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16 OSTOMY WOUND MANAGEMENT FEBRUARY 2009 www.o-wm.com
FEATURE
Pain is an ever-present problem in patients with pressureulcers.1 As a protective physiologic mechanism, pain is de-
fined as an unpleasant sensory and emotional experience as-sociated with actual or potential tissue damage.2 Irrespectiveof a patient’s age or health status, pressure ulcer pain needs tobe assessed and treated because it has widespread physical andpsychosocial implications for the patient, family, and clinician.Zanca et al3 identified 32 grants as part of their examinationof pressure ulcer research funding; topics included pressureulcer assessment, prevention, and treatment; quality of carestudies that include pressure ulcers in their outcomes; or footpressure management in patients with diabetes mellitus. Onlyone focused on pain. Although pressure ulcer pain is under-represented among the funded projects, practitioners areasked to base pain assessment and treatment on research evi-dence. This paper summarizes research findings specific to
pressure ulcer pain in terms of pain assessment tools, medica-tions, wound care, and nutrition.
Pathophysiology of Pressure Ulcer PainPressure ulcer pain may be caused by tissue trauma from
sustained loads, inflammation, damaged nerve endings, infec-tion, dressing changes, debridement, operative procedures,and other treatments. The skin has more sensory nerves thanany other body organ.4 As the pressure ulcer cellular damageexpands, chemicals are released that irritate nociceptive nerveterminals. Nociceptive pain is an appropriate physiological re-sponse to a painful stimulus and involves acute or chronic in-flammation.5,6 The ulcer erodes through tissue planes anddestroys nerve terminals. As peripheral nerves regenerate, thenociceptive nerve terminals send out immature sprouts ofnerve tissue that may be hypersensitive to both noxious and
Pressure Ulcer Pain: A Systematic
Literature Review and National Pressure
Ulcer Advisory Panel White Paper Barbara Pieper, PhD, ACNS-BC, CWOCN, FAAN; Diane Langemo, PhD, RN, FAAN; and JanetCuddigan, PhD, RN, CWCN, CCCN
AbstractPain is an ever-present problem in patients with pressure ulcers. As an advocate for persons with pressure ulcers, the Na-
tional Pressure Ulcer Advisory Panel (NPUAP) is concerned about pain. To synthesize available pressure ulcer pain literature,
a systematic review was performed of English language literature, specific to human research, 1992 to April 2008, using
PubMed and the Cumulative Index in Nursing and Allied Health Literature. Fifteen relevant papers were found; they exam-
ined pain assessment tools, topical analgesia for pain management, and/or descriptions of persons with pressure ulcer
pain. Studies had small sample sizes and included only adults. The literature established that 1) pressure ulcers cause
pain; 2) pain assessment was typically found to be self-reported using different versions of the McGill Pain Questionnaire,
Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive
level and medical challenges; 4) in some cases, topical medications can ease pain and although information on systemic
medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful,
particularly dressing changes. Research gaps include the prevention and treatment of pressure ulcer pain, the impact of
pain on nutrition, and pressure ulcer pain considerations for special groups (eg, children, end-of-life patients, and bariatric
patients). The NPUAP presents this white paper as the current scientific know-ledge base on the topic. Research regarding
the multidimensional aspects of pressure ulcer pain is strongly recommended.
Key Words: pressure ulcers, pain, literature review, evidence
Index: Ostomy Wound Management 2009;55(2):16–31
Potential Conflicts of Interest: None
Dr. Pieper is a Professor/Nurse Practitioner, College of Nursing, Wayne State University, Detroit, MI. Dr. Langemo is a Distinguished Professor Emeritus and Adjunct
Professor College of Nursing, University of North Dakota, Grand Forks, ND. Dr. Cuddigan is Associate Professor, Chair, Adult Health and Illness Department,
College of Nursing, University of Nebraska Medical Center, Omaha, NE. Please address correspondence to: Barbara Pieper, PhD, ACNS-BC, CWOCN, FAAN,
College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit, MI 48202: email: [email protected].
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PRESSURE ULCER PAIN WHITE PAPER
non-noxious stimuli. A heightened sensitivity to pain in thewound is primary hyperalgesia; a heightened sensitivity topain in the surrounding skin is secondary hyperalgesia.5,6 In-fection further irritates free nerve endings and may causepain.7 Pain, particularly acute pain, is also a stimulus to thestress response; thus, at the cellular level, hypoxia may developbecause of limited painful breathing and peripheral vasocon-striction and impede wound healing.8 Pain also may diminishappetite and decrease nutritional status.
Pain threshold and perception. Besides the physical causesand impact of pressure ulcer pain, pain threshold and percep-tion are important considerations. Pain threshold is theamount or degree of a noxious stimulus that leads a personto first interpret a sensation as painful. Pain perception is theactual awareness of the painful feeling or sensation; it may beacute or chronic. Pressure ulcer pain perception can be inten-sified by psychosocial factors, grief about the ulcer’s cause andpresence, and anger and fear in knowing its long-term treat-ment impact.
To enhance understanding and ultimately treatment ofpressure ulcer pain, this paper synthesizes the available rele-vant pressure ulcer pain literature. The National PressureUlcer Advisory Panel (NPUAP) presents this white paper asthe current scientific knowledge base on the topic.
Methodology Literature searches were performed using PubMed, a serv-
ice of the National Library of Medicine and the National In-stitutes of Health, and the Cumulative Index in Nursing andAllied Health Literature (CINAHL®) for the years 1992 to2008. Words/phrases used for the search included pressureulcer pain, bedsore pain, and decubitus ulcer pain. The searchwas limited to English language and human research. Fifteenpapers were identified — four addressed topical medicationtreatment and 11 presented varied aspects of pain measure-ment, pain treatment, and pain experiences. Papers aboutother types of wound pain and quality of life where pain wasone of many variables examined versus the critical variablewere not included in this review.
deLaat et al9 completed the last published systematic reviewabout pressure ulcer pain describing scientific evidence andmaking recommendations for practice; their review also in-cluded malodor and exudate. Six papers in deLaat’s review areincluded in the current review. Table 1 summarizes the pres-sure ulcer pain research obtained from this search in terms ofauthor/year, type of study, participants/sample, purpose, pro-tocol, and findings/main outcomes.
Results Pain assessment scales used in pressure ulcer pain re-
search. The single most reliable indicator of the existence andintensity of pain and any resultant distress is the patient’s self-report through the use of established reporting instruments.Three pain rating scales were used in pressure ulcer pain re-
search: the McGill Pain Questionnaire (MPQ), the Faces Rat-ing Scale (FRS), and the Visual Analog Scale (VAS).
