General Principles and Approaches to Wound Prevention and Care at End of Life: An Overview
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Moderate to severe pain is experienced by most patients with a wound,52-55 particularly with dressing changes and manipulation of the wound bed.56,57 A qualitative study found that 21 of 23 hospital inpatients (91%) 33 to 92 years old reported that a pressure ulcer or its treatment affected their lives physically, socially, emotionally, and mentally, including being painful.58 A systematic review59 revealed that 15 studies addressing the impact of pain with a pressure ulcer concluded that “pain was the most significant consequence of having a pressure ulcer and affected every aspect of patients’ lives.”
Pain assessment. Based on the 2000 Joint Commission on Accreditation of Healthcare Organizations (JCAHO)60 accreditation guidelines, routine pain assessment is now mandatory, even for individuals incapable of expressing pain. Three validated tools to assess for pain include the Numerical Rating Scale, the visual analog scale, and the Faces Pain Rating Scale. They can be used for individuals who are verbal and can comprehend data intervals.25,56,61-66 Cognitively impaired individuals can be assessed by observing behaviors such as facial expression, body movement, vocalizations, activity changes or mental status changes such as crying or irritability.63,67,68 Initial and routine pain assessment, as well as pain treatment, is recommended.
Pain control should be part of the goals and desires of the patient and family related to care and, as such, integrated into the treatment paradigm. Wound pain can be minimized by maintaining a moist wound bed, covering the wound, repositioning the patient frequently (unless contraindicated), and keeping linens unbunched. Managing pain associated with wounds is achieved through a balance of appropriate wound care, medication as needed, and conservative measures.2 Analgesics should be prescribed based on the World Health Organization (WHO) guidelines for control of cancer pain and within local prescribing parameters and guidelines.1 Premedication for breakthrough pain 30 to 60 minutes before treatments and dressing changes also is recommended.
Wound dressings. Comfort normally is enhanced with fewer dressing changes, so selecting a dressing that can remain in place for several days is advised. As a rule, nonadherent dressings are believed to cause less pain because they do not damage tissue when removed.5 The sacral area or other bony prominences should be protected with a low-friction transparent film, foam, or hydrocolloid to minimize friction.5
Exudate. Wound exudate is the fluid exuding from the extracellular spaces. Protecting periwound tissue is important and can be a challenge69,70; excess exudate can cause periwound maceration. Exudate can be managed using dressings with adequate moisture-retention ability and by using a skin protectant or barrier cream on the periwound area.5 When minimal or no drainage is present, a transparent, hydrocolloid, hydrogel, or composite dressing works well. With moderate exudate, a hydrogel, hydrocolloid, foam, composite, or calcium alginate dressing can be used. When exudate is abundant, a composite, foam, hydrofiber, or calcium alginate dressing should be selected.69,70 Most of these dressings come in adherent and nonadherent forms.