Wound pain is often underestimated and poorly managed. A variety of techniques can be used by health professionals to improve its assessment and management
Wound pain is often underestimated and poorly managed. This article explains the different types of pain and how to assess wound pain, and gives practical advice on how to manage or minimise the pain experienced by patients with wounds.
Citation: Brown A (2014) Strategies to reduce or eliminate wound pain. Nursing Times; 110: 15, 12-15.
Author: Annemarie Brown is nursing lecturer, BSc Adult Nursing, Department of Health and Human Sciences, University of Essex, Southend on Sea.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF, including any tables and figures
Patients with wounds often experience pain. However, there is evidence that this is often underestimated or mismanaged by health professionals (Herr, 2011; Hirsh et al, 2010).
- The type and intensity of wound pain a patient experiences is influenced by many physical factors, including:
- The cause/site of the wound, as in arterial leg ulceration, where circulation is reduced;
- Oedema due to allergic reactions or as a result of the inflammatory response;
- Wound debridement;
- Poor dressing techniques;
- The use of inappropriate dressings (European Wound Management Association, 2002).
In addition, there are many psychological and emotional factors associated with living with a wound that can affect patients’ perception of pain, such as anxiety, stress, fear and depression (Vuolo, 2009). Living with chronic wound pain, particularly when wound malodour or high exudate levels are present, can result in reduced self-belief, isolation and loss of identity; many patients also experience sleep disturbance, which further reduces their pain tolerance (Mudge et al, 2008; Soon and Acton, 2006).
Definition of pain
Pain is an unpleasant sensation and is felt as a result of the brain’s response to disease or damage to the body. There are different types of pain.
This arises from damaged tissue. Signals are picked up by sensory receptors in nerve endings in the damaged tissue. The nerves transmit the signals to the spinal cord, and then to the brain where the signals are interpreted as pain, which is often described as aching or throbbing.
This is caused by damage to or dysfunction of the nervous system, and is a major contributor to chronic pain. It differs in character from nociceptive pain and patients describe it as burning, tingling or shooting (Mudge and Orsted, 2010; World Union of Wound Healing Societies, 2004; EWMA, 2002).
Patients with wounds often experience a combination of nociceptive and neuropathic pain. Nurses should be aware that a new or unexpected type of pain developing could be the sign of a wound infection.
Signs of neuropathic pain are listed in Box 1 and signs of nociceptive pain in Box 2.
Box 1. Recognising neuropathic pain
- Is the skin or the wound abnormally sensitive to touch?
- Are there unpleasant sensations when the skin is lightly stroked?
- Does the pain feel like pricking, tingling, or pins and needles?
- Does the pain come on suddenly in bursts for no apparent reason?
- Has the temperature in the painful area changed? Does “hot” and “burning” describe these sensations?
Adapted from Bennett (2001)
Box 2. Recognising nociceptive pain
- May be due to an underlying condition such as ischaemia or tissue damage
- May be due to prolonged time for healing of a serious trauma, such as post-burn injury
- Caused by inflammatory markers that occur on injury
- Presents as “nagging”, “throbbing” or “gnawing” pain
Adapted from White and Harding (2006)
Pain caused by wound infection
Pain as a result of wound infection is caused by the inflammatory response, which is triggered when there are microorganisms in the wound. In the presence of high levels of bacteria, white blood cells release enzymes and free radicals, which cause tissue damage.
Pain may result from direct stimulation of peripheral pain receptors, tissue damage and from the swelling that occurs as part of the inflammatory response. Pressure ulcer infection is associated with increasing pain severity and/or change in nature of pain (Mudge and Orsted, 2010; EWMA, 2006; 2002).
In surgical wounds, infection is associated with unexpected pain/tenderness that begins or increases around the wound area. If the area surrounding the wound is painful to touch, this should be a cause for concern. Infection in burns and partial/full thickness wounds is associated with the onset of pain in a previously pain-free wound. Any sudden onset of pain, change in type of pain or increase in intensity of pain in any wound type is therefore a significant indicator for infection (Cutting et al, 2005). Types of wound pain are outlined in Table 1.