Szor and Bourguignon10 used the MPQ because its de-scription of pain qualities and measure of pain intensityprovided a quantitative measure of pain. The MPQ con-tains the Pain Rating Index scale score and Present Pain In-tensity scale score. The most frequently used descriptors bypressure ulcer stage were: tender, hurting, sore (Stage II);burning, tender, hurting, sharp, sore, wretched (Stage III);and tender, hurting, smarting, penetrating, and throbbing(Stage IV). Although persons with Stage IV pressure ulcershad higher Pain Rating Index and Present Pain Intensityscores, they did not differ significantly from ratings by per-sons with Stage II or Stage III pressure ulcers. Roth et al11
used the MPQ and a singular pain intensity rating. No dif-ferences were found in pain ratings for Stage III and StageIV pressure ulcers. Persons with either Stage III or Stage IVpressure ulcers had significantly (P <0.05) more severe pain(ie, MPQ total and sensory and affective subscales) thanpersons with other wounds.
In Brazil, Quirino et al12 used a short version of the MPQ.Key descriptors used by persons with Stages I and Stage IIpressure ulcers included throbbing, sharp, burning, aching,and tugging. No study provided reliability or validity dataabout use of the MPQ for pressure ulcer pain.
Dallam et al13 used the FRS and the VAS. They found theVAS correlated with the FRS (r = .92) and the VAS correlatedwith pressure ulcer stage (r = .37). The intensity of pressureulcer pain correlated with generalized pain (r = .59). Usingdata from the Dallam study,13 Freeman et al14 reported statis-tical properties of the VAS and FRS for pressure ulcer pain.VAS variability significantly increased (P <0.01) with increas-ing FRS values. VAS and FRS were highly reliable for pain as-sessment in persons with diminished verbal and abstractthinking abilities and participants did not find them difficultto use. Freeman et al14 presented a mathematical translationof the FRS findings into VAS units. The VAS has since beenused in studies about pressure ulcer pain and medication use(information to follow).15,16
Key Points
• To enhance understanding and ultimately treatment of
pressure ulcer pain, the authors reviewed and synthe-
sized available relevant pressure ulcer pain literature.
• Even though the vast majority of pressure ulcer pa-
tients report pain, research on the topic is limited;
gaps in the current knowledge base are identified.
• Recommendations for practice include recognizing
that all pressure ulcers — especially treatments — are
painful, using a valid tool to assess pain levels, and
providing strategies to relieve the pain.
Ostomy Wound Management 2009;55(2):16–31
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FEATURE
Table
1: R
esearc
h a
bout
Pre
ssure
Ulc
er
Pain
in A
scendin
g O
rder
of Public
ation
Au
tho
r (Y
ea
r)
Jep
so
n (1
99
2)3
1
Dalla
m e
t al
(19
95
)13
Szo
r an
d
Bo
urg
uig
no
n
(19
99
)10
Typ
e o
f S
tud
y/M
eth
od
Descrip
tive (le
tter
to the
ed
itor)
Cro
ss-s
ectional
Cro
ss-s
ectional, c
om
par-
ative; tw
o p
ain
ratings
(rest and
dre
ssin
g
change) on the s
am
e
day
Part
icip
an
ts/S
am
ple
Siz
e
N=
17 (9 m
en a
nd
8 w
om
en);
age 5
4–91 y
ears
. A
ll con-
fined
to c
hair o
r b
ed
; 13 h
ad
ad
vanced
cancer. 3
0 p
res-
sure
sore
s, sta
ges 1
A to 5
of th
e U
K c
lassific
ation
N=
132 p
atients
(54 m
en a
nd
78 w
om
en) in
acute
care
;
age 2
4–100 y
ears
(M
=71.4
,
SD
=16.4
). 4
4 (33.3
%) ab
le
to resp
ond
to instr
um
ents
;
88 (66.7
%) not ab
le to re-
sp
ond
. 48%
had
a c
ognitiv
e
imp
airm
ent; 5
2%
were
cog-
nitiv
ely
inta
ct. E
thnic
/race
inclu
ded
: 66%
white, 22%
Afr
ican-A
merican, 11%
His
-
panic
, 2%
Asia
n. 68.9
%
had
a s
acra
l p
ressure
ulc
er
N=
32 p
atients
in a
cute
, ex-
tend
ed
, and
hom
e c
are
; age
47–95 y
ears
, M
+74.7
,
SD
=12.8
Fin
din
gs/M
ain
Ou
tco
mes
At 24 h
ours
, 29 o
f th
e 3
0 u
lcers
were
pain
-fre
e.
At 48 h
ours
, all
were
pain
fre
e. B
enzyd
am
ine
3%
cre
am
rate
d e
ffective a
s a
local agent to
relie
ve p
ressure
ulc
er
pain
41%
denie
d p
ressure
ulc
er
pain
; 59%
had
som
e typ
e o
f p
ain
. W
ith F
RS
, 68%
had
som
e
pain
(in
clu
ded
patients
with c
ognitiv
e im
pair-
ments
). O
nly
3 (2%
) p
ers
ons w
ere
giv
en a
nal-
gesic
s w
ith 4
hours
of th
e inte
rvie
w. VA
S
corr
ela
ted
with F
RS
(r=
.92). Inte
nsity o
f p
res-
sure
ulc
er
pain
corr
ela
ted
with g
enera
lized
pain
inte
nsity (r=
.59). L
ocaliz
ed
VA
S c
orr
e-
late
d w
ith m
axim
um
pre
ssure
ulc
er
sta
ge
(r=
.37). P
atients
on s
tatic a
ir rep
lacem
ent
matt
resses h
ad
sig
nific
antly less p
ain
than
those o
n o
ther
surf
aces (P
<0.0
1). T
hose
treate
d w
ith h
yd
rocollo
id d
ressin
gs h
ad
sig
-
nific
antly less p
ain
than o
ther
top
ical d
ress-
ings. N
o s
ignific
ant d
iffe
rence in p
ressure
ulc
er
pain
ratings b
etw
een p
ers
ons w
ho w
ere
cognitiv
ely
im
paired
and
those w
ho w
ere
not.
Sub
jects
receiv
ing a
nalg
esic
s for
pre
ssure
ulc
er
pain
rep
ort
ed
sig
nific
antly m
ore
pain
than those n
ot re
ceiv
ing a
nalg
esic
s; th
is w
as
als
o tru
e for
tranq
uili
zers
28 p
atients
had
pain
at d
ressin
g c
hange; 21
rate
d this
pain
as m
ild c
om
pare
d to 5
as e
x-
cru
cia
ting. 27 p
atients
exp
erienced
pain
at
rest; 4
had
no p
ressure
ulc
er
pain
. 12 re-
port
ed
pain
as c
ontinuous d
uring rest and
dre
ssin
g c
hange. O
nly
2 p
atients
had
re-
ceiv
ed
med
ication for
the p
ressure
ulc
er
pain
.
