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Pain management of mixed aetiology ulcers

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Regardless of aetiology, leg ulcers can be painful. 

With more than half of sufferers reporting pain (Nemeth et al, 2003; Phillips et al, 1994) and almost 70% citing it as the worst aspect of having an ulcer (Hofman, 1997), it is not surprising that the impact of pain on quality of life is significant (Moffatt and Franks, 1998).

Despite evidence suggesting that pain delays wound healing (Pediani, 2001) it is often low on the list of nursing priorities (Roe et al, 1993). Inadequacies in care may be because pain theory is poorly understood (Kitson, 1994) or because nurses have preconceived ideas about pain (Ketovuori, 1987). Studies have also suggested that nurses underestimate pain in wound care (Choiniere et al, 1990) and that they have an insufficient understanding of analgesic interventions (Senecal, 1999). Some nurses fail to understand that pain can be an ongoing component of venous disease (Husband, 2001), while others assume that arterial ulcers are more painful than venous ones (Moffatt and Franks, 1998).

Understanding pain

Although pain is a very personal experience it is possible to classify it into two types according to its physiological origin:

- Nociceptive -caused by tissue damage or disease outside of the nervous system;

- Neuropathic - caused by damage to, or disease within, the nervous system.

Acute pain is usually nociceptive; it is a symptom of injury or disease and usually ceases when the underlying problem is resolved (Fowler, 2003). Chronic pain can be nociceptive and/or neuropathic. It is distressing because it is so persistent, often continuing long after the original tissue damage has resolved. The causes of pain are often multiple, which is a challenge in the assessment and management of ulcers. Neuropathic pain, which features strongly in chronic pain, can be sensory, motor or autonomic in origin.

Sussman (2003) identifies a third type of pain, and this relates to the emotional pain that people with leg ulcers experience; it is psychological in origin but can be associated with physical symptoms such as malodour.

How a patient experiences pain can have its basis in a multitude of psychosocial and environmental factors such as gender, education and history of previous pain (Walding, 1991). Pain associated with leg ulcers can be categorised in four ways:

- Background pain - relates to the underlying ulcer aetiology, local wound factors such as ischaemia or infection and associated pathologies such as rheumatoid arthritis. The pain is felt at rest and may be continuous or intermittent;

- Breakthrough pain - caused by specific incidents, such as knocking the ulcer;

- Procedural pain - relates directly to routine wound procedures such as wound cleansing;

- Operative pain - arises from surgical interventions (World Union of Wound Healing Societies, 2004).

Although evidence relating to the nature of pain experienced by patients with mixed aetiology ulcers is limited, it is reasonable to suppose that given there is both arterial and venous involvement, patients may experience pain related to either or both pathologies. The pain will not be twice as bad but there are more possible causes of pain to consider. Some possible pain triggers are identified in Box 1.

Assessment

The cause(s) of pain and its effects are inextricably linked and must be considered together for pain management to be effective. Assessment must take account of ulcer aetiology, the type/nature of the pain, patient behaviour, clinical signs and symptoms, plus methods of relief.

Description of pain - Assessment should include the patient’s own description of the pain and factors such as its intensity, frequency, duration and the timing of episodes. Pain that is neuropathic-related is often described as burning, tight or aching in nature, while nociceptive pain may be described as cramping, gnawing or sharp. When assessing patients with mixed aetiology ulcers expect to hear a combination of descriptors relating to both pathologies.

The timing and frequency of occurrence is important. Waking in the night with pain relieved only by hanging the legs down over the edge of the bed is a common description (and symptom) of arterial pain (Benbow, 2003). It may occur every night at about the same time and is triggered by raising the legs up in bed.

In other instances, pain may result from procedural or exercise-related triggers or something as seemingly innocuous as the brushing of some clothing across the skin.

Ulcer-related pain can result from heightened sensitivity in the wound bed (primary hyperalgesia) or in the surrounding area (secondary hyperalgesia), particularly in chronic wounds where there has been a prolonged inflammatory response (WUWHS, 2004).

Nurses must be aware that the pain experienced by some patients as a consequence of apparently innocuous stimuli, such as changes in pressure or temperature (a condition known as allodynia), can be excruciating.

Whatever the severity of the pain it is important that trends in intensity are measured so that the effectiveness of pain-relieving strategies can be assessed. Pain scales can be used to do this (WUWHS, 2004) and include a visual analogue scale, a numerical rating scale and a verbal rating scale. When selecting a pain scale, it is important to take patient preference into account and the patient’s ability to read and use the scale. The same scale must always be used so that comparisons between assessments can be made.

Self-assessment tools, such as pain diaries, can yield valuable information and give the patient an active role to play in the assessment process.

