New pain models better reflect patient experience
Pain assessment measure needed for each wound
The medical community has traditionally classified pain in two categories: acute (pain lasting for less than six months) or chronic (pain lasting for more than six months). A slight modification came in 1986 when the National Institutes of Health Consensus Development Conference on Pain created three categories: acute, chronic malignant, and chronic non-malignant. Neither system is sufficient for describing or categorizing the varied pain experiences of patients with chronic wounds.
Clinicians and researchers recently have introduced new pain algorithms specific to wound care. One is the Chronic Wound Pain Experience (CWPE) Model, designed in 1995 by Diane Krasner, PhD, RN, CETN, CWS, a postdoctoral fellow at the Johns Hopkins University School of Nursing in Baltimore. The CWPE divides pain into three categories: noncyclic acute wound pain, cyclic acute wound pain, and chronic wound pain. (See chart, above right.)
Noncyclic acute wound pain occurs during distinct episodes, such as sharp debridement or drain removal. Cyclic acute wound pain is periodic acute pain that recurs as a result of repeated treatments or interventions, such as daily dressing changes, turning, or repositioning. Chronic wound pain is persistent pain that occurs without manipulation, such as the throbbing of an abdominal wound when a patient is just lying in bed, according to Krasner.
Krasner says chronic wound patients may experience the three types of pain separately or simultaneously. She says the model can help wound care providers assess wound pain more accurately and therefore apply the most effective pain-prevention or pain-reduction interventions, because the type of pain should dictate the measures taken to give the patient relief.
For example, application of a topical anesthetic compress before sharp debridement may be more effective for reducing the noncyclic acute wound pain that debridement can cause. To reduce the cyclic acute wound pain that may stem from dressing changes, an oral analgesic an hour before the change might be in order. For chronic wound pain, around-the-clock oral medications may be the best route, along with adjunct therapy such as wound cleansing and pain-reducing dressings.
Though these measures seem like common sense, Krasner notes that many clinicians don’t take any of these measures, often leaving the patient to suffer unnecessarily.
Another algorithm for pain management was developed recently by Frank Ferris, MD, a palliative care physician at the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital in Toronto. (See chart, p. 124.) Ferris categorized three major types of wound pain: constant pain, incident pain, and anxiety or psychosocial/spiritual pain.
Constant pain can result simply from the wound’s presence, contact between the wound and other surfaces, or from underlying or concurrent disease processes or complications, according to Ferris. Incident pain is related to movement, dressing changes, and debridement. Anxiety or psychosocial/ spiritual pain, such as depression, can result from the physical pain caused by the wound and related activities. This type of pain also can result in more intense physical sensations, Ferris explains. For instance, if a patient is convinced that an upcoming dressing change will be painful because no pain management measures are taken, that patient’s experience of wound pain may increase needlessly. Studies also have shown that the presence of a wound can have a notable adverse effect on quality of life. Chronic wound patients often report that they feel socially isolated, depressed, and anxious. These phenomena all would fit into the category of psychosocial/spiritual pain.
As with the CWPE model, a thorough assessment of each patient is crucial to determine the type of pain a patient experiences. This information will allow wound care professionals to select the most effective interventions, according to Ferris. "Every wound needs to be assessed with an appropriate pain assessment measure," he says. "We have to understand the wound’s etiology and have a sense of its pathophysiology. Then we need to apply different treatment interventions. We also need an understanding of the pharmacology of medications we’re using and the associated psychosocial/spiritual pain that may be present," he says.
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