Pain
Rating Ind
ex a
nd
Pre
sent P
ain
Inte
nsity
were
not sig
nific
antly d
iffere
nt fo
r sta
ge o
f
ulc
er, rest vers
us d
ressin
g c
hange, fr
om
rest
to d
ressin
g c
hange a
cro
ss s
tages o
f ulc
ers
Pu
rpo
se
Exam
ine the e
ffective-
ness o
f aq
ueous-
based
cre
am
conta
inin
g 3
% b
enzy-
dam
ine for
pain
due to
pre
ssure
sore
s
Dete
rmin
e the p
erc
eiv
ed
inte
nsity a
nd
patt
ern
s
of p
ressure
ulc
er
pain
in h
osp
italiz
ed
patients
and
id
entify
rela
tions
betw
een p
ressure
ulc
er
pain
and
dep
ressio
n,
menta
l sta
tus, and
treatm
ent m
od
alit
ies
To c
om
pare
pain
exp
eri-
enced
by p
atients
with
Sta
ge II to
Sta
ge IV
pre
ssure
ulc
ers
at re
st
and
during d
ressin
g
change
Pro
toco
l
Ap
plie
d a
queous-b
ased
cre
am
conta
inin
g 3
%
benzyd
am
ine. C
overe
d
with s
em
i-p
erm
eab
le
film
and
tap
ed
in p
lace.
Patients
questioned
at
24 (n=
17) and
48 h
ours
(n=
14) re
gard
ing p
ain
re-
lief. P
ain
assessm
ent
scale
not p
resente
d
Sub
jects
evalu
ate
d w
ith
the F
ols
tein
Min
i-M
enta
l
Sta
te E
xam
ination,
Beck’s
Dep
ressio
n In-
vento
ry, Faces P
ain
Rat-
ing S
cale
(FR
S), a
nd
the
Vis
ual A
nalo
g S
cale
(VA
S)
Patients
rate
d p
ain
on the
McG
ill P
ain
Question-
naire
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FEATURE
Gunes17 used the MPQ andthe Faces Rating Scale-Revised(FRS-R) in a study involving 47persons with Stage II to StageIV pressure ulcers. He reporteda statistically significant rela-tionship between the patient’spresent pain intensity and theFRS-R (r = .90); FRS-R meanpain intensity scores were ratedas moderate pain. He alsofound that MPQ completiontime was challenging for someparticipants and that pain in-tensity increased with pressureulcer stage. Only six patientsreceived pain medicationwithin 6 hours before comple-tion of the questionnaire andnone of the medications wasprescribed specifically for pres-sure ulcer pain.
Qualitative pressure ulcerpain studies1,18-20 were notfound to use a specific painscale — rather, participantswere asked to respond to open-ended questions about pain.Langemo et al’s study1 includedeight participants who de-scribed their pressure ulcer ex-perience; pain emerged as atheme. Fox18 used a semi-struc-tured interview in which fivepatients shared individual expe-riences of living with a pressureulcer. Pain was the dominant,recurring physical factor theme— an overwhelming aspect ofliving with a pressure ulcer.Hopkins et al19 used unstruc-tured interviews with eight per-sons to probe for themes ofliving with a pressure ulcer;endless pain was one of threethemes. In Rastinehad’s study,20
10 patients described what itwas like to have a painful pres-sure ulcer. Although samplesizes were generally small inqualitative studies, pain was acritical theme.
Because pressure ulcer painresearch is limited, it is important
Table
1: R
esearc
h a
bout
Pre
ssure
Ulc
er
Pain
in A
scendin
g O
rder
of Public
ation (continued)
Au
tho
r (Y
ea
r)
Lan
gem
o e
t al
(20
00
)1
Fre
em
an
et
al
(20
01
)14
Fo
x (2
00
2)1
8
Typ
e o
f S
tud
y/M
eth
od
Descrip
tive, q
ualit
ative,
phenom
enolo
gic
al
stu
dy
Second
ary
data
analy
sis
of cro
ss-s
ectional d
ata
from
Dalla
m e
t al 1999
Descrip
tive, p
henom
eno-
logic
al
Part
icip
an
ts/S
am
ple
Siz
e
N=
8; 4 w
ith c
urr
ent p
ressure
ulc
er
and
4 w
ith p
revio
us
pre
ssure
ulc
er. 7
men a
nd
1
wom
an; age 2
7–52 y
ears
. 4
had
sp
inal cord
inju
ry
N=
44 (see D
alla
m e
t al)
N=
5, 4 m
en a
nd
1 w
om
an;
age 3
1–64 y
ears
; d
ura
tion
of p
ressure
ulc
ers
4–36
month
s; p
art
icip
ants
liv
ed
in
the c
om
munity
Fin
din
gs/M
ain
Ou
tco
mes
7 them
es e
merg
ed
: p
erc
eiv
ed
etiolo
gy o
f th
e
pre
ssure
ulc
er;
life im
pact and
changes; p
sy-
cho-s
piritual im
pact; e
xtr
em
e p
ain
fuln
ess a
s-
socia
ted
with the p
ressure
ulc
er;
need
for
know
led
ge a
nd
und
ers
tand
ing; need
for
and
effect of num
ero
us, str
essfu
l tr
eatm
ents
; and
the g
rievin
g p
rocess. E
xtr
em
e p
ain
fuln
ess
associa
ted
with a
pre
ssure
ulc
er
was d
e-
scrib
ed
as feelin
g lik
e b
ein
g s
tab
bed
, gett
ing
a k
nife a
nd
dig
gin
g in there
, sitting o
n n
ee-
dle
s, b
urn
ed
, stingin
g. P
ain
was p
resent th
e
majo
rity
of tim
e a
nd
are
a h
urt
aft
er
the u
lcer
heale
d. A
nalg
esic
use inclu
ded
op
ioid
and
non-o
pio
id m
ed
ications
VA
S v
ariab
ility
sig
nific
antly incre
ased
with in-
cre
asin
g F
RS
valu
es. B
etw
een s
cale
s, th
e
VA
S a
nd
FR
S w
ere
hig
hly
relia
ble
for
pain
as-
sessm
ent in
pers
ons w
ith d
imin
ished
verb
al
and
ab
str
act th
inkin
g a
bili
ties
Thre
e m
ain
them
es w
ith s
ub
-them
es e
merg
ed
from
the inte
rvie
ws: p
hysic
al (p
ain
, exud
ate
s,
loss o
f in
dep
end
ence), p
sycholo
gic
