VOL: 97, ISSUE: 28, PAGE NO: 63
Helen Hollinworth, MSc, BA, RNT, RN, is senior lecturer in nursing, School of Health, Suffolk College, IpswichIt is worrying that patients today continue to experience unnecessary wound pain. The reasons for this include inadequate assessment, the use of inappropriate strategies to cleanse wounds and the use of wound management products that cause trauma to the wound and surrounding skin.
It is worrying that patients today continue to experience unnecessary wound pain. The reasons for this include inadequate assessment, the use of inappropriate strategies to cleanse wounds and the use of wound management products that cause trauma to the wound and surrounding skin.
Although it is widely accepted that traditional dressings such as gauze and paraffin tulle may adhere to the wound causing significant pain on removal (Terrill and Varughese, 2000), those responsible for inflicting such pain often dismiss its significance.
In addition, a survey of almost 400 nurses confirmed there was considerable confusion over the various properties of wound management products (Hollinworth and Collier, 2000). This is a particularly pertinent finding because the nurses included in the survey had a special interest in wound care and tissue viability.
A postal survey sampled 1,000 members of two national UK wound care organisations in October and November 1999 (Hollinworth and Collier, 2000). They were asked to identify the main considerations that underpinned their approach to pain and tissue trauma during dressing changes, the strategies they used to avoid this and any factors that influenced their treatment choices. A total of 373 nurses responded with a response rate of 37%.
Practitioners' main considerations during dressing changes were preventing trauma to the wound and pain to the patient. Other considerations were preventing damage to the surrounding skin and the spread of infection.
The most common method of assessing wound pain was talking to the patient, monitoring facial expression and observing body language. However, personal coping strategies, such as distraction, can obscure visual expressions of pain.
It is also important to be cautious about using observation as the only means of assessing wound pain because there is a low correlation between nurses' assessment of non-verbal behaviour and patients' self-reporting of pain (Teske et al, 1983). A visual assessment of wound pain is also more complicated in people with confusion or mental illness. A visual pain scale can be a useful tool in such cases and when assessing children's pain (Fig 1)
It was worrying that few respondents to the survey used a pain assessment tool as nurses' views on the amount of pain patients are in correlate poorly with patients' own assessments (Singer et al, 1999).
Sources of pain
A significant number of respondents noticed that patients experienced most pain during removal of dressing products. While traditional dressings can cause considerable pain on removal (Hollinworth and Collier, 2000), hydrocolloids and foams with all-over adhesives can also cause pain and tissue trauma (Sussman and Bates-Jensen, 1998, Jones and Milton, 2000).
A few practitioners identified that pain was experienced during wound cleansing and while the dressing was in place. Cold fluids, wiping across the wound with gauze and high-pressure irrigation can also cause wound pain. In addition, alginates can give rise to a burning sensation on wounds with little or no exudate (Flanagan, 1997), and fibrous alginates can cause mechanical damage to fungating wounds (Grocott, 2000). Some hydrophilic dressings, such as sugar paste or a cadexomer-iodine dressing that exert an osmotic 'pull' on the wound bed, are also likely to increase pain (Hampton, 1997). The respondents identified leg ulcers, infected wounds, superficial burns, and superficial cuts and abrasions as wound types that were particularly painful during dressing changes. In several studies, patients have described pain as the worst aspect of leg ulceration (Walshe, 1995; Hofman et al, 1997). This can be exacerbated by the excoriation of the surrounding skin caused by exudate.
Chronic wound pain is often underestimated and poorly managed, according to Briggs and Hofman (1999), and similar concerns have been expressed about patients with surgical wounds (Loveman and Gale, 2000).
The presence of infection causes irritation of the nerve endings, which exacerbates pain.
Strategies to relieve pain
In this survey, the most common strategies used to overcome pain and trauma to the wound and surrounding skin were the selection of dressings that are non-traumatising and avoidance of adhesive products. Many practitioners soaked dressings before removal. However, this technique is rarely effective because granulating tissue often grows through traditional products, and viscous dry or drying exudate and dressing adhesives are rarely loosened in this way. Furthermore, wound healing principles advocate a moist rather than a wet wound environment, and soaking increases the risk of skin maceration and tissue trauma.
Giving prescribed analgesia before a dressing change was a strategy often described in the survey, but it is neither effective nor good practice to use procedures or dressings that are known to cause pain. It is worrying that few practitioners consulted the patient or supported the skin during removal of adhesive products.
Many respondents were not aware of products designed to minimise wound pain and trauma during dressing changes and listed a wide range of products that are not designed for this purpose. In addition, there was confusion over the properties of different dressings and how they work.
The range of wound management products has increased dramatically in the past decade, but nurses need to understand the different properties of products if wound pain is to be prevented. This has added significance when considering the freedom of choice practitioners have. Nurses will need to extend their knowledge and practical skills in selecting dressings if they are to retain such autonomy.
The survey findings, together with the many potential causes of wound pain, emphasise the importance of the practical actions nurses can take to monitor and relieve wound pain.
Monitoring wound pain
Strategies that aim to monitor wound pain focus on assessment tools, and professional experience, but the patient must be central to any assessment of pain. Nurses can monitor wound pain by using a range of techniques.
