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SouthWestRegionalWoundCareToolkit

B.5.3WHOPainLadderwithPainManagementGuidelines TheWHOPainLadderiwasdevelopedin1986asaconceptualmodeltoguidethemanagementofcancerpain.There isnowaworldwideconsensuspromotingitsuseforthemedicalmanagementofallpainassociatedwithseriousillness, includingpainfromwounds.

Red Flags Unrelieved pain should raise a red flag that attracts the attention of the interdisciplinary team.

Severe Pain 7 - 10 / 10 Step3: Startstrongoralopioidaroundtheclockii Morphine510mgq4htitratetopain Dilaudid14mgq4htitratetopain MSContinorotherlongacting3060mgq812h Fentanyl25g/hourplusMorphineSulphate5mg.q2 hoursforbreakthrough*nevertobeadministeredto opioidnaiveclients +Adjuvants* Notes:Useshortactingpreparationofsamemedication forbreakthroughpain.Considerlowerdoseinopioidnave andelderlypatients

Painpersistingor increasing

Moderate Pain 4 6 / 10

Step2: AddOpioidforModeratePainaroundtheclock2 Acetaminophen325mg+codeine30mgq4h(Tylenol#3)or Acetaminophen325mg+codeine60mgq4h(Tylenol#4)or Acetaminophen325/500mg+oxycodone5mgq4h(Percocet/Roxicet) +Adjuvants* Note:Considerstrongeropioidifpainnotcontrolledbythese combinationsatatotaldailydoseif400mg/dayofcodeineor80mg/dayof oxycodone

Painpersistingor Mild Pain increasing 1 3 / 10 Step1: Nonnarcoticaroundtheclock2 Acetaminophen650mgq4hor ASA650mgq4hor Ibuprofen400mgq4hor otherNSAIDs +Adjuvants* *Adjuvanttherapymedicationsthatcanhelptoenhancetheeffectsofnonopioidandopioidanalgesics 1)NSAIDs(nonsteroidalantiinflammatories)canbeusedascoanalgesicsandareusefulinreducinginflammation 2)TricyclicantidepressantsNortriptyline,Desipramine,andAmitriptylineareoptions,althoughAmitriptylinecancauseconfusion intheelderly.Studieshaveconfirmedtheireffectivenessintreatingdiabeticneuropathyandneuropathicpainfromothersources 3)AnticonvulsantmedicationsGabapentin,Pregabalin,andCarbamazepinecanrelievetheshooting,electricalpainsofperipheral nervedysfunction.iii
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WorldHealthOrganization,(2009).WHOsPainReliefLadder.www.who.int/cancer/palliative/painladder/en/ Roden,A.&Sturman,E.(2009).Assessment&Managementofpatientswithwoundrelatedpain.NursingStandard,23(45)5362 3 Principlesofbestpractice:Minimizingpainatwounddressingrelatedprocedures.Aconsensusdocument.(2007).Toronto,Ontario,Canada:cWoundPediaInc. 2007.


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SWRWCToolkit_B.5.3WHOPainLadderwithPainManagementGuidelines_Jan7_2011AdaptedfromaCarePartners/ETNOWformwith permission2010.Appropriatecreditorcitationmustappearonallcopiedmaterials.