Caring for a Patient Receiving Continuous Wound Perfusion Pain Management

Skill 10-6

Caring for a Patient Receiving Continuous Wound Perfusion Pain Management

Continuous wound perfusion or infiltration management systems are one strategy to be considered as a component of multimodal analgesia (Cinar et al., 2021; Mijovski et al., 2020; Polomano et al., 2017). Continuous wound perfusion pain management systems deliver a continuous infusion of local analgesia to intraarticular and wound sites (Polomano et al., 2017). These systems are used as an adjuvant in the management of postoperative pain in a wide range of surgical procedures (Cinar et al., 2021; Porter et al., 2021; Singh et al., 2017). The system consists of a balloon-type pump filled with local anesthetic and a catheter placed near an incision, in a nerve close to a surgical site, or in a wound bed (Figure 1). The catheter is placed during surgery and is not sutured into place; the site dressing holds it in place. The catheter delivers a consistent flow rate and uniform distribution to the surgical site. Continuous wound perfusion may also be delivered via patient-controlled analgesia systems (Mijovski et al., 2020).

Continuous wound perfusion catheters decrease postoperative pain and opioid use and side effects and have been associated with decreased postoperative nausea and vomiting as well as increased and earlier patient mobility (Cinar et al. 2021; Li et al., 2020; Mijovksi et al., 2020; Porter et al., 2021; Singh et al., 2017). The following skill outlines general guidelines for the care of a patient with a continuous wound perfusion pain management system with a balloon-type pump. There are many different systems and applications of this intervention.

Nurses need to be familiar with the particular device and system in use by their patient and to refer to the specific manufacturer's recommendations and facility policies for use.

Delegation Considerations

Care related to continuous wound perfusion pain management systems is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, specific aspects of the care related to continuous wound perfusion pain management systems, such as monitoring the infusion and assessment of patient response, may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Electronic medication administration record (eMAR) or medication administration record (MAR)
Pain assessment tool and pain scale
Gauze and tape, or other dressing, based on facility policy
Gloves
Additional PPE, as indicated

Assessment

Review the patient's health record and plan of care for specific instructions related to continuous wound perfusion analgesia therapy, including the prescribed intervention and conditions indicating the need for therapy. Review the patient's history for allergy to the prescribed medication. Assess the patient's understanding of a continuous wound perfusion pain management system and the rationale for its use. Assess the patient's level of discomfort and pain using an appropriate assessment tool and pain scale (refer to Fundamentals Review 10-1 through 10-4). Assess the characteristics of any pain. Assess for other symptoms that often occur with the pain, such as headache or restlessness. Assess the surgical site (see Chapter 8). Ask the patient what interventions have and have not been successful in the past to promote comfort and relieve pain.

Assess for signs of adverse effect that require immediate action: increase in pain; fever, chills, sweats; bowel or bladder changes; difficulty breathing; redness, warmth, discharge, or excessive bleeding from the catheter site; pain, swelling, or a large bruise around the catheter site; dizziness or lightheadedness; blurred vision; ringing or buzzing in the ears; metal taste in the mouth; numbness and/or tingling around the mouth, fingers or toes; or drowsiness or confusion (Avanos Medical, 2018d).

Assess the catheter insertion-site dressing (see Chapter 8). Assess the patient's vital signs and respiratory status, including rate, depth, and rhythm, and oxygen saturation level using pulse oximetry. Assess the patient's response to the intervention to evaluate its effectiveness and for the presence of adverse effects.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Acute pain
Knowledge deficiency
Infection risk

Outcome Identification and Planning

The expected outcome to achieve is that the patient reports increased comfort and/or decreased pain without adverse effects. Other appropriate outcomes may include that the patient exhibits a dry, intact dressing with the continuous wound perfusion system catheter in place; the patient remains free from infection; and the patient demonstrates an understanding of the functioning of the wound perfusion system and the reason for its use.

