Diane L. Krasner

Painful venous ulcers: themes and stories about living with the pain and suffering

Purpose Describe and explore the meaning of the experience of living with painful venous ulcers. Subjects and Setting Fourteen people with active painful venous ulcers at the time of initial interview at an outpatient wound center. Method A descriptive qualitative approach, known as Heideggerian hermeneutic phenomenology was used for this study. Semistructured interviews were audio taped, transcribed, and analyzed using Martin Qualitative Analysis Software. Results Four of the eight most compelling themes identified by the patients are reviewed in this article. These themes are expecting pain with the ulcer, swelling equals pain, not standing, and starting the pain all over again (painful débridements). Conclusions The identified pain descriptors and the constitutive pattern “carrying on despite the pain” have important implications for WOC nursing practice, education, and research.

Assessment and management of persistent (chronic) and total wound pain

Persistent (chronic) wound‐related pain is a common experience that requires appropriate assessment and treatment. It is no longer adequate for health care professionals to concentrate on the acute (temporary) pain during dressing change alone. The study provides useful recommendations and statements for assessing and managing total wound‐related pain for patients, health care professionals and other policymakers. The recommendations have been developed with the involvement of an interprofessional panel of health care professionals from around the world.

Scale: Skin Changes at Life's End

PURPOSE To enhance the learners competence with knowledge of Skin Changes at Lifes End (SCALE). TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Apply SCALE knowledge to patient care scenarios and documentation procedures. 2. Analyze the expert panels 10 statements on Skin Changes at Lifes End (SCALE).PURPOSE: To enhance the learners competence with knowledge of Skin Changes at Lifes End (SCALE). TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: Apply SCALE knowledge to patient care scenarios and documentation procedures. Analyze the expert panels 10 statements on Skin Changes at Lifes End (SCALE).

Managing painful chronic wounds: the Wound Pain Management Model.

Chronic wound pain is not well understood and the literature is limited. Six of 10 patients venous leg ulcer experience pain with their ulcer, and similar trends are observed for other chronic wounds. Chronic wound pain can lead to depression and the feeling of constant tiredness. Pain related to the wound should be handled as one of the main priorities in chronic wound management together with addressing the cause. Management of pain in chronic wounds depends on proper assessment, reporting and documenting patient experiences of pain. Assessment should be based on six critical dimensions of the pain experience: location, duration, intensity, quality, onset and impact on activities of daily living. Holistic management must be based on a safe and effective mix of psychosocial approaches together with local and systemic pain management. It is no longer acceptable to ignore or inadequately document persistent wound pain and not to develop a treatment and monitoring strategy to improve the lives of persons with chronic wounds. Unless wound pain is optimally managed, patient suffering and costs to health care systems will increase.

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy: a consensus paper from the International Expert Wound Care Advisory Panel.

INTRODUCTION As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008. They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses. The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel.

43,180 per hospital stay. The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions. The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008. Physician/provider* determination and documentation during the hospitalization that the pressure ulcer was present at the time of admission is critical. Since this

Why combine a foam dressing with ibuprofen for wound pain and moist wound healing

As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008.1,2 They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses.2,3 The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be

Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers--a consensus paper from the International Expert Wound Care Advisory Panel©.

43,180 per hospital stay.2,3 The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions.4 The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008.5 Physician/provider* determination and documentation during the hospitalization that J Wound Ostomy Continence Nurs. 2008;35(5):485-492. Published by Lippincott Williams & Wilkins

Palliative wound care management strategies for palliative patients and their circles of care.

Six out of ten patients with chronic wounds suffer from persistent wound pain (1). A novel dressing combination has been formulated to provide pain relief and moisture balance at the local wound site (ibuprofen-foam, Biatain-Ibu foam dressing, Coloplast A/S). Foam dressings with polyurethane cells have been known to absorb moisture and provide moisture balance. These second generation foams have the ability to partially retain some fluids and to exchange other fluid, providing moisture balance to the wound surface. This type of foam is less likely to cause maceration of the periwound skin (2). Healing wounds requires five initial important components: debridement, prevention of bacterial damage, pain and prolonged inflammation and maintaining moisture balance. Painful wounds take longer time to heal, and some patients cannot tolerate the treatment of wounds and some can become immobile, which in turn can lead to social isolation, depression and feelings of hopelessness (3). Non steroidal anti-inflammatory drugs (NSAIDs) are excellent pain-reducing agents, but when administered systemically in the elderly patients, they may cause side effects such as gastrointestinal bleeding, decreased renal function and even deaths. To overcome the safety concern, very small doses of ibuprofen can have an excellent local effect on the superficial wound compartment, without detectable systemic levels. The equivalent of a quarter tablet (50 mg, 1010-cm dressing) of ibuprofen can exert adequate anti-inflammatory and pain-reducing effects up to 7 days. Conceptually, we have a safe combination of moisture-balancing foams with continuousrelease, low-dose ibuprofen to exert a local pain-reducing effect.

Clarification from the American Nurses Association on the nurse's role in pressure ulcer staging.

WHY DO WE CARE?Pressure ulcers (PrUs) are a significant problem across all healthcare settings in the United States. Annually, 2.5 million patients are treated in acute-care facilities for PrUs. Patients with PrUs are 3 times more likely to be discharged to a long-term-care facility than those with