VOL: 97, ISSUE: 14, PAGE NO: 57
Alison Howard, RGN, RSCN, is a children's community nurse, South Peterborough Primary Care NHS TrustAlison Howard, RGN, RSCN, is a children's community nurse, South Peterborough Primary Care NHS Trust
The importance of effective pain management is often underestimated. In children the pain experienced after surgery can have a direct and often devastating psychological impact, and it will also have a physical and an emotional effect on their immediate family (Carter, 1995).
Many children will be discharged from hospital with a wound that will require management in the community. These wounds will be due to surgery, for example following an appendectomy or orthopaedic procedure, or the result of trauma, such as burns or abrasions.
While early discharge of a child to the home environment has obvious benefits, pain management in the community can present a number of challenges to the children's community nurse (CCN). For example, types of analgesia are more limited in the community than in hospital, it is unlikely that stronger analgesics will be prescribed on discharge, and there are often constraints on the time available to spend with a single child.
It is at dressing changes that the CCN will have most contact with a child (Teare, 1997). This is also the point at which the child is likely to experience the greatest pain (Hollinworth, 1995; Moody, 1992).
Response to pain
The psychological effect of pain and anxiety experienced during a change of wound-dressing will depend largely on the individual child. It should not be assumed that children of a similar age who undergo a similar procedure will experience the same degree of pain (Carter, 1995; Hollinworth, 1995). The child's age, their experience in hospital, the nature of the surgery or trauma resulting in the injury and experiences at previous visits will all influence how they will react when the CCN walks through the door. The attitude of the parents or other family members will also play a part.
It is extremely important to spend time talking to all the family members who are involved in the child's care. An explanation of all procedures should be given to carers and to the child at an appropriate level for his or her age. However, spending too much time on explanations before a dressing change may add to the child's anxiety, and nurses should use their knowledge of the child and the family to judge whether some questions should be answered once the procedure has been completed (Teare, 1997). It is important to remember that the child's experience of wound management will influence how they react to health service personnel in the future.
In order to effectively manage wound pain it is necessary to assess the level of pain being experienced (Broughton et al, 1998; Llewellyn, 1996; Carter, 1994). Physiological signs, such as an increase in pulse rate and blood pressure, pallor and sweating, provide some indication that the patient is in pain, but this type of observation should be used mainly to supplement a more objective assessment.
The child is the best person to evaluate his or her pain levels, although this may be difficult to quantify in young children. A variety of pain assessment tools is available which, when used carefully in conjunction with listening to the child and observing their behaviour, allow a reasonable estimate of the pain being experienced (Llewellyn, 1996; Carter, 1994) [Fig 1].
The parents' perception of their child's pain must also be taken into account, as they will have a greater awareness of how their child reacts to pain (Carter, 1995).
The most accurate picture of the child's level of pain will be achieved by combining the information gained from all methods of assessment. However, it is the child's perception that should always take precedence, unless fear of other interventions - for example, an injection - is obviously influencing reporting (Hodges, 1998; Llewellyn, 1996; Carter, 1994).
The results of the assessment should be documented at each dressing change so that there is a basis for any alteration to the wound care regime or analgesia.
Analgesia tends to be underused after surgery, and this is most acute among children (Pediani, 1994). The reasons for this are complex but may include a fear of overdosing the child or causing distress by administering an injection. Few nurses would suggest that children do not feel pain, but it could be argued that this opinion prevails, as pain is often ignored (Boden, 2000). It is possible that the work or stress associated with administering further analgesia or reviewing a regime might encourage the nurse to be too ready to take children's statements that they are painfree at face value (Boden, 2000; Hodges, 1998; Teare, 1997).
Working in the community can present further difficulties which need to be overcome if the child is to receive adequate analgesia before a change of dressing. In addition to the fact that certain stronger analgesics may not be readily available, the timing of visits is a significant factor. Gauging the best time to administer analgesia before changing a wound dressing can be problematic and parental cooperation is essential wherever this is possible. Analgesics such as paracetamol or ibuprofen, when administered half to one hour before the change of dressing, are often enough to control the pain.