Implementation

Action	Rationale
1. Check the medication prescribed against the original health care provider's order, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's disorder and can also be used to educate the patient about the medication.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures that the right patient receives the intervention and helps prevent errors.
5. Close the door to the room or pull the bedside curtain.	Closing the door or curtain provides for patient privacy.
6. Assess the patient's pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4). Administer postoperative analgesic, if necessary, as ordered.	Continuous wound perfusion pain management is an adjuvant therapy; patients may require postoperative pain medication, with reduced frequency. Accurate assessment is necessary to guide treatment and relief interventions and to evaluate the effectiveness of pain control measures.
7. Check the medication label attached to the pain management system balloon. Compare it with the health care provider's order and eMAR or MAR, per facility policy. Assess the patient for signs of adverse reaction. Refer to discussion in the previous Assessment section. Assess the patient's vital signs.	Checking the medication label with the order and MAR ensures correct therapy for the patient. These symptoms may indicate local anesthetic toxicity (Avanos Medical, 2018d). Changes in vital signs may indicate adverse effect.
8. Put on gloves. Assess the wound perfusion system. Inspect tubing for kinks; check that the white tubing clamps are open (see Figure 1). Check filter in tubing, which should be unrestricted and free from tape (see Figure 1).	Gloves prevent contact with blood and body fluids. Tubing must be unclamped and free of kinks and/or crimping to maintain consistent flow of analgesic. Tape over filter interferes with properly functioning system.
9. Check the flow controller to ensure it is in contact with the patient's skin. Tape in place, as necessary (see Figure 1).	Checking the flow restrictor for adequate contact ensures accurate flow rate.
10. Check the insertion-site dressing. Ensure that it is intact. Assess for leakage and dislodgement. Assess for redness, warmth, swelling, pain at site, and drainage.	Transparent dressing holds the catheter in place. Dressing must stay in place to prevent accidental dislodgement or removal. These symptoms may indicate infection.
11. Review the device with the patient. Review the function of the device and reason for its use. Reinforce the purpose and action of the medication to the patient. If the device is used in the community setting or the patient will be discharged with the device in place, provide patient teaching regarding use. Refer to the discussion in the Community-Based Care Considerations section at the end of the Skill.	Explanation encourages patient understanding and engagement and reduces apprehension.
To Remove the Catheter
12. Check to ensure that infusion is complete. Infusion is complete when the delivery time has passed, and the balloon is no longer inflated.	Depending on the size and volume of the balloon, the infusion typically lasts 2 to 5 days. Infusion time should be recorded in the operative note or postoperative instructions. The balloon will no longer appear full, the outside bag will be flat, and a hard tube can be felt in the middle of the balloon (Avanos Medical, 2015).
13. Perform hand hygiene. Identify the patient. Put on gloves. Remove the catheter-site dressing. Loosen adhesive skin closure strips at the catheter site.	Hand hygiene and use of gloves reduce the risk of infection transmission. Identifying the patient ensures that the right patient receives the intervention and helps prevent errors. Loosening of materials allows the catheter to be free of constraints.
14. Grasp the catheter close to the patient's skin at the insertion site. Gently pull catheter to remove. Catheter should be easy to remove and not painful. Do not tug or quickly pull on the catheter during removal. Check the distal end of the catheter for the black marking.	Gentle removal prevents patient discomfort and accidental breakage of the catheter (Avanos Medical, 2018e). Checking for the black mark at the distal end ensures the entire catheter was removed (Avanos Medical, 2018e).
15. Cover the puncture site with a dry dressing, according to facility policy.	Covering the wound prevents contamination.
16. Dispose of the balloon, tubing, and catheter, according to facility policy.	Proper disposal reduces the risk for infection transmission and contamination of other items.
17. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the patient reports increased comfort and/or decreased pain without adverse effects; the patient exhibits a dry, intact dressing with the continuous wound perfusion system catheter in place; the patient remains free from infection; and the patient demonstrates an understanding of the functioning of the wound perfusion system and the reason for its use.

Documentation

Guidelines

Document system patency, the condition of the insertion site, system, and dressing, vital signs and assessment information, analgesics administered, and the patient's response to the therapy.