al (e
mo-
tional fa
cto
rs, w
orr
y a
bout healin
g, re
lation-
ship
s, b
od
y im
age), a
nd
socia
l (s
ocia
l
isola
tion). P
ain
was a
dom
inant p
hysic
al fa
c-
tor
and
recurr
ing them
e thro
ughout th
e inte
r-
vie
w. P
ain
varied
in level of in
tensity a
nd
dis
turb
ed
sle
ep
. D
eep
ulc
ers
were
pain
ful
Pu
rpo
se
To e
xp
lore
the liv
ed
ex-
perience o
f havin
g a
pre
ssure
ulc
er
in o
rder
to d
ete
rmin
e the e
s-
sential str
uctu
re o
f th
e
exp
erience
To e
xam
ine s
tatistical
pro
pert
ies o
f th
e F
aces
Rating S
cale
(FR
S) and
describ
e the rela
tion-
ship
with the V
isual
Analo
gue S
cale
(VA
S)
To e
xp
lore
and
describ
e
exp
eriences o
f p
atients
livin
g w
ith a
pre
ssure
ulc
er
Pro
toc
ol
Part
icip
an
ts a
sked
to
describ
e t
he e
xp
eri-
en
ce o
f h
avin
g a
pre
s-
su
re u
lcer
Co
mp
ariso
n o
f p
atien
t
ratin
gs f
rom
FR
S a
nd
VA
S –
no
nlin
ear
least-
sq
uare
s r
eg
ressio
n w
ith
a G
au
ss-N
ew
ton
ite
ra-
tive p
roced
ure
Sem
i-str
uctu
red
in
ter-
vie
w
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FEATURE
Table
1: R
esearc
h a
bout
Pre
ssure
Ulc
er
Pain
in A
scendin
g O
rder
of Public
ation (continued)
Au
tho
r (Y
ea
r)
Zep
pete
lla e
t al
(20
03
)15
Flo
ck (2
00
3)3
2
Qu
irin
o e
t al
(20
03
)12
Typ
e o
f S
tud
y/M
eth
od
Rand
om
ized
, d
oub
le-
blin
ded
, p
laceb
o-c
on-
trolle
d, cro
ssover
pilo
t
stu
dy
Rand
om
ized
, d
oub
le
blin
d, p
laceb
o-c
on-
trolle
d c
rossover
tria
l
Descrip
tive, cro
ss-s
ec-
tional
Part
icip
an
ts/S
am
ple
Siz
e
N=
5; 3 m
en a
nd
2 w
om
en;
age 6
2–87 y
ears
; hosp
ice
inp
atients
with a
dvanced
malig
nant d
isease; had
pain
ful p
ressure
ulc
er, n
ot
infe
cte
d, not covere
d w
ith
necro
tic tis
sue a
nd
suitab
le
for
once-d
aily
tre
atm
ent
with Intr
aS
ite*
gel. P
atients
had
sta
ble
analg
esic
regi-
mens. They w
ere
ab
le to
com
ple
te the V
AS
score
N=
13 h
osp
ice inp
atients
with
cancer;
3 m
en a
nd
10
wom
en; m
ean a
ge 7
6.5
years
. S
tage II (n
=8) or
Sta
ge III (n=
5) p
ressure
ul-
cers
. 7 p
atients
com
ple
ted
the s
tud
y
N=
20 fro
m 3
Bra
zili
an h
osp
i-
tals
; 15 m
en a
nd
5 w
om
en;
mean a
ge 5
7.2
5+
19.3
2
years
. 14 w
hite, 3 b
lack, 3
Asia
n. 16 h
ad
one p
ressure
ulc
er. 1
7 w
ere
sacra
l ulc
ers
.
Pre
ssure
ulc
er
sta
ges: 9
Sta
ge I; 8 S
tage II; 2
Sta
ge
III; a
nd
1 S
tage IV
Pers
ons
with p
ara
- or
tetr
ap
legia
and
para
- or
tetr
ap
are
sis
were
exclu
ded
Fin
din
gs/M
ain
Ou
tco
mes
All
had
low
er
VA
S s
core
s w
ith the m
orp
hin
e
treatm
ent. L
ocal or
syste
mic
ad
vers
e e
vents
were
not att
rib
ute
d to the m
orp
hin
e. A
uth
ors
conclu
ded
morp
hin
e a
pp
lied
top
ically
is a
n e
f-
fective m
eth
od
of p
rovid
ing local analg
esia
,
well
tole
rate
d b
y p
atients
and
not associa
ted
with s
yste
mic
ad
vers
e a
ffects
Pain
score
s im
pro
ved
sig
nific
antly (P
<0.0
03 a
nd
P<
0.0
05)at 1 a
nd
12 h
ours
, re
sp
ectively
, aft
er
dia
morp
hin
e g
el com
pare
d to b
aselin
e. In
tra-
Site g
el had
no e
ffect on p
ain
. M
ean p
ain
score
s w
ere
not giv
en. O
ne p
atient exp
erience
sym
pto
ms s
imila
r to
op
ioid
toxic
ity,
but th
ese
were
rela
ted
to h
er
fenta
nyl p
atc
h, not th
e g
el.
Although d
iam
orp
hin
e g
el is
pro
bab
ly s
afe
, a
larg
er
stu
dy is n
eed
ed
All
exp
erienced
pre
ssure
ulc
er
pain
. 80%
had
no
typ
ical t
ime p
att
ern
to the p
ain
; 55%
had
pain
at re
st and
45%
had
pain
with m
ovem
ent. 8
0%
had
consta
nt p
ain
. P
ain
did
not im
pair s
leep
(55%
), a
pp
etite
(75%
), o
r w
alk
ing (90%
). C
om
-
mon p
ain
descrip
tors
: 35%
burn
ing, 25%
thro
bb
ing, 25%
tuggin
g, 20%
sharp
. M
ean
pain
inte
nsity =
5.8
0±
2.9
3. S
ignific
ant associa
-
tions w
ere
found
betw
een p
ain
and
eth
nic
ity,
eth
nic
ity a
nd
ap
petite
, tim
e o
f d
ay a
nd
num
ber
of ulc
ers
, and
age a
nd
imp
aired
walk
ing (P
valu
e r
ange 0
.002 to 0
,034). 1
4 p
ers
ons took
nonste
roid
al a
nti-i
nflam
mato
ry p
ain
med
ication;
71.4
% rep
ort
ed
litt
le o
r no a
nalg
esic
effect. 1
3
describ
ed
rep
ositio
nin
g in
bed
, w
et d
ressin
gs,
and
massage a
s p
ain
managem
ent str
ate
gie
s
with 5
3.8
% rep
ort
ing s
atisfa
cto
ry o
utc
om
es
Pu
rpo
se
To e
xam
ine the a
nal-
gesic
effects
of m
or-
phin
e a
pp
lied
top
ically
to p
ain
ful
pre
ssure
ulc
ers
To d
ete
rmin
e the e
f-
fectiveness o
f d
i-
am
orp
hin
e g
el to
contr
ol p
ressure
ulc
er
pain
and
com
-
pare
it to
a p
laceb
o
To q
uantita
tively
and
qualit
atively
describ
e
pre
ssure
ulc
er
pain
Pro
toco
l
Part
icip
ants
were
tre
ate
d
for
2 d
ays w
ith m
or-
phin
e (m
orp
hin
e s
ulfate
inje
ction 1
0 m
g/m
i in
8 g
Intr
asite g
el)
or
pla
ceb
o
(wate
r fo
r in
jection in 1
mLin
8 g
Intr
asite g
el)
and
covere
d w
ith a
Tegad
erm
ad
ressin
g.
