Wound Pain Management Model© (WPM)© 2008 Wound Pain Management Model©

Developed in consultation with:

Assoc. Prof. Karsten Fogh, DK Dr. Chris Glynn, UK Prof. Dr. Michael Jünger, DE Dr. Bo Jørgensen, DK Dr. Diane L. Krasner, US Prof. Dr. Jürgen Osterbrink, DE/AT Prof. Patricia Price, UK Prof. R. Gary Sibbald, CA

Venous leg ulcers Ischaemic ulcers Pressure ulcers Diabetic foot ulcers Miscellaneous (examples) Consider: Consider: Consider: Consider: Consider: >> Compression stockings >> Bypass grafting >> Risk assessment >> Proper diabetic control >> Infection (cellulitis, Wound Assessment >> Compression therapy >> Balloon angioplasty >> Pressure distribution/ >> Preventive foot care osteomyelitis) Preventive and >> Elevation redistribution >> Pressure downloading/ >> Inflammation (vasculitis, treatment strategies >> Repositioning offloading pyoderma gangrenosum) >> Preventive skin care >> Removal of callus and >> Malignancy debridement of wound >> Rheumatoid arthritis

Devitalized tissue Critical colonization/ Persistent inflammation Exudate/Oedema Peri wound skin clinical infection Consider: Consider: Consider: Consider: Consider: >> Cleansing >> Wound cleansing/ >> Topical medications >> Dressing selection >> Skin sealants/barriers Local Wound Management >> Debridement debridement (immune modifiers) >> Compression >> Creams, ointments Preventive and (surg., autoly., enzyma., >> Exudate management >> Elevation >> Topical medications treatment strategies mechan., biologi.) >> Antimicrobials >> Devices >> Allergy >> Antibiotics

Location Duration Intensity Description QoL/ADL

>> Within or around wound >> Days/weeks/months >> VAS/FRS/VRS/NBS >> Nociceptive (throbbing or >> Sleep disturbances Wound Pain >> Referred pain Persistent pain >> Descriptive questionnaires gnawing pain) >> Mood/Anxiety/Depression >> D i u r n a l >> With activity >> Neuropathic (shooting or >> Mobility >> Functional limitation >> At rest stabbing pain) >> Appetite Assessment >> Mixed Temporary pain >> Dressing change >> Cleansing >> Debridement

Explanations: VAS: Visual Analogue Scale >> FRS: Faces Pain Rating Scale >> VRS: Verbal Rating Scale >> NBS: Numeric Box Scale >> QoL: Quality of Life >> ADL: Activities of Daily Living Wound Pain Management Model©

Persistent/chronic pain Management of wound pain Temporary/acute pain >> Pain at rest >> Pain of dressing removal >> Pain with activity >> Pain when cleansing >> Pain at night >> Pain at debridement Local treatment Psycho-social Oral/Systemic treatment 1) >> Encourage patients to organize their day (socialization, exercising, relaxation) Non-pharmacological Pharmacological If predominantly If predominantly treatment treatment 1) nociceptive pain neuropathic pain Pain & Wound Specific Local Analgesics >> Foam dressing with local Local Anesthetics release of ibuprofen >> Use Amide local >> Autolytic debridement 2) Tricyclic Antidepressants/ anesthetics (Xylocaine, WHO Clinical Ladder >> Cleanse with luke warm Anticonvulsants Prilocaine) water, saline Step 1: >> Compression strategy >> Avoid ester local >> NSAIDs (Non Steroidal (oedema control) anesthetics (Benzacaine) Anti-Inflammatory Drugs) >> Acetominephen (para- Pain Specific cetamol) >> Allow procedural time-outs >> Avoid excessive irrigation Step 2: force >> Mild opiates (e.g. >> Avoid adhesive, adherent codeine, tramadol) dressings >> Minimise wound Step 3: exposure >> Strong opiates Wound Specific (morphine, hydromorphone, >> Moisture- balanced transdermal fentanyl) dressings >> Protect surrounding skin Other therapies >> TENS, Acupuncture If mixed nociceptive/neuropathic pain => combination therapy

