"As a direct and proximate result of the negligence of the defendants, individually and vicariously through their nurses, staff, employees, and medical personnel, plaintiff developed a pressure ulcer, severe dehydration, and malnutrition with resulting pain and suffering, loss of quality of life, premature death, and medical expense." "Me and Jenny goes together like peas and carrots." – Forrest Gump

Introduction

Just like Forrest's peas and carrots, a pressure ulcer lawsuit and a pain and suffering allegation inevitably "goes together." For good reason, because pain is an ever-present problem in patients with pressure ulcers, venous and arterial ulcers, and even diabetic ulcers, despite sensory issues. How do you, as a health care provider, best protect and defend yourself against a pain and suffering allegation?

Sources of Wound Pain

First, let's remember the sources of wound pain, which, according to Woo et al.,¹ can be related to:

• Infection or inflammation, with increasing bioburden or infection
• Moisture balance, with too much or, perhaps more often, too little moisture, resulting in dressings that stick and cause bleeding and trauma
• Tissue debridement and trauma, where selection of dressings may be inappropriate or dressings too frequently changed, or by using aggressive adhesives, as well as during wound cleansing or irrigation

Case Scenarios: Wound Documentation Mistakes

Frequent Issues

Facilities have gotten better about requiring routine pain assessments, but I frequently find problems in reviewing charts for attorneys. These are:

• Not recording location with each and every pain assessment. Just as in real estate, location, location, location is a critical factor in pain assessments and documentation. If, for instance, a patient has an orthopedic injury such as a fractured arm or recent hip replacement, or chronic back pain, the pain may be more due to that factor than to any existing skin condition. However, if staff is recording a high pain level but is not giving a location, a plaintiff attorney will present that as pain from the ulcer, which is the subject of the lawsuit, thereby strengthening the pain and suffering allegation.
• Not documenting pain levels routinely as ordered and not performing pain level reassessments after medication administration
• Not reporting high pain levels to health care providers, for possible readjustment of the care plan or medications
• Not documenting patient education and discussions related to pain and not collaborating with patient and family to optimize pain control. Poor communication with patients and family can often be the tipping point between "sue" and "not sue."
• Not premedicating for pain before dressing changes. Szor and Bourguignon² reported that 87.5% of participants had pain at dressing change, thus making that the most critical wound assessment and treatment period.

Tips That May Help to Keep You out of Court

• Obtain a physician's order to assess pain at least daily to every shift or more often, depending on patient condition and need.
• Add the order to any treatment administration record or wherever it fits in your documentation system, and document the pain level and, at the very least, the location of the pain in that part of the record.
• Do a pain risk assessment on admission, and perform one routinely. How often? Again, this should be individualized based on patient condition, but at least quarterly seems like a good idea.
• Use a valid tool to assess pain levels. Some patient populations require specialized tools, such as the FLACC scale (Face, Legs, Activity, Cry, and Consolability) for babies and young children, and the PAINAD scale (Pain Assessment in Advanced Dementia) for cognitively impaired patients. Make sure staff has been well in-serviced on the use of these tools.
• Have a more extensive pain assessment and reassessment method, perhaps in a narrative note or on a specific pain form.
• Query the patient directly about pain associated with the ulcer, and document! It is helpful to use the patient’s own words and description of pain.
• Include wound pain on all wound documentation forms such as weekly assessments, with full description and level.
• There are numerous mnemonics for performing a comprehensive assessment of pain. One recommendation is the PQRSTU.¹ This stands for Provoking and palliating factors; Quality of pain; Regions (location!) and radiation; Severity or intensity; Timing or history; Understanding (what is important for you for pain relief? How would you like to get better?). Another is OLDCART—go ahead and look it up!
• Administer around the clock routine pain medications spaced out evenly over the 24 hours. An order for three times daily dosing could result in 8 am, 12 pm, and 4 pm administration, potentially leaving the patient without any pain coverage for 16 hours. Does that make any sense?
• Use dressings that don’t cause pain, such as silicone-backed dressings. And certainly, wet-to-dry must die!
• Decrease the frequency of dressing changes as much as possible.
• Use topical pain treatments such as morphine or EMLA (lidocaine 2.5% and prilocaine 2.5%) instead of or in addition to systemic drugs.
• Document all discussions and patient education related to pain management.

Conclusion

Wound-associated pain is complex. A comprehensive assessment and treatment plan is necessary to treat pain adequately and, hopefully, in the process avoid the dreadful pain and suffering allegation.

References

1. Woo KY, Krasner DL, Sibbald RD. Pain in people with chronic wounds: clinical strategies for decreasing pain and improving quality of life. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014.

2. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dressing change. J Wound Ostomy Continence Nurs. 1999;26(3):115-129.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.