Aft
er
2 d
ays, th
ere
was
a 2
-day w
ashout aft
er
whic
h they c
rossed
over
to the o
ther
treatm
ent.
VA
S s
core
s w
ere
record
ed
tw
ice d
aily
3 d
ays Intr
aS
ite
bgel and
3 d
ays d
iam
orp
hin
e g
el
or
vic
e v
ers
a. A
pp
lied
once d
aily
. A
ll had
pre
s-
sure
-relie
vin
g c
ushio
ns
and
matt
resses. P
ain
was a
ssessed
befo
re
and
1 h
our
and
12 h
ours
aft
er
the g
el ap
plic
ation.
Pain
scoring: 0, no p
ain
;
1, m
ild; 2, m
od
era
te; 3,
severe
; 4, overw
helm
ing
Part
icip
ants
were
id
enti-
fied
by a
nurs
e, m
enta
l
sta
tus w
as a
ssessed
by
the M
enta
l E
valu
ation
Questionnaire, and
sig
ned
consent ob
-
tain
ed
. P
art
icip
ants
re-
sp
ond
ed
to a
dem
ogra
phic
question-
naire, p
ain
chara
cte
ristic
questions, and
the
McG
ill P
ain
Question-
naire. A
ll q
uestions w
ere
asked
befo
re top
ical
wound
care
. N
PU
AP
pre
ssure
ulc
er
sta
gin
g
was u
sed
a3M
Health C
are
, S
t. P
aul, M
Nb
Sm
ith &
Nep
hew
Larg
o, FL
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24 OSTOMY WOUND MANAGEMENT FEBRUARY 2009 www.o-wm.com
FEATURE
Table
1: R
esearc
h a
bout
Pre
ssure
Ulc
er
Pain
in A
scendin
g O
rder
of Public
ation (continued)
Au
tho
r (Y
ea
r)
Ro
th e
t al
(20
04
)11
Pre
ntice
(20
04
)16
Ho
pkin
s e
t al
(20
06
)19
[su
m-
marized
by
Bale
et
al
(20
07
)52]
Typ
e o
f S
tud
y/M
eth
od
Cro
ss-s
ectional,
pro
sp
ective
Rand
om
ized
doub
le-
blin
ded
pla
ceb
o-c
on-
trolle
d trial
Heid
eggerian p
henom
e-
nolo
gy.
Inclu
sio
n c
rite
-
ria: >
65 y
ears
of age,
Gra
de 3
or
4 p
ressure
ulc
er
for
more
than a
month
, and
ab
le to g
ive
consent. E
xclu
sio
n c
ri-
teria: sp
inal cord
inju
ry
Part
icip
an
ts/S
am
ple
Siz
e
N=
69. A
ll m
en; m
ean a
ge 5
9
years
. 39 h
ad
Sta
ge III a
nd
Sta
ge IV
pre
ssure
ulc
ers
. 30
had
oth
er
wound
s (eg,
Sta
ge II p
ressure
ulc
ers
,
posto
pera
tive w
ound
s, ve-
nous s
tasis
ulc
ers
, or
dia
-
betic u
lcers
)
31 p
atients
ente
red
; 1 w
ith-
dre
w. A
ge r
ange 3
8–92
years
. 17 w
ere
in the b
enzy-
dam
ine h
yd
rochlo
rid
e g
roup
and
13 in the p
laceb
o
gro
up
. A
ll w
ere
in p
alli
ative
care
and
had
cancer
8 p
art
icip
ants
(7 fro
m U
nited
Kin
gd
om
and
1 fro
m B
el-
giu
m) fr
om
4 c
ente
rs a
nd
multip
le d
ata
colle
cto
rs
Fin
din
gs/M
ain
Ou
tco
mes
19 p
art
icip
ants
had
wound
pain
. A
tre
nd
for
a
gre
ate
r p
erc
enta
ge o
f p
atients
with S
tages III
and
Sta
ge IV
pre
ssure
ulc
ers
to e
xp
erience
wound
pain
com
pare
d to the o
ther
gro
up
(P=
.07). S
pin
al cord
inju
ry s
tatu
s d
id n
ot af-
fect p
ain
score
s. 28%
had
wound
pain
unre
-
late
d to d
ressin
g c
hange. W
ound
sta
ge w
as
positiv
ely
rela
ted
to p
ain
severity
. P
art
icip
ants
with S
tage II/IV
ulc
ers
had
more
severe
pain
on the M
PQ
tota
l, s
ensory
, and
affective
score
s than the o
ther
gro
up
. P
ain
cata
str
o-
phiz
ing w
as rela
ted
to p
ain
inte
nsity a
nd
to
hig
her
levels
of affective d
istr
ess a
nd
dep
res-
siv
e s
ym
pto
ms
The p
ain
score
s d
id n
ot d
iffe
r b
etw
een the tw
o
gro
up
s
Thre
e them
es w
ere
id
entified
: end
less p
ain
, re
-
str
icte
d life, and
cop
ing w
ith the p
ressure
ulc
er. E
nd
less p
ain
had
4 s
ub
them
es: con-
sta
nt p
resence, keep
ing s
till,
eq
uip
ment p
ain
,
and
tre
atm
ent p
ain
Pu
rpo
se
To c
om
pare
the u
tilit
y o
f
the s
ingula
r p
ain
inte
n-
sity r
ating s
cale
(N
u-
merical P
ain
Rating
Scale
[N
PR
S]) a
nd
a
multid
imensio
nal p
ain
questionnaire (M
cG
ill
Pain
Questionnaire
[MP
Q]). To
dete
rmin
e if
patients
with m
ore
se-
vere
wound
s rep
ort
more
severe
pain
in-
tensity.