Assessing pain should form part of an initial assessment and must be an ongoing process to ensure management strategies are effective.
A pain history should include intensity, quality, location(s) (including radiation), pattern (including onset, duration and frequency), and aggravating and relieving factors (Hadjistavropoulos et al, 2007; Herr, 2005).
Non-verbal cues, such as guarding the wound area, grimacing and restricted movement, should also be noted, particularly if the patient is not able to provide a description of the pain. In some cases, it may be necessary to gather information and a history from other sources, such as the primary caregiver (Herr, 2005).
Psychological aspects of pain
It is now recognised that pain is complex and is influenced by many factors including emotions, social background, the meaning of the pain to patients, together with their beliefs, attitudes and expectations (Price, 2006).
For example, many older people believe that pain is normal with old age and may refuse to take analgesia (Price, 2006). Worrying about the reason for the pain is common and, when it is not effectively managed, as may happen in chronic wounds, patients can become depressed, have poor concentration, poor sleep quality and may fear movement, which in turn leads to functional limitations and increasing disability (Mason, 2009).
Prior experiences of pain will also affect patients. For example, a patient who has previously experienced pain on dressing change will anticipate the pain each time a dressing is changed and will become anxious and tense, resulting in an increase in pain experienced.
Pain assessment tools
There are several pain measurement tools available to help patients communicate their level of pain and to allow levels to be monitored over time, with any changes highlighted.
The simplest example is the visual analogue scale (VAS), which asks patients to indicate the severity of their perceived pain on a straight line graded from “no pain” to “worst possible pain”. Other basic pain assessment tools include numerical/descriptive colour scales and pain faces (Douglas and Way, 2006).
In addition, there are a number of validated tools, including the McGill Pain Questionnaire, which asks specific questions about patients’ pain experiences and can provide valuable insight into the nature of their pain and its effect on quality of life (Melzack, 1975).
Pain scales are also available for patients with dementia, such as the Pain Assessment for the Dementing Elderly (PADE) (Villanueva et al, 2003) and the Pain Assessment in Advanced Dementia (PAINAD) Scale (Warden et al, 2003).
Pain diaries are also useful in trying to understand how pain affects a patient on a day-to-day basis (Hockenberry et al, 2009).
Pain related to dressing changes
Many patients experience pain on dressing removal or change, which is largely preventable with the use of appropriate products (EWMA, 2002). EWMA (2002) found that:
- Dressing removal is considered to be the time of most pain, followed closely by wound cleansing;
- Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes;
- Gauze is most likely to cause pain, while products such as hydrogels, hydrofibres, alginates and soft silicone dressings are least likely;
- Supporting the surrounding skin during dressing removal is not considered a priority, despite evidence that many adhesive products may lead to skin stripping and potential skin trauma and pain (Dykes et al, 2001);
- Health professionals ranked venous leg ulcers as the most painful wounds, and superficial burns ranked second. They ranked infected wounds, pressure ulcers, cuts and abrasions, paediatric wounds, cavity and fungating wounds as less painful wounds (adapted from EWMA, 2002).
The principles of wound pain management apply to any painful wound. The appropriate use of analgesics alone and in combination is key to minimising pain (Price et al, 2008; World Union of Wound Healing Societies, 2004).
Several analgesic regimens may be required for the different types of pain, for example background pain, pain arising from wound procedures, and neuropathic and nociceptive pain. Unfortunately, not all wound pain responds to systemic analgesics and studies have revealed that there is often a stigma attached to the use of pain-relieving medication. This includes fear of polypharmacy and dependency or addiction, particularly in older patients (Herr, 2011; Vuolo, 2009).
Senecal (1999) adapted the World Health Organization (1996) analgesic ladder for use in wound pain; the recommended steps given in Box 3 are a useful guideline for adjusting the strength and dose of analgesia to the level of pain.
