5.4 Pain Management, Wound Care & Palliative Care

5.4 Pain Management, Wound Care & Palliative Care

Multimodal Pain Assessment & Management

Pain Physiology & Classification

Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Registered nurses must understand the physiological mechanisms of pain to implement effective multimodal analgesia. Pain is broadly categorized into:

1. Nociceptive Pain: Arises from actual or threatened damage to non-neural tissue and is mediated by intact nociceptors. It is subdivided into Somatic pain (originates from skin, muscle, bone, joints; localized, aching, throbbing) and Visceral pain (originates from internal organs; poorly localized, cramping, deep pressure, often accompanied by autonomic symptoms like nausea and sweating).
2. Neuropathic Pain: Caused by a lesion or disease of the somatosensory nervous system (e.g., diabetic neuropathy, post-herpetic neuralgia, phantom limb pain). It is described as burning, electric-shock, shooting, tingling, or lancinating, frequently exhibiting allodynia (pain due to a stimulus that does not normally provoke pain) and hyperalgesia.
3. Chronic Pain: Pain that persists or recurs for longer than 3 months, often leading to central sensitization, neuroendocrine stress, and psychological distress.

Systematic Pain Assessment

Systematic Pain Assessment follows the PQRST mnemonic:

• P (Provoking / Palliative factors): What makes the pain better or worse?
• Q (Quality): What does the pain feel like (sharp, dull, aching, burning)?
• R (Region & Radiation): Where is the pain located, and does it radiate anywhere else?
• S (Severity): Pain intensity measured using validated tools.
• T (Timing & Duration): When did it start, is it constant or intermittent, how long does it last?

Validated Pain Rating Tools:

• Numeric Rating Scale (NRS 0–10) and Visual Analogue Scale (VAS): Standard self-report tools for alert, articulate adults.
• FLACC Scale (Face, Legs, Activity, Cry, Consolability): Observational behavioral tool scored 0–10 for infants, young children, or non-verbal pediatric patients.
• Critical Care Pain Observation Tool (CPOT) or BPS (Behavioral Pain Scale): Observational tools evaluating facial expression, body movements, muscle tension, and ventilator compliance in intubated or critically ill adults.
• PAINAD (Pain Assessment in Advanced Dementia): Evaluates breathing, vocalization, facial expression, body language, and consolability in patients with severe dementia.

Pharmacotherapy & The WHO Analgesic Ladder

The WHO Analgesic Ladder provides a framework for pain escalation:

• Step 1 (Mild Pain, NRS 1–3): Non-opioid analgesics (Paracetamol 1 g QID; NSAIDs like Ibuprofen 400 mg or Naproxen 500 mg, ensuring renal function and GI bleeding risk are checked) +/- Adjuvant analgesics.
• Step 2 (Moderate Pain, NRS 4–6): Weak opioids (Codeine 30–60 mg or Tramadol 50–100 mg) combined with Step 1 non-opioids +/- Adjuvants.
• Step 3 (Severe Pain, NRS 7–10): Strong opioids (Morphine, Oxycodone, Fentanyl, Hydromorphone) combined with Step 1 non-opioids +/- Adjuvants.
• Adjuvant Analgesics: Administered at any step to target specific pain mechanisms. Include Gabapentinoids (Gabapentin, Pregabalin) and Tricyclic Antidepressants (Amitriptyline) for neuropathic pain; Corticosteroids (Dexamethasone) for nerve compression or bone pain; and Antispasmodics (Baclofen) for muscle spasms.

Opioid Safety & Sedation Monitoring

Opioid administration carries risks of sedation, respiratory depression, constipation, nausea, and urinary retention. Sedation ALWAYS precedes respiratory depression. Nurses should assess sedation using the Pasero Opioid-Induced Sedation Scale (POSS):

• S = Sleep, easy to arouse (acceptable).
• 1 = Awake and alert (acceptable).
• 2 = Slightly drowsy, easily aroused (acceptable).
• 3 = Frequently drowsy, arousable, drifts off to sleep during conversation (unacceptable; decrease opioid dose by 25–50%).
• 4 = Somnolent, minimal or no response to verbal/physical stimulation (unacceptable; stop opioid, consider Naloxone). If respiratory depression occurs (respiratory rate <10 breaths/minute, severe sedation, hypoxia), stop the opioid, call for immediate medical review, provide oxygen, and administer Naloxone 100–400 mcg IV (diluted and titrated slowly to avoid rapid opioid reversal, severe pain crisis, or pulmonary edema).

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Tissue Viability, Wound Assessment & Dressing Selection

Wound Classification & Pressure Injury Staging

Wound care requires structured assessment of tissue viability, underlying etiology, and wound bed characteristics. Surgical wounds heal by Primary Intention (clean approximated edges closed by sutures/staples), Secondary Intention (edges not approximated, heals from base up via granulation tissue, higher scar formation), or Tertiary/Delayed Primary Intention (left open intentionally due to infection/edema, closed later).