Sample Documentation

6/3/25

0935 Continuous wound perfusion pain management system in place. Exit site clean and dry. Transparent dressing in place. Temperature 98.7°F; pulse, 82 beats/min; respirations, 14 breaths/min and effortless; blood pressure, 112/74 mm Hg. Pulse oximetry 96% on room air. Patient alert and quickly responds to verbal stimuli. Denies nausea, vomiting, vision changes, paresthesias, dizziness, or ringing in ears. Patient rates pain in RLE 3/10. Ibuprofen 800 mg po given as ordered.

—T. James, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient reports and/or your assessment identifies the following symptoms: increase in pain; fever, chills, sweats; bowel or bladder changes; difficulty breathing; redness, warmth, discharge, or excessive bleeding from the catheter site; pain, swelling, or a large bruise around the catheter site; dizziness or lightheadedness; blurred vision; ringing or buzzing in the ears; metal taste in the mouth; numbness and/or tingling around the mouth, fingers or toes; or drowsiness or confusion (Avanos Medical, 2018d). Close the clamp on the system tubing to stop the infusion. Report the symptoms to the health care team immediately. The presence of any of these symptoms may indicate local anesthetic toxicity (Avanos Medical, 2018d).
Catheter and tubing are accidentally pulled out: Check the distal end of the catheter for the black marking to ensure the entire catheter was removed. Assess the insertion site. Cover the site with a dry, sterile dressing. Notify the health care team. Assess the patient's level of pain and administer analgesic, as ordered.
Resistance is encountered and/or the catheter stretches during its removal: Stop. Do not continue to try to remove the catheter. Wait 30 to 60 minutes and attempt to remove the catheter again. The patient's body movements may relieve constriction on the catheter to allow easier removal. If catheter is still difficult to remove, contact the patient's health care provider. Do not forcefully remove the catheter. Do not continue to apply tension if the catheter begins to stretch (Avanos Medical, 2018e).

Special Considerations

General Considerations

During the infusion, the pump will gradually lose its shape and flatten. Be aware that a change in the appearance and size of the pump may not be evident for more than 24 hours after surgery, owing to the slow flow rate of the device (Avanos Medical, 2018b).
Do not expect to observe a fluid level line in the balloon and fluid moving through the system tubing (Avanos Medical, 2015).
Over time, expect to see the outside bag on the balloon becoming looser, with creases beginning to form in the bag. As the medication is delivered, the pump will gradually become smaller (Avanos Medical, 2015).
Do not tape or cover the filter (Avanos Medical, 2015).
Ensure the tubing clamp remains open and avoid kinks in the pump tubing (Avanos Medical, 2015).
Do not forcefully remove the catheter (Avanos Medical, 2018e).
Do not reuse or refill balloon. System is intended for one-time use.
Protect the balloon and catheter site from water. Do not submerge the pump in water (Avanos Medical, 2015).
Clip the balloon to the patient's clothing to prevent the application of tension on the system and site.
Avoid placing cold therapy in the area of the flow controller (see Figure 1). Contact with cold therapy will decrease flow rate (Avanos Medical, 2015).

Community-Based Care Considerations

Instruct patients to immediately close the clamp on the pump tubing and call their health care provider or 911 if they experience any of the following symptoms (Avanos Medical, 2018b): increased pain; fever, chills, sweats; bowel or bladder changes; difficulty breathing; redness, warmth, discharge, or excessive bleeding from the catheter site; pain, swelling, or large bruise around the catheter site; dizziness or lightheadedness, blurred vision, ringing in the ears; numbness and/or tingling around the mouth, fingers or toes; metal taste in the mouth; or drowsiness or confusion.
Patients may experience numbness at and around the surgical site and should take care to avoid injury at the site (Avanos Medical, 2018e).
Patients may be instructed to remove the ON-Q* catheter at home. Provide written details and explanation. Instruct the patient to contact their health care provider for any issues with removal or if they do not see the black marking on the catheter upon removal (Avanos Medical, 2018e).

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Skill 10-6