management of chronic wound pain 2014

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management ofchronic wound painSabo Y. Machudo,Senior Nurse Educator;KAUH. KSA.

synopsisPain is a major issue for patients suffering from many different wound types.

The last decade has focused on healing as the principal outcome of wound management.

An emphasis which arose out of the acknowledgement that patients were being treated ineffectively, resulting in delayed healing and prolonged care

This approach has been pivotal in our understanding of evidence based care, with its emphasis on clinical and cost effectiveness. However, complete healing as outcome of successful treatment has been at the expense of other important patient centered outcomes, such as pain and other quality of life issues.2GoalAt the end of this lecture, participants will be able to:

understand the guide to pain management during wound dressing.

be aware of the options of product range and ability to select dressings that reduce pain and provide comfort.

3

introductionWounds require complex care because they have many causes & complications:

Pain can affect everyone; the psychological impact of pain cannot be measured nor underestimated and is likely to affect wound healing.

introductionPoor techniques in wound care can further traumatize wounds resulting in an increased pain for the patient & slowed healing. Strategies can be adopted through which pain can be avoided or minimized.

what are principles of wounds careWound bed management paradigm previously developed by Sibbald et al, 2003b) is a basis for the management of chronic wounds and has been used extensively by wound care specialists.

It consists of four major principles:Treating the cause.Addressing patient-centred concerns.Providing local wound care.Using advanced therapies when the wound is not healing at the expected rate.

Treating the cause:Treating the cause of a chronic wound may involve removing the source of the problem, for example with a venous ulcer edema can be reduced with compression therapy.

Addressing patient-centred concerns:Pain in chronic wounds is a major concern for patients and healthcare professionals (Sibbald, 1998; Neil and Munjas, 2000).

Pain was identified as the third biggest issue after time to healing and limb preservation (Eager, 2005).

Pain control is often more important to patients than it is to healthcare professionals (Queen et al,2005).

advanced therapies:Pain friendly dressings:

Hydrogel.Calcium alginate.Hydrocolloidal.Foam.Transparent.

factors that influence pain?

factors that influence pain:Dressings

Debridement

Infection/inflammation and

Moisture balance

Dressings:Dressing removal is usually cited as the time when the most pain occurs.

Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes, with gauze removal being the most common cause of this pain.

Newer products, such as soft silicone dressings, hydrogels, Hydrofiber (ConvaTec, Ickenham), and alginates are less likely to cause pain (Hollinworth and Collier, 2000).

Debridement:Wound debridement by surgical autolytic, enzymatic, and or mechanical means (Davies et al. 2005).

The more aggressive the debridement regimen (e.g. surgical and mechanical), the more potential pain for the patient.

For surgical debridement, application of topical local anaesthetics, such as 4% topical lidocaine, amethocaine 4% gel or EMLA, 3060 minutes before the procedure may be helpful.

Infection/inflammation:Infection and inflammation can be painful in themselves (Gardner et al, 2001).

Superficial infections may be treated with topical antimicrobials, while deeper infections require systemic agents (Krasner and Sibbald, 1999).

Infection/inflammation:Many topical preparations, both pharmacological and non -pharmacological (e.g. antibacterial dressings), exist to treat both infection and inflammation. Silver-containing dressings are both anti-inflammatory and antimicrobial (Wright et al, 2002).

Moisture balance:Moist wound healing has been demonstrated to result in faster healing, less scarring, and less pain (Rovee, 1991; Kannon and Garrett, 1995).

The pain reduction has been attributed to the bathing of the exposed nerve ending in fluid, preventing dehydration.

Moisture balance:Fibrous products (eg. alginates, Hydrofiber) are excellent primary contact layers.

In the presence of wound fluid, these fibres transform into gels to facilitate a moist interactive local wound bed environment and result in a soothing sensation.

additional Factors influencing wound pain:

Products or techniques used to cleanse wounds.

Lack of empathy.

Skin excoriation from exudates or wound drainage .