To d
ete
rmin
e if
patients
with p
ain
dis
-
pla
y a
patt
ern
of p
sy-
cholo
gic
al d
istu
rbance
and
mala
dap
tive p
ain
cop
ing s
trate
gie
s
To c
om
pare
pain
red
uc-
tion fro
m top
ical b
en-
zyd
am
ine
hyd
rochlo
rid
e 3
%
cre
am
to
pla
ceb
o
To e
xp
lore
the e
xp
eri-
ence o
f old
er
peop
le
livin
g w
ith p
ressure
ul-
cers
Pro
toco
l
Part
icip
ants
were
as-
sessed
per
their w
ound
sta
tus b
y a
nurs
e a
nd
physic
ian. E
ach p
ers
on
was s
een a
maxim
um
of
6 v
isits a
nd
asked
ab
out
pain
. If w
ound
-rela
ted
pain
was p
resent, p
art
ic-
ipants
com
ple
ted
ad
di-
tional q
uestionnaires.
Oth
er
questionnaires in
the s
tud
y: B
rief S
ym
p-
tom
Invento
ry, C
ente
r
for
Ep
idem
iolo
gic
Stu
d-
ies D
ep
ressio
n S
cale
and
the c
ata
str
op
hiz
ing
scale
of th
e C
op
ing
Str
ate
gie
s Q
uestion-
naire. E
ach v
isit w
as
com
pensate
d ($10)
Each p
atient com
ple
ted
the 1
00 m
m V
AS
and
an
11-p
oin
t num
erical p
ain
score
at 24 h
ours
prior
to a
nd
im
med
iate
ly b
e-
fore
ap
plic
ation o
f th
e
cre
am
and
aft
er
at 2, 6,
12, and
24 h
ours
Unstr
uctu
red
inte
rvie
ws
and
use o
f p
rob
ing
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26 OSTOMY WOUND MANAGEMENT FEBRUARY 2009 www.o-wm.com
FEATURE
to consider evaluating pressure ulcer painassessment options for special popula-tions of patients. Patients with cognitiveimpairment have been found to respondto pain assessment tools such as the FacesPain Scale and the Present Pain Intensitysubscale of the MPQ.21,22 Simple yes/noquestions (eg, Are you uncomfortable?Do you feel pain?) are used to assess pain.Family members or caregivers can reportexpressions/behaviors they recognize asindicators of pain. For critically ill inten-sive care patients, the Behavioral PainScale (BPS) assesses pain in terms of fa-cial expression, upper-limb movement,and ventilator compliance.23
Pressure ulcers in children need to beconsidered a source of pain.24 Pain as-sessment scales used with this popula-tion include the 0 to 10 pain rating scaleor the FACES.25 The Face, Legs, Activity,Cry, Consolability (FLACC) scale26 is abehavioral pain assessment instrumentinitially developed for scoring postoper-ative pain in young children. TheFLACC has been found to have high (r= .94) reported inter-rater reliability.27
The revised FLACC scale that includesspecific descriptors and identifies uniquebehaviors for individual children hasbeen found to have intra-class correla-tion coefficients ranging from 0.76 to0.90.28 Construct validity was demon-strated by decreasing FLACC scores fol-lowing analgesic administration.28 Forassessment of pain in neonates (ages 0 to6 months), the Crying; Requires O2 forSaturation >95%; Increasing vital signs;Expression; Sleepless (CRIES) scale hasbeen used effectively and has a high re-ported reliability.29,30
Medications for pressure ulcer paintreatment. Researchers have examinedthe use of topical medications for pres-sure ulcer pain treatment.15,16,31,32 Zep-petella’s,15 Prentice et al’s,16 and Flock’s32
studies used a randomized double-blindplacebo controlled design; in addition,Zeppetella’s15 and Flock’s32 studies in-cluded a crossover component. Jep-son’s31 descriptive study (N = 17) waspresented as a letter to the editor.
Zeppetella et al15 used the VAS to ex-amine the analgesic effect of 10 mg ofT
able
1: R
esearc
h a
bout
Pre
ssure
Ulc
er
Pain
in A
scendin
g O
rder
of Public
ation (continued)
Au
tho
r (Y
ea
r)
Rastin
eh
ad
(20
06
)20
Sp
ilsb
ury
et
al
(20
07
)44
Gu
nes (2
00
8)1
7
Typ
e o
f S
tud
y/M
eth
od
Heid
eggerian h
erm
eneu-
tic p
henom
enolo
gy,
qualit
ative
Qualit
ative s
em
i-str
uc-
ture
d inte
rvie
ws
Descrip
tive q
uantita
tive
and
qualit
ative
Part
icip
an
ts/S
am
ple
Siz
e
10 p
atients
, age 3
0 to 9
0
years
cap
ab
le o
f d
escrib
ing
their p
ain
exp
erience. 7 h
ad
Sta
ge II p
ressure
ulc
ers
; 2,
Sta
ge III; 1, S
tage IV. 8 u
l-
cers
on s
acra
l re
gio
n; 1,
heel; 1
, scap
ula
23 h
osp
italiz
ed
patients
; 5
men a
nd
18 w
om
en; ages
33–92 y
ears
(m
ed
ian 7
8
years
). M
ost com
mon p
res-
sure
ulc
er
locations: heel
and
sacru
m. P
ressure
ulc
er
gra
des w
ere
2 thro
ugh 5
47 h
osp
italiz
ed
patients
; 29
men a
nd
18 w
om
en; age 3
8
–72 y
ears
(m
ean 6
0.1
years
). P
atients
with s
en-
sory
moto
r d
eficie
ncie
s
were
exclu
ded
. P
ressure
ul-
cers
(n=
68) in
clu
ded
6
Sta
ge II, 3
2 S
tage III, and
9
Sta
ge IV. The m
ost com
mon
locations w
ere
sacru
m,
trochante
r, a
nd
heel
Fin
din
gs/M
ain
Ou
tco
mes
22 them
es a
nd
1 c
onstitu
tive p
att
ern
em
erg
ed
.
Pap
er
focuses o
n 2
them
es: P
ain
descrip
tors
and
failu
re o
f te
chnom
ed
icin
e to p
rovid
e
care
/com
fort
and
the c
onstitu
tive p
att
ern
;
pain
as e
xis
tence. P
ain
term
s w
ere
cate
go-
rized
as s
ensory
, evalu
ative, and
affective
Pain
was e
xp
erience b
y 2
1 p
ers
ons. P
ain
ranged
fro
m w
ors
e to little. P
ain
could
be
consta
nt or
varied
acro
ss the d
ay.
8 h
ad
pain
with d
ressin
g c
hange
Pre
ssure
ulc
er
pain
was rep
ort
ed
by 9
4.6
%
(n=
44) of th
e s
am
ple
. 13 w
ord
s w
ere
used
to
describ
e p
ressure
ulc
er
pain
; th
e n
um
ber
of
word
s incre
ased
as the p
ressure
ulc
er
sta
ge
incre
ased
. The m
ost com
mon term
was h
ot-
burn
ing. S
tage IV
pre
ssure
ulc
ers
had
the
hig
hest p
ain
inte
nsity.
