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.
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Psychosocial Assessment Goal Psychosocial, Pain Wound … · tissue perfusion, both of which retard healing rates. ... Body Language and Non-Verbal Cues • Frowning, grimacing, fearful
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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.
• 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
• 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
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
• 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.