Psychosocial, Pain Considerations, and Palliative

Wound Care

Psychosocial Assessment Goal• Formulate POC consistent with individual & family

preferences, goals, and abilities• All individuals should undergo psychosocial assessment to

determine their ability and motivation to comprehend and adhere to treatment program

• Should include:– Mental status, learning ability, depression– Social support– Polypharmacy or overmedication– Alcohol and/or drug abuse– Goals, values, and lifestyle– Sexuality– Culture and ethnicity– Stressors

• Methodology of assessing and reporting an individual’s perspective on their health and illness

• Measurement of any aspect of patient's health status that comes directly from the patient…without interpretation of the patient's responses by healthcare provider

• Helps healthcare professionals design plans of care that include the individual’s perspective of their needs

• Focus on person center concerns• Employ short, self-completed questionnaires • Measures patient’s health status or health-related quality of life at

a single point in time• Example: CMS requires LTC facilities to interview residents about

their quality of life on the MDS 3.0

Patient-Reported Outcome Measures (PROMs)

http://nidcr.nih.gov/research/DER/BSSRB/PowerPointPresentations/PROsToolsMeasurementQualityofLife.htm. Accessed 11/8/15.Price, P. , Krasner DL. Health-related quality of life and chronic wounds: evidence and implications for practice. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014:123-130.

Health-Related Quality of Life• The impact of health and illness on physical and

social functioning and psychological well being• Takes into consideration importance of both

objective functioning and subjective well being• Complex – multidimensional concept reflecting

total impact of health and illness on individual• More than absence of pain

Price P, Krasner DL. Health-related quality of life and chronic wounds: evidence and implications for practice. In: Krasner DL (ed): Chronic Wound Care: The Essentials. HMP Communications, Malvern, PA, 2014, pp.123-130.

Health-Related Quality of Life (HRQoL)

• Price: “The impact of disease and treatment on disability and daily living, or as a patient-based focus on the impact of a perceived health state on the ability to lead a fulfilling life.”

Price P, Krasner DL. Health-related quality of life and chronic wounds: evidence and implications for practice. In: Krasner DL (ed): Chronic Wound Care: The Essentials. HMP Communications, Malvern, PA, 2014, pp.123-130.

• Franks and Moffatt: “The state of ill health may be defined as feelings of pain and discomfort or change in usual functioning and feeling.

• This is key to the concept of health-related quality of life since it’s the patient’s own sense of well-being which is important, not the clinician’s opinion of [the patient’s] clinical status.”

Baranoski S, Ayello E. Wound Care Essentials. Philadelphia, PA: Lippincott Williams & Wilkins. 2004;1:2-18.

Factors Affecting PatientResponse to Wounds

• Include:– Etiology– Preparedness– Visibility– Response of others– Pain– Odor, leakage– Healing outcomes

• Expectation of healing• Time to healing• Acute vs chronic

• Meaning, significance• Impact on activities of

daily living• Coping patterns• Spirituality• Social support• Age • Gender

Baranoski S, Ayello E. Wound Care Essentials. Philadelphia, PA: Lippincott Williams & Wilkins. 2004;1:2-18.

Pain is Considered the 5th Vital Sign…

• Therefore pain intensity ratings should be recorded along with temperature, pulse, respiration, and blood pressure.

• Pain what the patient says it is• Reported 88% of people with PrUs reported pain

during dressing change• 84% reported pain at rest

• Woo KY, Krasner DL, Sibbald RG. Pain in people with chronic wounds: clinical strategies for decreasing pain and improving quality of life. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communication;2014:111-122.

• Dallam LE, Ayello EA, Woo KY, Sibbald GR. Pain Management and Wounds. In Baranoski S, Ayello EA eds. Wound Care Essentials: Practice Principles 4th Edition. Philadelphia, PA: Wolters Kluwer; 2016:281-306.

Pain in People with Chronic Wounds Wound Associated Pain• Nociceptive pain – ongoing activation of primary

afferent neurons by noxious stimuli• Neuropathic pain – initiated or caused by a primary

lesion or dysfunction of the nervous system– Usually described as burning, stabbing, electrical– Diabetic ulcer pain– Shingles

Krasner D, Sibbald G. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Malvern, PA: HMP Communications. 2001.

The Chronic Wound PainExperience (CWPE)

• Background pain• Absence of manipulation• Continuous/intermittent

• Background pain• Absence of manipulation• Continuous/intermittent

Chronic Wound Pain

• Periodic acute wound pain• Regular repetitive treatments (ie,

dressing change, turning/positioning)

• Periodic acute wound pain• Regular repetitive treatments (ie,

dressing change, turning/positioning)

Cyclic Wound Pain(Most Common)

• Provoked by sporadic procedures (ie, sharp debridement)

• Provoked by sporadic procedures (ie, sharp debridement)

Noncyclic Wound Pain

Van Rijswijk and Braden • “Manage pain by eliminating or controlling the

source of pain (ie, covering wounds, adjusting support surfaces, and repositioning) and providing analgesia as needed to treat procedure-related and chronic wound pain.”

Krasner D, Sibbald G. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Malvern, PA: HMP Communications. 2001.

Multi-National Survey Findings• Dressing removal: time of most pain• Dried out dressings and adherent products most

likely to cause pain and trauma at dressing changes• Soft silicones are one of the key products identified

as least likely to cause pain• NPUAP/EPUAP/PPPIA statement:

– “Select a wound dressing that requires less frequent changing and is less likely to cause pain.”

Moffatt CJ, et al. Understanding Wound Pain and Trauma: An International Perspective. EWMA Position Document. Pain at Wound Dressing Changes. 2002:2-7.Haesler E (ed): National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Cambridge Media, Osborne Park, Western Australia, 2014.