Holistic patient assessment
A thorough holistic patient assessment that is carefully documented can underpin care. It is important to identify whether the pain affects a person's ability to sleep or partake in activities and find out whether anything exacerbates or relieves the pain. Dressing changes, topical applications, compression therapy and movement are possible factors.
Pain assessment tools are underused as a strategy to monitor wound pain, but although simple tools seem to be the most useful (Fig 1) it is important to be consistent with the method selected. The faces rating scale is useful for children and people with limited communication abilities and the five-point descriptive scale is easy to use with a predominantly elderly population.
Assessment tools should be used to monitor existing pain and at times when wound pain may be exacerbated, such as during dressing changes. Pain assessment must be acted on and strategies to relieve wound pain documented.
Observation of the wound and surrounding tissues as dressings are removed is also a useful method of monitoring wound pain. Dressings that have adhered to the wound are clearly difficult and painful to remove. Wound exudate that leaks onto surrounding tissues can cause maceration or excoriation and exacerbate eczema in patients with leg ulcers, often increasing pain.
Assessing the effects of the dressing
The patient should be assessed for tissue trauma and pain caused by adhesive dressings and tapes on delicate skin, particularly in the case of babies and patients on long-term steroids.
During bandage removal, nurses should visually assess for pain from pressure damage over bony prominences, the bunching together of bandage layers and ridges or restricted movement that can be caused by bandages that are too tight.
Wound pain may be linked to aetiology, for example ischaemic wounds, and it is important that nurses recognise this. It is also important not to dismiss pain in deep cavities or pressure ulcers and in venous leg ulcers.
Some textbooks state that deep wounds and venous leg ulcers are not painful. However, moderate to severe pain was reported by patients during cavity-wound dressing changes (Gates and Holloway, 1992), and venous leg ulcers cause excruciating pain.
Unexpected pain stimuli
Even after a wound or ulcer has healed, wound pain may still occur. It can also be caused by a stimulus that does not normally cause pain, such as movement of air and temperature changes.
Compression therapy may initially exacerbate leg ulcer pain, as can the use of other therapies, so it is important to check patients' and carers' understanding of treatment strategies. It is critical that existing pain is controlled before embarking on further treatments options.
Patients' reluctance to continue with treatment may be linked to wound pain. The adhesive properties of some products can cause allergies, especially in patients with leg ulcers, and iodine products can sting on application.
It is important to assess the wound for signs of infection while recognising that some clinical indicators may not be present in elderly people, those with diabetes and other immunocompromised patients. Pain in and around a wound that has, up until the assessment, been healing can be an early indicator of infection.
Nurses should be sensitive to patients' needs and have a positive regard for the individual. Many patients, particularly older people, prefer not to complain. Previous negative experiences of poorly managed wound pain can leave a lasting impression. It is essential to take time to listen to patients and explore their experiences.
Fungating wounds, trauma and burns all have significant implications for altered body image. Such wounds give rise to psychological as well as physical wound pain, so professionals need to take this into account.
Other indications of pain can be observed from a patient's reactions. Does the patient flinch, grimace or pull away when the dressing is being changed? Does the patient appear stressed or anxious, or express concern that the wound care or dressing procedure will be painful? It is worth remembering that people with Alzheimer's or Parkinson's disease may not give any visual indications of pain. Wound pain in babies can be assessed by heart rate and cries (McGrath, 1997).
Alternative strategies for wound assessment
It is important to use touch where appropriate. Black skin can be difficult to monitor for visible indicators of pain but heat, hardness and oedema can all be detected by gentle touch.
Strategies to relieve wound pain
Practical strategies to relieve wound pain can be divided into pharmacological interventions non-pharmacological interventions, and wound management strategies. A combination is often needed, but the value of pre-emptive analgesia needs to be recognised.
Opiate analgesics play an important role in relieving severe wound pain, but it is vital to ensure that unsubstantiated fears of opiate addiction do not influence decisions to provide adequate pain relief.
Sustained pain control can be achieved with opiate patches, slow-release tablets or an intravenous or spinal infusion, and nasal diamorphine has proved a safe and effective alternative (Kendall et al, 2001). The advantages of intravenous opioids are predictable absorption and rapid onset, but in practice the intramuscular route is still commonly used.
Simple analgesics such as paracetamol, and non-steroidal anti-inflammatory drugs such as ibuprofen, may effectively relieve less severe wound and ulcer pain. These over-the-counter remedies provide a practical way of returning control of pain relief to the patient, but nurses may still need to encourage them to take adequate analgesia and emphasise that pain control before wound care usually means less pain afterwards.
Nitrous oxide and oxygen is another practical and rapid method of managing wound pain and offers the advantage that the patient has control over the medication. This method can also be taught to children for managing wound pain. A patient directive should be in place to ensure safe practice (Street, 2000).
Local anaesthetic creams can be used topically to reduce wound pain effectively, but this group of products is not licensed for use on open wounds. They can cause itching and burning, and the effect on healing is not clear.