1) For all drugs, please refer to individual product monographs 2) World Health Organization, Cancer Pain Relief (2nd ed). Geneva: WHO, 1996. Wound Pain Management Model Management Pain Wound (QoL) and Activities of Daily Living (ADLs) needs to be taken into account. into taken be to needs (ADLs) Living Daily of Activities and (QoL) Life of Quality patient’s the on pain wound the of impact the addition, In debridement. or changes dressing during example for related procedurally is pain the if Determine treatment. pharmacologic appropriate an select to order in origin, in neuropathic or nociceptive predominantly is pain the whether describe to important also is It pain. wound the of intensity and duration location, consider Assessment Pain the During Assessment Pain Wound oedema/exudate. by caused pain wound control may devices and tion eleva- compression, selection, dressing e.g. pain, the relieve to order in wound painful the of irrespective considered be should strategies treatment and Prevention infection, colonization/clinical critical as: such pain wound the intensify or cause to expected issues other treat to order in addressed be to needs Management Wound Local Management Wound Local management. pain to relation in considered be to needs leg the of elevation and/or therapy compression stockings, compression ulcer, leg venous painful a e.g. is, wound the If pain. the relieve to wound chronic painful of type each for considered be should strategies treatment and Prevention diagnosis. a making when addressed be to needs occurrence pain wound chronic of cause underlying The Assessment Wound Model Management Pain Wound The CA. Sibbald, Gary R. Prof. and UK Price, Patricia Prof. DE/AT, Osterbrink, Jürgen Dr. Prof. US, Krasner, L. Diane Dr. DK, Jørgensen, Bo Dr. DE, Jünger, Michael Dr. Prof. UK, Glynn, Chris Dr. DK, Fogh, Karsten Prof. Assoc. with consultation in developed been has guide The The dimensions of the model are: model the of dimensions The time. same the at pain the and wound the both treat and assess to recommended therefore is It properly. wounds chronic painful treat and prevent to order in simultaneously considered be to need that levels four of consists guide The management. and assessment peri wound skin problems, oedema/exudate and/or persistent inflammation. persistent and/or oedema/exudate problems, skin wound peri © (WPM) is a practical guide on wound pain wound on guide practical a is (WPM) © type of of type

Wound Pain Management Model Management Pain Wound 2 1 Reference: system nervous the in dysfunction or lesion primary a by caused or initiated Pain pain: Neuropathic stimuli. noxious by (nociceptors) receptors pain visceral or peripheral of stimulation is aetiology predominant The pain: Nociceptive Explanations: together. management neuropathic and nociceptive combining by facilitated often is pain wound chronic of management The relevant. then is therapy combination and nociceptive/neuropathic mixed as described be also can pain The used. are anticonvulsants or antidepressants neuropathic predominantly as described is pain wound the If used. be can ladder analgesic clinical WHO the nociceptive, predominantly being as described is pain wound the If consideration. into taken be also should painkiller oral an e.g. with, treatment general or Systemic debridement. sharp e.g. during pain wound acute relieve to order in anaesthetics local be could treatment relieving pain local active An ibuprofen. of release local with healing wound moist or healing wound moist as such technology dressing a of selection the be could management local Non-active, treatment. active or non-active a be either can it considered, is pain wound the of management local If around the wound. the around or in manipulation of kind any without arises and etc.) mobility night, (at changes > patient. the of repositioning and debridement cleansing, es, > co-exist: pain wound of types Two patient. the to provided be now can Management Pain Wound Appropriate Management Pain Wound ) ) > > International Association for the Study of Pain (IASP) Pain Terminology Pain (IASP) Pain of Study the for Association International 2007. Communications, HMP PA: Malvern, edition). (4th Professionals Healthcare for Book Source Clinical A Care: Wound Chronic RG. Sibbald GT, Rodeheaver DL, Krasner In 85-97. pp. 11, Chapter Pain. of Management and Assessment Wound and Skin SWAMP: the of Out Patients Helping RG. Sibbald J, Papen DL, Krasner Persistent/chronic wound pain is experienced by the patient between dressing between patient the by experienced is pain wound Persistent/chronic chang- dressing as such procedures, to relates pain wound Temporary/acute 1) ©

(WPM) revised February 2008 February revised (WPM) www.coloplast.com Denmark 3050 Humlebæk Holtedam 1 Coloplast A/S 2)