Generally speaking, parents are familiar with the use of these drugs and feel confident to administer them as directed by the nurse, but planning the daily nursing workload so that visits happen exactly as intended is difficult. Mobile phones are essential to ensure that analgesia is administered at the optimum time. In this way the nurse can contact the parents close to the time of the visit, so that unexpected delays are less likely, and advise them of the best time to give the analgesia.
If necessary, stronger analgesia can be prescribed by the GP. However, if the level of pain at a dressing change is very severe then the appropriateness of caring for the child in the community needs to be considered.
Choice of dressing
The wound contact material used can contribute to the degree of pain that is associated with a wound, particularly that experienced at dressing changes (Hollinworth, 1995; Teare, 1997; Williams, 1996). It is important that an appropriate dressing is used. In the community this will also need to be available on prescription. While some of the newer wound contact materials may appear to be expensive, when assessing overall costs this should be balanced against the length of time that the dressing can stay in place, its effectiveness and the impact these will have on nursing time.
Wound contact materials frequently used in the author's area of work include alginates, hydrocolloids, film and foam dressings.
When applied appropriately alginates are comfortable and easy to remove, causing minimal discomfort (Dale, 1997; Thomas, 2000). Hydrocolloids can be left in situ for a number of days, thereby reducing the frequency of dressing changes, benefiting the patient and the nurse.
Clear film wound contact materials can reduce the degree of pain experienced as a result of nerve stimulation in partial thickness burns and abrasions (Hollinworth, 1995). They also allow the wound to be monitored without the need to remove the dressing.
It should be noted, however, that some children and adults will be distressed by the fact that they can see the wound. This type of wound contact material also needs careful removal to minimise discomfort (Dale, 1997; Hagelgans, 1993).
Foam dressings can be useful to manage exudate and thereby minimise the need for frequent dressing changes. Where possible, the use of adhesive tape to secure a dressing should be avoided, as this can cause discomfort on removal.
In the community the most appropriate wound contact material will sometimes differ from what would be chosen in hospital. This is because there is often not the same degree of nursing input in the community, dressings have to stay in place for longer and the possibility of slipping or leaking has to be minimised. It is also very important that the dressing is acceptable to the patient to minimise interference and removal when the nurse is not present (Teare, 1997).
Changing the dressing
An advantage of early discharge is that children are usually more relaxed in the home environment. This, in turn, can lead to less anxiety at dressing changes and therefore a reduction in pain levels (Llewellyn, 1996; Carter, 1995).
It is important to gain the trust and cooperation of the child before changing the dressing. How this is achieved will depend on the individual and the experience of the nurse, but dolls, books and videos can be used to build a rapport and understanding. If the child and other significant family members trust the nurse to stop if requested to do so this will help to reduce anxiety associated with the procedure. If the child is old enough to understand this, it will help them to feel more in control of the situation (Teare, 1997; Hollinworth, 1995).
If the child and parent wish to be involved in changing the dressing this should be encouraged where appropriate. The child may want to remove the dressing and watch the whole process. However, some children cope better if they are distracted - for example, with a favourite toy or video. Parents and siblings can be involved in this. It is also helpful if the nurse has a small supply of toys or books, as the novelty of a different toy can be useful.
If the child is old enough it might be helpful in some instances to leave certain uncontaminated pieces of equipment, such as a gauze square, behind to encourage familiarity.
A family-centred approach to care will help to ensure that all people who want and need to be involved are accommodated in order to reduce unnecessary anxiety and pain. In some cases it is appropriate for a parent to learn how to do the dressing with appropriate support from the nurse.
Pain can contribute to delayed wound-healing and cause considerable distress. It is therefore of paramount importance that it is managed effectively. The exact level of pain experienced may be difficult to assess in very young children, but with the cooperation of the family and child a useful estimation is possible (Twycross, 1998).
The cooperation of the family is essential when caring for a child in the community and the nurse needs to spend the time necessary to achieve this. It is also important that visits are carefully planned to coincide with the optimum analgesic effect.
As Rossiter states (1997), 'the child's emotional needs must be met and dressing changes must be pain- and anxiety-free if wound care is to be successful'.