Failure to record patients earlier reports of pain.

Poor techniques when using compression bandaging .

Other Factors influencing wound pain:

Dressing removal is considered to be time of most pain.

Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes.

Gauze is most likely to cause pain.

other factors include:

other factors include:Products designed to be non-traumatic are most frequently used to prevent tissue trauma.

Awareness of product range and ability to select appropriate dressings.

Use of valid pain assessment tools is considered a low priority in assessment, with greater reliance on body language and non-verbal cues.

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wound care and pain;considerations at dressingPrevent trauma.

Prevent pain.

Prevent infection.

Prevent skin damage.

The most important strategy to avoid wound damage was the use of non-traumatic dressing.

Importance of dressing characteristics.

Awareness of products.

Ability to choose the dressing

Prevention of trauma.

Regularly scheduled interventions such as dressing changes.Perform dressings when patient is less fatiguedPre-medicateIf dressing has dried out, dampen itConsider alternatives to sharp surgical Debridement:Hydrogels, hydrocolloids, Hypertonic saline solution, or enzymatic agents.Medicate before, during, and after as appropriate.

Prevent pain:Infection and inflammation can be painful in themselves (Gardner et al, 2001).

Increased pain in the area of an ulcer is a sign of possible deep infection.

Prevent infection.

1. Studies have shown that chronic wound exudates has an abnormally high concentration of proteases (particularly matrix metalloproteinases, or MMPs) (Mast and Schultz, 1996). 2. The increased proteases shift the wound healing balance into a continuing chronic inflammatory phase that result in tissue injury and contributes to chronic wound pain. 26Superficial infections may be treated with topical antimicrobials, while deeper infections require systemic agents (Krasner and Sibbald, 1999).

Many topical preparations, both pharmacological and non pharmacological (e.g. Antibacterial dressings), exist to treat both infection and inflammation. Silver-containing dressings are both anti-inflammatory & antimicrobial (Wright et al, 2002).

Prevent infection.

Skin adhesives play an important role in keeping wound dressings in place.

Tissue trauma caused by the removal of adhesive tapes and dressings is known to increase the size of wounds, exacerbate wound pain and delay healing (Hollinworth & White, 2006).

Silicone and nonsilicone adhesives offer low-trauma alternatives for wound-care applications.

Prevent skin damage.

Unfortunately, if dressings adhesives are too aggressive, then removal may cause trauma to the wound and surrounding skin.These factors can adversely affect patients quality of life and have cost implications for healthcare providers.

28Monitor for pain during the intervention(s).

Minimize daily dressing changes.

Avoid tape on fragile skin.

Montgomery straps if appropriate.

Avoid aggressive packing.

Avoid drying out wound or wound bed

Others:Consider Ostomy appliance for heavily draining wound.

Time-out.

Provide analgesia as needed when repositioning.

Protect peri-wound area (Skin protectant, barriers).

Others:

Careful wound assessment is required, as selecting the correct dressing can ensure comfort can reduce pain.

Emotional responses can also influence the perception of pain.

Pain should be assessed prior to each dressing change and appropriate action taken.Nursing roles in wound pain management:

Campbell 1995The way patients detect pain appears to be related to the type of damage causing it (Campbell 1995)

2. It is recommended that a simple visual analogue scale is used.31

Nursing roles :Analgesics should be given in anticipation prior to dressing/care.

Give careful consideration to any activities that exacerbate pain.

Patients be closely observed throughout dressing procedure for reaction.

2. In the case of acute pain there is little time to titrate the dose against the patients response. 3. WHO analgesic ladder forms the basis of many approaches to the use of analgesic drugs.

32

Nursing roles:Instruct Pt. to inform when pain is worse at any particular time during dressings.

WHO analgesic ladder forms the basis of many approaches to the use of analgesic drugs.

33Dressing removal: Suggested methods of dressing product removal are: (local guidelines to be followed)

Removal in shower (if applicable) .

Soaking with normal saline (Sodi