Box 3. Steps in wound pain analgesia
- Step 1 Use non-steroidal anti- inflammatory drugs such as aspirin/ ibuprofen ± local anaesthetic such as Emla cream
- Step 2 Add a mild opioid such as codeine (use oral medication if possible)
- Step 3 Replace mild opioid with potent opioid analgesic such as buprenorphine or morphine
Adapted from WHO (1996) by Senecal (1999)
These strategies are useful and can be employed alongside pharmaceutical methods, particularly if the patient is reluctant to take analgesia or the analgesia is poorly tolerated.
Time invested before dressing removal is time well spent. Talking to patients about how much pain they can expect, together with an explanation of measures that are in place to minimise their pain will help to reduce feelings of fear and anxiety.
Patients who feel more pain than expected from a procedure may become less confident about the nurse treating them and be more anxious about future dressing changes (Smith et al, 1997; Vingoe, 1994). Anxiety is thought to generate an autonomic response such as muscle tension and an increase in heart rate, while focusing on the pain, past experience and the meaning of the pain all contribute to the level of pain a patient experiences (Vingoe, 1994).
Smith et al (1997) have suggested some simple measures that can be used for reducing anxiety during painful dressing procedures (Box 4).
Box 4. Reducing pain relating to dressings
- Avoid applying products that can cause pain, such as gauze, knitted viscose, film dressings and paraffin tulle, as these tend to stick to the wound (Bethel, 2003)
- Avoid any unnecessary stimulus to the wound, such as draughts from open windows, prodding and poking
- Handle wounds very gently, being aware that any slight touch can cause extreme pain
- Avoid using adhesive dressings; if possible, choose a non-adherent wound product designed to minimise pain on removal, such as silicone-coated dressings
- Treat any wound infection appropriately and ensure that exudate is managed effectively
- Do not allow dressings to dry out
- Change as per manufacturer’s instructions and according to exudate levels
- Protect the surrounding skin using skin barrier creams/films. Excoriated wound margins caused by poor exudate management can cause considerable pain
- Allow patients to remove their own dressings if appropriate
- Reassure patients that you will stop the procedure if the pain is severe and allow “time-out” sessions if patients indicate they need it (Hollinworth and Hawkins, 2002)
Adapted from Smith et al (1997)
Any therapy that diverts the patient’s attention can help with coping with pain, particularly when changing dressings on children.
Listening to music, breathing and relaxation exercises, and providing a warm, calm environment, can help patients to relax.
Acupuncture and acupressure have been used for many years to manage pain (James, 2009). Although it is not clear how acupuncture works, it is believed that the needles allow endogenous opioids to be released in the body, which in turn improves local circulation (James 2009; Tsuchiya et al, 2007).
Touch therapy and massage can also help to reduce the intensity of the pain and can be performed by health professionals or family members.
Other techniques, such as transcutaneous electrical nerve stimulation and cognitive behavioural therapy, are also useful techniques to manage pain; however, these generally require specialist equipment or specific training.
Wounds will always be painful to some extent, but much can be done to control the impact of this pain on our patients.
Accurate initial and ongoing assessment, good preparation, adequate analgesia and the use of appropriate dressings can improve the patient’s ability to cope with pain.
Unfortunately, this important aspect of wound management is frequently underestimated and poorly managed. The direct benefit of pain relief on wound healing rates requires more detailed research, but simply showing respect, empathy and care to our patients is the essence of good healthcare. It is essential that practitioners are professionally competent, knowledgeable and motivated to act in the best interests of their patients.
- Pain in wound management is often under-estimated and ineffectively managed
- Pain assessment should form an intrinsic part of wound assessment
- Strategies to improve wound pain can be pharmacological and/or non-pharmacological
- Assessment of pain in wound care should be an ongoing process
- Distraction therapy can be particularly useful with children
Bennett M (2001) The LANSS pain scale: the Leeds assessment of neuropathic symptoms and signs. Pain; 92: 1-2, 147-57.
Cutting K et al (2005) Clinical identification of wound infection: a Delphi approach. In: European Wound Management Association (EWMA). Position Document: Identifying Criteria for Wound Infection. London: MEP.
