(3): Available from http://www.woundsinternational.com

Coulling S. Fundamentals of pain management in wound care. Br J Nurs. 2007 Jun 14:16(11):S4-S12

Acton S. Reducing pain during wound dressing changes. Wound Essentials. 2008: Volume 3

White R (2008) Pain assessment and management in patients with chronic wounds. Nursing Standard. 22,32,62-68. Date of acceptance: February 29 2008.

Alberta Health Services. Fentanyl citrate injection. Long Term Care Formulary. Revised February 24 2005

Krasner D, Rodeheaver G, Sibbald R. editors. Chronic Wound Care: a clinical source book for healthcare professionals. 4th ed. Malvern, PA: HMP Communications; 2007.

Baranoski S, Ayello E. Wound care essentials practice principles. Philadelphia: Lippincott Williams & Wilkins; 2004.

Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004. Bibliography/Reference list Operative Procedural Incident Background Psychosocial Factors Environmental Factors Routine/basic interventions
Dressing removal
Wound cleansing
Dressing application Non-pharmacological techniques and
analgesia may both be required to
manage the pain. Movement-related activities
Friction
Dressing slippage
Coughing May require breakthrough pain
analgesia Persistent underlying pain
Cause of wound
Local wound factors-infection
Other pathologies-diabetic neuropathy Persistent pain when nothing
is being manipulated may require
regularly scheduled analgesia Cutting of tissue
Prolonged manipulation
Debridement
Wound biopsy Normally performed by specialist
clinician and requires anesthetic
(local or general) to manage pain Age Gender Culture Education Anxiety Depression Fear Grief Timing of procedure Setting Noise Positioning Resources Assessment of Pain Goal is to minimize pain and optimize wound healing
Always involve patient and customize assessment
Use pain rating scales (visual,numerical, and verbal)
Document pain before, during, and after wound care
Do not make assessment additional stressor
Changes in pain scoring may indicate infection or poor dressing choice
Previous negative pain experience can lead to increased expectations of pain Pharmacologic Pain Treatment Severe Pain
Opioid analgesics
(morphine, hydromorphone, fentanyl, meperidine-short term acute pain only)
+/- non-opioid
+/-adjuvant Moderate Pain
Weak opioid analgesics
(codeine,tramadol, combo products-
Percocet, Tylenol #3)
+/- non-opioid
+/-adjuvant Mild Pain
Nonopioid analgesics
(acetaminophen, NSAIDS)
+/- adjuvant STEP 1 STEP 2 STEP 3 Pain persisting
or increasing Pain persisting
or increasing WHO Analgesic Ladder Classes of Analgesics Opioids:

Moderate to severe pain
May use long acting for background pain
IV, IM, SC, Oral, SL, Transdermal
Use fast acting top-up analgesics for managing more acute pain NSAIDS:

Useful in controlling throbbing or aching pain
Caution in elderly
Contraindications include history of ulcer, clotting or renal problems
Inflammation may be useful in the inital stage of wound healing (first 2 days) Acetaminophen:

Useful in mild to moderate pain
Around-the-clock dosing may provide better pain management.
Give alone or in combination with opioid
Maximum daily dose in healthy person is 4000 mg.
In elderly person, decreased renal, or hepatic function the max dose may be 2600 mg or lower. Topical local anesthetics:

Examples are lidocaine or EMLA (contains lidocaine and prilocaine)
Use small doses for short periods of time
May be useful for specific procedure or operative event
Effects on wound healing are unclear Adjuvants Add for synergistic effect
Especially useful for neuropathic pain (burning,stinging,stabbing, shooting pain)
Examples include TCA's (nortriptyline, amitriptyline), anti-epileptics (gabapentin, carbamazepine), and pregabalin (Lyrica) Nonpharmacolgical Interventions Patient education
Avoid excessive stimuli environment
Communicate with patient/carer
Reduce anxiety
Diversion
"Time out" Other pharmaceuticals:

For extremely painful procedures, it may be necessary to consider general anlagesia, local neural blockade, spinal analgesia, or a mixture of nitrous oxide and oxygen
Topical opioids such as morphine gel (not commercially available) have been reported for treating painful wounds - with less systemic effects Factors Affecting Wound Healing Systemic:
Age, Nutrition, Trauma,
Metabolic disorders (Diabetes mellitus)
Immunosuppression (Chronic or high dose steroids)
Chemotherapy drugs
Smoking Local:
Mechanical injury, infection, edema, ischemia/necrotic tissue
Topical agents (cytotoxic agents such as betadine or hydrogen peroxide)
Ionizing radiation, low oxygen tension, foreign bodies Practical Tips Dressing choice and change procedure
Treat infections
Treat local factors
Use warm normal saline or sterile water to clean wounds
Evaluate need for analgesia given before a procedure
Choose analgesia that has a short time to peak effect, be easily titrated, and cause minimal side effects
Prevent/avoid medication adverse effects (eg. prescribe laxative with narcotic- Lactulose 15-30 ml daily or BID is recommended)
If around-the-clock pain medication is necessary- long acting drugs preferable
Use short acting agents (at 10% of total daily dose) for breakthrough pain
Taper opioid analgesic dose by 25% every 2 to 3 days when decreasing dose. Monitor for withdrawal or pain symptoms. The goal of pain management is to provide the patient adequate relief with minimum side effects (eg, drowsiness). Always begin therapy with the lowest dose of any medicine that provides significant relief. Timing of Analgesics Parenteral Opioids: provide swift and potent analgesia

Morphine- onset of analgesia is rapid, with peak effect in 1-2 hours and an elimination half-life of three to five hours

Fentanyl- approximately 100 times more potent and more lipid soluble than morphine, which results in a more rapid onset of action, and a shorter half-life of 2-3 hours.

Hydromorphone (Dilaudid)- has a more rapid onset of analgesia (within 30 minutes) and a shorter half-life (2.4 hours) than morphine. Oral Analgesics:

Generally require 1 to 2 hours to reach peak effect Sublingual Fentanyl:

Parenteral form can be administered SL
Patient must be able to keep drug there for at least 5 minutes
Oral bioavailablity is negligible
Onset of action is 5-15 minutes, with peak at 20 minutes, and duration of action has max effect up to 45 minutes
May be given minutes before dressing change, and minimizes the lingering effects of a longer acting opioid
Do not use if unable to hold under tongue (give SC in this case), decreased level of consciousness, or if they do not have incident pain Types of Pain Nociceptive:

A physical response to painful stimuli
Often gnawing, aching, tender, or throbbing Neuropathic:

Inappropriate response caused by dysfunction in nervous system
May be burning, stinging, shooting, or stabbing Most patients probably experience a combination of nociceptve and neuropathic pain
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