Patient behaviour - A patient’s non-verbal behaviour can provide information about pain; for example, grimacing, tensing and withdrawal. There may also be a change in usual function, such as loss of mobility or the development of incontinence. Sussman (2003) suggests that non-verbal expressions of pain may include missed appointments and non-concordance.

Clinical signs and symptoms - A thorough wound assessment will have identified relevant clinical signs and symptoms influencing the development of ulcer-related pain. These could include signs of infection, oedema, eczema and exudate-related excoriation. There could also be some localised erythema indicating an allergic reaction or signs of scratching due to discomfort or irritation in the area.

When an ulcer has already been identified as being of mixed aetiology it is particularly important to be alert to clinical signs that might indicate a further deterioration in vascular status. These include an increase in pain, a falling ankle brachial pressure index, reduced skin perfusion, cool limbs and extremities and reduced tolerance to exercise. An urgent specialist opinion should be sought if vascular status is of concern.

Pain relief - Patients should be asked what relieves their pain. Health professionals should be wary of discontinuing anything that the patient feels very positive about.

Ways of minimising pain

Ulcer cleansing: check the temperature of the fluid used; if washing the ulcer do not immerse/withdraw the limb too quickly and do not leave it to soak because of the theoretical risks of cellular damage from prolonged contact with water. The absorption of fluid into the skin tissues leads to an increase in exudate, and the cooling of fluid causes a delay in cellular division, which has an impact on ulcer healing.

Dry the limb gently by patting it with soft, fibre-free wipes. Where possible allow patients to care for themselves and do not cleanse the ulcer bed unless this is necessary.

Dressings: removing a dressing and/or changing one is the most common pain trigger with chronic wounds (Meume et al, 2004; Moffatt et al, 2002; Hollingworth and Collier, 2000) and the point at which the most severe pain is reported.

To counteract this, select dressing products with low-adherence components such as hydrofibres, hydrogels, silicones and hydrocolloids. Check that the dressings match the wound type and that they remain effective under bandaging. Avoid dressings with adhesives when the surrounding skin is fragile. If adhesives are necessary, avoid removing them frequently, as this can cause trauma.

Consider the volume of exudate produced by a wound, as effective exudate management is important to avoid maceration or excoriation of surrounding skin. An unpleasant drawing sensation can occur when highly absorbent dressings are used on low-exudate wounds.

Observe for signs of an allergic reaction and read the manufacturer’s instructions to see how to use products correctly.

Protecting peri-wound skin: Using non-sting barrier sprays and keyhole dressings can protect fragile skin from adhesive/exudate damage.

Analgesia: this should address both nociceptive and neuropathic pain. The analgesic ladder (WHO, 1996) is a pain relief pathway that starts with using non-opioid analgesics for mild pain and progresses to opioid analgesics for moderate to severe pain (Box 2). At all stages, non-opioid/adjuvant drugs can be used to maximise relief. In addition, some non-analgesic drugs, such as anticonvulsants and tricyclic antidepressants, can help in the management of neuropathic pain.

Constant background pain requires regular medication, with the addition of appropriate analgesics before known pain triggers such as wound cleansing. Some patients find non-steroidal anti-inflammatory drugs (NSAIDs) given before an intervention are particularly good at managing post-procedural pain.

Entonox (50% nitrous oxide and 50% oxygen) is a self-administered, inhaled gas that can be useful for procedure-related pain because it enables patients to retain control over their situation. However, regular use may risk the development of side-effects (Pediani, 2003).

Topical opioids can reduce pain in wounds owing to the presence of opioid receptors on peripheral nerve endings (Flock, 2003; Zeppetella et al, 2003; Twillman et al, 1999). Evidence for their use with leg ulcers and of best practice in dosage and application is limited, therefore specialist advice must be sought.

Topical anaesthetics may be effective in the management of pain associated with debridement (Briggs and Nelsen, 2003). However, sharp debridement is not usually appropriate for mixed aetiology ulcers because of the underlying arterial disease.

Diversion/distraction: diversion tactics can be useful in pain management, especially when used in combination with analgesic interventions. Distraction can be achieved through audio or visual means, such as radio or television, or simply by chatting to the patient.

Pets can also be an excellent way of reducing anxiety (which can lead to increased pain) even if they cannot be present during a clinical procedure.

Education and information can also help by improving patients’ understanding of the care they are receiving (Wright and Shirey, 2003). Relaxation techniques can be useful, while Fowler (2003) suggests giving patients breaks during procedures to help them regain composure during moments of severe distress.

Conclusion

The assessment and management of pain in patients with mixed aetiology ulcers is complicated by the presence of not one but two aetiologies. However, once pain has been identified it is incumbent on health professionals to act on their findings as a matter of priority.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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