Douglas V, Way L (2006) The assessment of wound pain: a review. Practice Nurse; 17: 11, 532-542.
Dykes PJ et al (2001) Effects of adhesive dressings on the stratum corneum of the skin. Journal of Wound Care; 10: 2, 7-10.
European Wound Management Association (2006) Position Document. Management of Wound Infection. London: MEP.
European Wound Management Association (2002) Position Document: Understanding Wound Pain and Trauma: an International Perspective. London: MEP.
Hadjistavropoulos T et al (2007) An interdisciplinary expert consensus statement on assessment of pain in older persons. Clinical Journal of Pain; 23: 1 (supplement), S1-S43.
Herr K (2011) Pain assessment strategies in older patients. The Journal of Pain; 12: 3 (Suppl. 1), S3-S13.
Herr K (2005) Pain assessment in the older adult with verbal communication skills. In: Gibson SJ, Weiner DK (eds): Pain in Older Persons. Seattle, WA: IASP Press.
Hirsh AT et al (2010) Evaluation of nurses’ self-insight into their pain assessment and treatment decisions. The Journal of Pain; 11: 5, 454-461.
Hockenberry MJ et al (2009) The use of a chronic pain diary in older people. British Journal of Nursing; 18: 8, 490-494.
Hollinworth H, Hawkins J (2002) Teaching nurses psychological support of patients with wounds, British Journal of Nursing Tissue Viability Supplement; 11: 20, S8-S18.
James S (2009) Non-pharmacological methods of pain control. In: White R, Harding K (eds) (2009) Trauma and Pain in Wound Care Vol 2. Aberdeen: Wounds UK.
Mason V (2009) Psychological factors of pain perception, communication and responses to treatment. In: White R, Harding K (eds) (2009) Trauma and Pain in Wound Care Vol 2. Aberdeen: Wounds UK.
Melzack R (1975) The McGill pain questionnaire: major properties and scoring methods. Pain; 1: 3, 277-299.
Mudge E et al (2008) A focus group study into patients’ perception of chronic wound pain. Wounds UK; 4: 2, 21-28.
Mudge E, Orsted H (2010) Wound Infection and pain management made easy. Wounds International; 1: 3.
Price P (2006) The psychology of pain and its application to wound management. In: White R, Harding K (eds) Trauma and Pain in Wound Care. Aberdeen: Wounds UK.
Price PE et al (2008) Dressing-related pain in patients with chronic wounds: an international perspective. International Wound Journal; 5: 2, 159-171.
Senecal SJ (1999) Pain management of wound care. Nursing Clinics of North America; 34: 4, 847-860.
Smith NK et al (1997) Non-drug measures for painful procedures. American Journal of Nursing; 97: 8, 18-20.
Soon K, Acton C (2006) Pain-induced stress: a barrier to wound healing. Wounds UK; 2: 4, 92-101.
Tsuchiya M et al (2007) Acupuncture enhances generation of nitric oxide and increases local circulation. Anaesthesia and Analgesia; 104: 301-307.
Villanueva MR et al (2003) Pain Assessment for the Dementing Elderly (PADE): reliability and validity of a new measure. Journal of the American Medical Directors Association; 4: 1-8.
Vingoe FJ (1994) Anxiety and pain: terrible twins or supportive siblings? In: Gibson HB (ed) Psychology, Pain and Anaesthesia. New York, NY: Chapman and Hall.
Vuolo JC (2009) Wound-related pain: key sources and triggers. British Journal of Nursing; 18: 15, S20-S25.
Warden V et al (2003) Development and Psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association; 4: 1, 9-15.
White R, Harding K (2006) Trauma and Pain in Wound Care. Aberdeen: Wounds UK.
World Union of Wound Healing Societies (2004) Principles of Best Practice: Minimising Pain at Wound Dressing-Related Procedures. A Consensus Document. London: MEP.
World Health Organization (1996) Cancer Pain Relief. Geneva: WHO.