The F
aces m
ean p
ain
inte
nsity w
as m
od
era
te p
ain
. 32 rep
ort
ed
dre
ssin
g c
hange a
ggra
vate
d the p
ain
Pu
rpo
se
To e
xp
lore
the q
ues-
tions, “W
hat is
it lik
e to
have a
pain
ful p
ressure
ulc
er?
”
To e
xp
lore
patients
’ p
er-
cep
tions a
nd
exp
eri-
ences o
f th
e im
pact of
a p
ressure
ulc
er
and
its
treatm
ent on h
ealth
and
qualit
y o
f lif
e
To d
escrib
e the q
uanti-
tative a
nd
qualit
ative
chara
cte
ristics o
f p
ain
rela
ted
to p
ressure
ul-
cers
Pro
toc
ol
Sem
i-str
uctu
red
in
ter-
vie
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morphine sulfate injection in 8 g Intrasite gel (Smith &Nephew) applied topically to painful pressure ulcers com-pared to water for injection 1 mL in 8 g Intrasite gel for fivepatients.15 Participants continued with their regularly sched-uled analgesia. They had lower (P <0.01) VAS scores with themorphine gel treatment (gel alone mean + standard deviation= 47 + 11 versus morphine gel = 15 + 11). Three patients re-ported localized discomfort with the gel alone but not withthe morphine gel. Systemic adverse effects were not noted withthe morphine gel.
Flock32 examined the effectiveness of diamorphine gel tocontrol pressure ulcer pain for 13 patients with grade 2 orgrade 3 pressure ulcers. Pain scores were rated as none (score0) to overwhelming (score 4). Among the seven patients whocompleted the study, pain score significantly improved 1 and12 hours after the diamorphine gel was applied; this was nottrue for the gel alone. New symptoms that patients developedduring the study (ie, skin irritation, pruritus, nausea/vomit-ing) were similar for the two treatments. One patient devel-oped symptoms similar to opioid toxicity when her fentanylpatch was increased; her symptoms resolved when the fentanyldose decreased.
Jepson31 reported that a aqueous-based cream containing3% benzydamine was effective within 24 hours in reducingpressure ulcer pain. The pain scale used in the study was notnamed. In a study with more controls, Prentice et al16 used theVAS and an 11-point numerical pain score to examine the ef-fect of topical benzydamine hydrochloride 3% cream as com-pared to a topical placebo cream on relief of pressure ulcerpain (N = 30). VAS and numerical pain scores decreased inboth groups. The reduction in pain was greater in the benzy-damine group but not significantly different. Comparing theVAS and numerical pain scale scores over time, Prentice16
noted the R-square values increased (ie, 66.4%, 74.2%, and94.5%), indicating participants learned how to use the variousscoring methods across the study.
The pressure ulcer pain literature included limited descrip-tive information about the use of systemic analgesics for thispain. Dallam et al13 reported three out of 132 participants(2.3%) were given pain medication for pressure ulcer painwithin 4 hours of pain measurement. Drugs used by these pa-tients that may have decreased pressure ulcer and other painincluded narcotics, nonsteroidal anti-inflammatory drugs(NSAIDs), tranquilizers, psychotropics, and sedatives. Szorand Bourguignon10 reported seven persons (21.8%) receivedpain medication within 6 hours before completing the painstudy; the medication was prescribed specifically for pressureulcer pain for only two of these persons. None of the sevenparticipants reported an absence of pain from the medication.
Studies on the use of systemic and/or local analgesics for pres-sure ulcer pain management in vulnerable patient groups (ie,neonates and children, patients with a history of substance abuse,morbidly obese/bariatric, minority groups, and at end of life)could not be found. This is an important concern. Children as
young as 3 years of age have been found to have painful memoriesof procedures.33 Minority groups have been found to be at riskfor inadequate pain control.34 Persons who have chronically usedopioids have been found to have a decreased tolerance for pain.35
In addition, clinicians may have misconceptions and value judg-ments about pain treatment in persons who used illicit drugs, es-pecially when the drugs were injected.36
Obese children and adults experience analgesic medicationadministration issues because excess body fat can alter drug ab-sorption37 — for example, drugs that are highly soluble in fat (eg,diazepam and carbamazepine) need the dose calculated using thepatient’s actual body weight, but drugs absorbed mainly in leantissue (eg, acetaminophen) should have the dose calculated usingthe patient’s ideal body weight.37 If an obese patient is to receivepain medication by intramuscular injection, standard intramus-cular needle length may not be sufficient to penetrate past theadipose tissue. Although the intravenous route is an option formore consistent administration of pain medication, vein accesscan be problematic in patients who are obese, as well as in personswho inject illicit drugs.
Langemo38 noted pressure ulcers are a concern for patientsreceiving palliative care but that little is known about woundsin these patients.38 For patients at the end of life, regular as-sessment for pain and use of therapies proven effective tomanage pain are recommended.39,40
Although research was not found about the impact of sys-temic analgesics on pressure ulcer pain, systemic analgesicsare a critical component in overall pain management and thusneed to be considered for chronic pressure ulcer pain. TheWorld Health Organization’s (WHO) Analgesic Dosing Lad-der41 frequently is used as a guide for systemic pain medicationmanagement. The WHO ladder includes many categories ofsystemic medications for pain management (eg, NSAIDS, opi-oids, and adjuvants) and encourages matching the analgesicto the patient’s level of pain. Using a 10-point scale where 10is the highest pain level, recommendations for analgesia in-clude mild opioids for scores 1 to 3, moderate opioids forscores 4 to 6, and strong opioids for scores 7 to 10.42 Sponta-neous or induced wound pain usually is treated with a sup-plemental systemic, rapid-acting opioid.43 Breakthrough painmedications should be administered with sufficient time totake effect, such as before a painful pressure ulcer treatment.A pain management specialist may help determine the mostappropriate medication protocols to minimize medicationside effects and toxicity maximize pain reduction/relief.
Wound care and pressure ulcer pain. Pressure ulcer pain as-sociated with treatment and/or wound care was reported in somestudies. Dallam et al13 noted patients whose ulcers were treatedwith hydrocolloid dressings as opposed to management withother topical dressings (P <0.02) had significantly less pain. Szorand Bourguignon10 reported 87.5% of participants had pain atdressing change. This pain ranged from mild (n = 21) to excru-ciating (n = 5). Pain did not differ at rest and at dressing changeacross the stages of ulcers. Spilsbury et al44 reported that eight out
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of 23 persons (34.8%) had pain with dressing change. Gunes17 reported that 32 out of47 patients (68.1%) stated dressing change aggravated pressure ulcer pain.