• “It is well known that pain during dressing changes has a direct effect on the quality of life, which can lead to depression, loss of appetite, and sleeplessness.

• Deterioration in the quality of life has also been shown to increase vasoconstriction and decrease tissue perfusion, both of which retard healing rates.”

Source: Moffatt, CJ, Doherty D, Franks PJ

Joint Commission Pain StandardsPatients have the right to appropriate assessment and management of pain• Intent of Standards:

– Pain can be a common part of the patient’sexperience

– Unrelieved pain has adverse physical andpsychological effects

– The patient’s right to pain management is respected and supported

Joint Commission Pain StandardsPain is assessed in all patients• Intent of Standards:

– Patients with pain are identified in an initial assessment– When pain is identified, the patient is treated within the

organization or referred for treatment based on the care setting and services provided

PQRSTCharacteristic of Pain

Questions to Ask PatientP = Palliative/provocative factors

What makes pain better?What makes pain worse?

Q = Quality Describe pain.(ie, burning, sharp, dull/aching, throbbing)

R = Radiation/Region Location of pain? Does pain move? Where?

S = Severity Is pain mild, moderate, severeRate pain on scale of 0-10 (0=none, 10 excruciating)

T = Temporal factorsDoes pain intensity change with time of day? Is it intermediate or constant? Does it occur only with movement or activities? What kind of activities exacerbate pain?

DiPiro JT, Talbert RL, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York, NY: The McGraw-Hill Companies, Inc; 2005:1091. http://www.uspharmacist.com/content/s/108/c/16465/. Accessed 11/8/15Dallam LE, Ayello EA, Woo KY, Sibbald GR. Pain Management and Wounds. In Baranoski S, Ayello EA eds. Wound Care Essentials: Practice Principles 4th Edition. Philadelphia, PA: Wolters Kluwer; 2016:281-306

Pain Assessment and Documentation

Wong-Baker

Assessing Pain Indicators:Body Language and Non-Verbal Cues

• Frowning, grimacing, fearful facial expressions, grinding of teeth

• Bracing, guarding, rubbing • Fidgeting, increasing/recurring restlessness • Striking out, increasing/recurring agitation • Eating or sleeping poorly • Sighing, groaning, crying, breathing heavily • Decreasing activity levels • Resisting certain movements during care • Change in gait or behavior • Loss of function

Emily Haesler, ed., National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia, Cambridge Media, 2014.

Plan for the Pain

• Have nursing pre-medicate patient• Topical lidocaine liquid or gel• Have patient take pain medication prior to coming to the

clinic (designated driver) or once they arrive

Pain persisting or increasing

Pain persisting or increasing

Freedom from Pain

www.who.int/cancer/palliative/painladder/en/. Accessed 11/10/2015.Dallam LE, Ayello EA, Woo KY, Sibbald GR. Pain Management and Wounds. In Baranoski S, Ayello EA eds. Wound Care Essentials: Practice Principles 4th Edition. Philadelphia, PA: Wolters Kluwer; 2016:281-306

Non-Pharmacologic Interventions

Deep BreathingTime-out/breaksDistractionMusicRapport/Empathy

Palliative Care• Physical• Emotional• Spiritual

Palliative Care• Goal may be NOT wound healing• Non-healing chronic wounds

– Malignancy– Host immunocompromised– Inability of the patient to muster energy needed for wound

healing• Key objectives may be

– Pain management– Prevention of infection– Prevention of wound deterioration– Odor control– Exudate management

Palliative Care• Patients will often require high levels of analgesia to

control pain– Specifically for tumors as they grow in size and depth

• Creative dressing strategies can assist with alleviating pain and suffering associated with these types of wounds

Sheffield P, Smith A, Fife C. Wound Care Practice. In: Krasner D, ed. Flagstaff, AZ: Best Publishing. 2004.

Skin Changes at Life’s End• April, 2008 in Chicago, IL • Expert panel (18 internationally recognized opinion

leaders)• 52 international reviewers reached consensus on the

final statements• Skin Changes at Life’s End (SCALE)• Discusses the nature of SCALE, including the

Kennedy Terminal Ulcer aka the unavoidable pressure ulcer

• Skin (largest organ) subject to loss of integrity• Not all pressure ulcers are avoidable• Understanding of complex skin changes at life’s end

limited• Additional research/expert consensus needed

Organ Failure Stratification

Acute

ChronicEnd-Stage

Risk Factors• Chronic illness• Older population• Multiple comorbidities• Decline in mentation• Decreased functional

ability• Malnutrition

Physical Manifestations• Loss of fat & muscle

mass• Decreased mobility• Skin & underlying

tissue changes

Chronic Skin Failure

• Comorbid conditions combined with degeneration in the individual’s overall function layered on top of age-related decline, all contribute to acceleration of loss in function in the end stages of life, which in turn contributes to chronic skin failure.

Skin Failure

• Generally occurs in areas of body with end arteries, such as the fingers, toes, ears, nose

• May exhibit early signs of vascular compromise and ultimate collapse

• Dusky erythema, mottled discoloration, local cooling, and eventually infarcts and gangrene

• Normal protective function may be to shunt a larger percentage of cardiac output from the skin to more vital internal organs during critical illness or disease state,

• Averts immediate death• Chronic shunting of blood to vital organs may also occur as

a result of limited fluid intake over a long period of time

Diminished Perfusion Most Significant Risk Factor for SCALE

SCALE: Skin Changes at Life’s End. Consensus Statement. Wounds 2009;21(12):329-336.

• Patient reported outcome measures questionnaires and health related quality of life from the patient’s perspective help healthcare providers to frame a plan of care that puts the patient at the center of the care plan, ensuring it is consistent with the individual’s and family preferences, their goals for care, and patient’s physical, emotional, cognitive, social and financial abilities.

Summary