Patient involvement in wound care is a practical and effective strategy for relieving pain. Adults and children can be encouraged to help loosen and remove bandages and dressings, usually under supervision to prevent the spread of infection. This approach is effective, even with pain caused by burns.
Giving the patient information - perhaps about the procedure or dressings used - reduces stress. For example, the progress of healing can be demonstrated through consecutive wound tracings or photographs which, together with a sensitive approach to care, can contribute to controlling the pain and helping the patient to feel involved. Talking to the patient can reduce anxiety and, consequently, wound pain.
Other practical measures to relieve pain include taking care when positioning patients ensuring that they are warm and comfortable, providing appropriate pressure relief, and promoting rest and sleep. Careful use of appropriate aromatherapy oils can reduce odour and create a more pleasant environment.
Distraction techniques such as listening to music, encouraging relaxation and the involvement of a play therapist in the case of children can contribute to reducing wound pain. Transcutaneous electrical nerve stimulation can also help. However, these strategies may not be effective if pain increases suddenly and often need to be used in conjunction with appropriate analgesia.
Psychological support, gentle touch and a sensitive wound care technique are important. Sometimes the presence of a loved one can help, but nurses must ensure the individual is comfortable with this role.
Wound management strategies
The methods used to cleanse and dress wounds are among the most practical procedures to relieve wound pain. If cleansing is necessary, irrigation with warm isotonic saline or tap water (rather than wiping across the wound with gauze), using gloved hands rather than forceps, and minimising the length of exposure can help to prevent wound pain.
Odour control can contribute to relieving the psychological effects of wound pain. Malodour is often caused by micro-organisms invading devitalised tissue. These can be removed by autolytic debridement, using a hydrogel or hydrocolloid, or sharp debridement using scissors or a scalpel.
However, considerable expertise is necessary to carry out such debridement and wound pain can be exacerbated if nerve receptors in viable tissue are stimulated by invasive instruments.
Products that contain charcoal cease to be helpful when they are saturated with wound exudate. In some cases occlusion may control odour more effectively (Grocott, 2000).
There are a number of practical ways that nurses can help to relieve wound and leg ulcer pain: using adequate paddings under compression bandages; using cotton compression bandages and hosiery to minimise allergies; paying attention to bandaging techniques and, perhaps, using a cohesive bandage to prevent slipping.
Pain from excoriated tissue can be reduced by protecting the skin with a barrier such as white soft paraffin, a hydrocolloid dressing cut to frame the wound or a barrier film dressing.
A number of dressings can be used to relieve wound pain and tissue trauma. Alginates, for example Comfeel Seasorb, Sorbsan or Kaltostat, are useful alternatives to products traditionally used to gently pack cavity wounds (Morgan, 1996).
Alginates interact with wound exudate to form a moist gel at the wound interface. This bathes exposed nerve endings and is usually painless during dressing change. However, alginates may dry out and adhere to the wound if the level of exudate reduces. They usually require a secondary dressing.
Hydrogels, for example Aquaform, Nu-Gel or Intrasite Gel, are another type of dressing that can be used to reduce wound pain. They are painless to remove and can be used on a wide range of wounds. The use of hydrogels, including in sheet form, should be considered carefully in heavily exuding wounds because maceration of the surrounding tissues can occur. The potential problem of trauma to the surrounding skin is compounded by the need for a secondary dressing, often with adhesive properties.
Many dressings products incorporate an adhesive or have adhesive properties, including vapour-permeable films, hydrocolloids and foams. Because they exclude air and retain some moisture at the wound surface, they have the advantage of preventing the spread of infection and relieving pain.
However, adhesives can cause pain and tissue trauma on removal, especially if the patient is on steroid or radiotherapy treatment or has eczema. A practical tip is to stretch film dressings parallel with the skin and support the skin with the other hand when removing such dressings.
The pros and cons of using adhesive products should be carefully considered if frequent dressings changes or observation of wounds in patients with diabetes are indicated. A new foam adherent dressing that has a silicone wound contact layer (Mepilex) has the potential to overcome these problems.
A hydrocolloid presentation that absorbs wound exudate directly into the fibres, creating a soft cohesive mass of gel (Aquacel), has been shown to reduce pain in a range of wounds and is easy to change compared with traditional products (Robinson, 2000). As with alginates, a secondary dressing is needed.
Soft silicone (Mepitel) has been shown to reduce the wound pain experienced by children with partial-thickness scalds at dressing changes, with significantly faster healing rates (Gotschall et al, 1998).
Under normal conditions of use, soft silicone can be removed from even the most fragile or sensitive tissue without causing pain or trauma. The dressing is left in place for seven days or more, with only the secondary dressing being changed.
While more expensive than traditional products, the extended wear time and the dressing's acceptability to the patient means these dressings are cost-effective, especially when the alternatives of delayed healing and the cost of analgesia are taken into account. However, it is important for practitioners to differentiate between this product and those coated with silicone, such as N-A Ultra.
Although wound pain is a complex issue, it may be trivialised or treated without a comprehensive assessment. Wound pain can affect patients' willingness to continue with treatment and can significantly affect the quality of their life. There are many practical approaches that nurses can take to monitor and relieve patients' wound pain, thereby enhancing their care and management.