Although procedural pain may be addressed in literature regarding specific treat-ments, information on pressure ulcer pain research conducted during procedures/treat-ments was not found. Some authors presented findings about wound dressings andpain in general. For example, the Thunder Project II45 (N = 6,201) described pain re-lated to procedures commonly performed in critical care settings; one of the painfulprocedures was wound dressing change. Adolescents gave wound care the highest painintensity score and adults rated it the third most painful procedure (following turningand wound drain removal).
Choosing dressings that may mitigate the pain associated with dressing changes andadministering an analgesic before dressing changes have been found to be possiblestrategies for pain management.46 Pain rated as moderate (eg, 4 on a 1 to 10 scale)should prompt breaks during the dressing change, improved analgesia, and a reviewof current dressing protocols.6 The World Union of Wound Healing Societies,6 using amodified Delphi approach, developed a document that lists principles of best practicefor minimizing pain at wound dressing-related procedures. These principles include:1) be aware of current wound pain, 2) avoid unnecessary manipulation of the wound,3) explore patient-controlled techniques to minimize wound pain, 4) assess the skinand surrounding tissue for infection, necrosis, and the like, 5) consider the temperatureof the wound products, 6) avoid excessive pressure to the wound from dressing mate-rials, and 7) provide ongoing evaluation and manipulation of the management plan.
Nutrition and pressure ulcer pain. Specific research related to the impact ofpressure ulcer pain on nutrition could not be found. However, Bosley et al47 re-ported chronic pain was associated with self-reported appetite impairment in olderadults. The authors identified the need for research on the effect of pain reductionon appetite. Herr et al’s48 guideline about acute pain management in older adultsincludes a section about monitoring for nausea that may negatively impact nutri-tion. Guidelines49,50 on palliative care recommend minimizing dietary restrictions,offering small quantities of food at a time, and offering food more frequentlythroughout the day. Patients should select foods that match their appetite in termsof appearance, consistency, and aroma. The decision to use medications to stimu-late appetite should be made on an individual basis. Pain medication in and ofitself may affect appetite and taste.
ConclusionThe NPUAP is an advocacy organization that believes that all, or nearly all, pressure
ulcers cause pain. The NPUAP also believes it is crucial to increase the scientific knowl-edge base for pressure ulcer pain and disseminate this knowledge, particularly to thebedside clinician. Healthcare providers report that dressing change and wound treat-ment are among the most painful times for an individual with a pressure ulcer.
Pain assessment scales are available and have been used in research to measure pres-sure ulcer pain. Open-ended questions about pain also have identified the presence ofpain in persons with pressure ulcers. Clinicians should have a high index of suspicionof pressure ulcer pain in patients including those who cannot respond (eg, patientswith dementia, ischemia, and cancer). Irrespective of the pain assessment format used,patients with pressure ulcers need to be asked about their pain, using a structured toolor open-ended questions for assessment. Although pressure ulcer pain research has in-cluded Stage I through Stage IV to some degree, information on Stage I and Stage IVis more limited in published studies.
In general, research regarding pressure ulcer pain is limited. However, the results ofthis review underscore a number of perspicuous points. First, pressure ulcers causepain. Pressure ulcer pain was identified in both quantitative and qualitative studies.Second, pain levels in individuals with pressure ulcers — including neonates, children,
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adults, and the elderly — must be routinely assessed. Third, anumber of pain assessment tools have been used in pressure ulcerpain research and include the MPQ, FRS, and VAS. Pressure ulcerpain assessment tools should match the cognitive level of the pa-tient and be appropriate for special groups, such as persons withcompromised mental competence, substance abuse, bariatricconcerns, spinal cord injury, and other neurological illness orend-of-life issues that can impair perception and pain reporting.Fourth, some research has noted the positive effects of topicalmedications for pressure ulcer pain. Research about the impactof systemic medications was not available. Fifth, wound caretreatments such as dressing changes can cause pain. Given thatdressings and their need for changing may cause pain, it is im-portant to consider dressings based on their comfort and fre-quency of change. Lastly, pain medication can affect appetite andtaste. The effect of pressure ulcer pain on nutritional status mustbe assessed. Pain medications should be administered on a sched-ule that maximizes the patient’s ability to eat and to be comfort-able during pressure ulcer treatment. The goal is to optimizefood/fluid intake and decrease the risk of nutritional problemssuch as weight loss and delayed healing.
Inadequate knowledge of pain is a barrier to its management.Although this review did not examine literature about pressureulcer pain education, pressure ulcer education needs to includecontent regarding pain assessment and management. This edu-cation should focus on the patient, family, caregivers, and clini-cians. Krasner51 noted clinicians need to become more sensitiveto pressure ulcer pain and respond to it. Continued pressure ulcerpain research is needed to identify the most effective methods ofassessing and managing pressure ulcer pain across the age con-tinuum and for special populations.
The NPUAP, in collaboration with the European PressureUlcer Advisory Panel, is developing pressure ulcer preven-tion and treatment guidelines with international application.These guidelines will be released at the NPUAP BiannualConference in Arlington, Virginia, February 27 – 28, 2009.Specific recommendations will be made for management ofpressure ulcer pain.
Further research is needed about pressure ulcer pain, includ-ing the degree and type of pain for each pressure ulcer stage. Re-search questions might include: Are certain topical analgesicsmore effective for pain in different stages of pressure ulcers or onpressure ulcers in different body locations? Are certain systemicanalgesics more effective for pain in different stages of pressureulcers? Are certain analgesics more effective for acute pressureulcer pain? What analgesic issues are relevant to chronic pressureulcer pain? Are certain analgesics, whether topical or systemic,more effective for different aged individuals with a pressureulcer? What are analgesic concerns and effectiveness issues forindividuals with a history of substance abuse or for individualsat the end of life? What is the most effective timing schedule ofanalgesic medications in relation to effective nutrition and fluidintake? How can pain scale ratings be used to guide medicationor dressing selection for a person with a pressure ulcer? What is
the best method to assess the presence of pressure ulcer pain andto assess if pressure ulcer pain is relieved in the non-cognitivelyintact individual or in children? Research also might considerpain management strategies including, but not limited to, med-ications and nonpharmacologic strategies such as physical andoccupational therapy, counseling, music, massage, and relaxation.The responses to these questions and concerns will help guideand improve care for patients with pressure ulcer pain. ■
AcknowledgmentThe author thanks members of the National Pressure Ulcer
Advisory Panel (NPUAP) Board of Directors 2007–2008 whoprovided critique of the manuscript.
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