Vascular Ulcer Differentiation:

• Arterial Ulcers: Result from peripheral artery disease; located on toes, heels, or lateral malleolus; punched-out appearance with smooth borders; pale or necrotic wound bed; severe pain aggravated by leg elevation; cool skin, delayed capillary refill, weak or absent peripheral pulses. Compression therapy is strictly CONTRAINDICATED.
• Venous Ulcers: Result from venous insufficiency; located on medial malleolus; shallow with irregular borders; ruddy granulating wound bed with heavy exudate; aching pain relieved by leg elevation; hyperpigmented surrounding skin (hemosiderin staining) and stasis dermatitis; normal peripheral pulses. Multilayer compression therapy is the gold standard treatment (after confirming Ankle-Brachial Pressure Index - ABPI >0.8).

Pressure Injury Staging (NPIAP / NZ Wound Care Society):

• Stage 1: Intact skin with non-blanchable erythema of a localized area, usually over a bony prominence.
• Stage 2: Partial-thickness loss of skin with exposed dermis. Presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister.
• Stage 3: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough/eschar may be visible. Bone, tendon, and muscle are NOT exposed.
• Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.
• Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
• Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration. Pressure injury prevention relies on the Braden Scale (evaluating sensory perception, moisture, activity, mobility, nutrition, friction/shear; scores ≤15 indicate high risk). Prevention protocols include 2-hourly repositioning, pressure-relieving dynamic air mattresses, barrier creams for incontinence, and optimizing nutritional intake (high protein).

The TIME Framework for Wound Bed Preparation

• T (Tissue Management): Removal of non-viable tissue (slough, eschar) via debridement (autolytic using hydrogels, enzymatic, sharp/surgical, or mechanical).
• I (Infection / Inflammation Control): Managing bacterial bioburden and biofilm. Evaluated for classic signs of infection (increased pain, erythema, warmth, purulent exudate, offensive odor). Treated with topical antimicrobials (cadexomer iodine, silver-impregnated dressings, medical-grade honey) or systemic antibiotics for spreading cellulitis.
• M (Moisture Balance): Maintaining an optimal moist wound environment. Dry wounds require hydration (Hydrogels, Hydrocolloids); heavily exuding wounds require moisture absorption (Alginates, Foams, Superabsorbent polymer dressings) to prevent surrounding skin maceration.
• E (Edge / Epithelial Advancement): Ensuring wound margins are advancing. Non-advancing rolled edges (epibole) require reassessment of systemic barriers (malnutrition, hypoxia, uncontrolled diabetes) or advanced therapies like Negative Pressure Wound Therapy (NPWT).

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Palliative Care & End-of-Life Care in New Zealand

Holistic Palliative Care Principles

Palliative care in New Zealand seeks to improve the quality of life of patients and their whānau facing life-threatening illness through the prevention and relief of suffering. Care delivery integrates the Te Whare Tapa Whā model of Māori health, acknowledging four pillars of well-being: Taha Tinana (physical health), Taha Hinengaro (mental and emotional health), Taha Whānau (family and social health), and Taha Wairua (spiritual health). Cultural safety demands respecting tikanga (customary practices) surrounding dying, death, and tapu (sacredness) of the deceased body.

End-of-Life Symptom Management (Te Ara Whakapiri Framework)

Te Ara Whakapiri is the national framework guiding care for dying adults in New Zealand. Key clinical management involves anticipatory prescribing for the five most common end-of-life symptoms:

1. Pain: Subcutaneous Morphine boluses (2.5–5 mg SC Q2H PRN) or continuous SC infusion via a Syringe Driver.
2. Dyspnea / Breathlessness: Subcutaneous Morphine (1.25–2.5 mg SC PRN), which reduces respiratory center sensitivity and sensation of suffocation, combined with sublingual Lorazepam for associated panic.
3. Terminal Restlessness & Agitation: Subcutaneous Midazolam (2.5–5 mg SC PRN) or Haloperidol (1.5–3 mg SC PRN).
4. Terminal Respiratory Secretions ("Death Rattle"): Subcutaneous anticholinergic agents such as Hyoscine Hydrobromide (400 mcg SC Q4H PRN) or Glycopyrronium (200 mcg SC PRN) to dry noisy upper airway secretions. Must be started early for maximum efficacy.
5. Nausea & Vomiting: Subcutaneous Metoclopramide (10 mg SC PRN) for impaired gastric emptying, Haloperidol for chemical/metabolic nausea, or Cyclizine for motion/raised ICP-related nausea.

Advance Care Planning (ACP) & End of Life Choice Act 2019

Advance Care Planning (ACP) enables individuals to outline their values and preferences for future healthcare, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) directives and appointing an Enduring Power of Attorney (EPOA) for personal care and welfare.

End of Life Choice Act 2019 (NZ): Came into effect in November 2021, legalizing assisted dying in New Zealand for eligible individuals. Strict statutory criteria require that a person must be a NZ citizen/permanent resident aged 18 or older, suffer from a terminal illness likely to end life within 6 months, be in an advanced state of irreversible decline in physical capability, experience unbearable suffering that cannot be relieved in a tolerable manner, and possess capacity to make an informed decision. Role of the Registered Nurse: Registered nurses are legally prohibited from initiating any discussion about assisted dying or suggesting it to a patient. If a patient directly requests information, the nurse must provide neutral, official Ministry of Health resources and direct the patient to their attending medical practitioner. Registered nurses have a statutory right to conscientiously object to participating in any assisted dying process.