Professional Documents
Culture Documents
Minimizing pain in
wound management
I
n response to the Francis report (2013), having the potential to contribute to anxiety Julie M Day
commissioning groups have been advised to and depression (Wounds International, 2012).
utilise valuable resources to improve quality The pain can arise from the wound itself (neu- discusses how the
and health outcomes, measure patient ropathic pain), wound treatments or be antici-
satisfaction and promote equality in health patory in nature (Solowiej et al, 2010). assessment of
(The Mid Staffordshire NHS Foundation Trust Wound assessment, undertaken by a skilled wound related pain
Inquiry, 2013; Department of Health (DH), and competent practitioner, is fundamental to
2013). The ambition to improve health-related planning care, with outcomes for the wound should be an
quality of life for people with long-term identified and monitored by ongoing assess-
conditions, is of particular relevance. It has ment (Wounds UK, 2008). The assessment integralcomponent
been identified that to meet the health needs of should include the assessment of wound- of wound
the population, competent staff are required related pain and the impact on the patients
with the ability to understand an individual’s quality of life. However, there is evidence to assessment
health and social needs, and with the expertise, suggest that pain assessment is often consid-
clinical and technical knowledge to deliver ered to be a low priority (Moffatt et al, 2002).
effective care and evidence-based treatments The intensity of the patient’s pain should
(NHS Commissioning Board et al, 2012). be investigated using a simple pain scale, such
Chronic wounds are considered to be a as a visual, numerical or verbal scale, or pain
long-term condition, with non-healing diary (World Union of Wound Healing
wounds having an impact on both mortality Societies (WUWHS), 2004). The description
risk and quality of life (Posnett et al, 2009). It of the pain, frequency and duration should
is estimated that approximately 200 000 indi- also be recorded, as this can guide the practi-
viduals have a chronic wound in the UK, of tioner to the cause. Patients use various terms
which 68% are treated in the community to describe the pain for example, ‘sharp’,
(Posnett and Franks, 2008). ‘stabbing’, ‘aching’ ‘throbbing’ (Enoch and
The Royal College of General Practitioners Price, 2004). The assessment of wound-relat-
(RCGP) (2012), together with an educational ed pain should be an ongoing process, so that
advisory group of experienced practice nurs- the effects of analgesia can be monitored and
es, has devised a competency framework for any subtle changes in pain can be identified.
a nurse to become a general practice nurse. Practice nurses undertaking university tissue
This document includes the assessment and viability modules reflect that the use of elec-
care of uncomplicated wounds, the selection tronic patient records make it difficult to record
and application of appropriate treatments all aspects of the wound assessment, and that
and wound care products, and the assessment they have been unable to access an appropriate
of wound-related pain. wound assessment proforma that is compatible
Therefore, there is an opportunity to reflect with computer systems. They reflect that impor-
on current practices in relation to the man- tant aspects of wound assessment are not
agement of wound pain and discuss evidence- included, and opportunities for continuity of
based practice in relation to the management care are missed.
of wound-related pain. In many cases practice nurses see patients in
10 minute time slots; thus limiting the poten-
Wound-related pain tial for an in-depth exploration of the com- JulieMDayisclinicalnursespecialist,
Wound-related pain is a significant problem plexities of wound pain. Furthermore, many Department of Vascular Surgery,
for patients with wounds, and studies have practice nurses work part-time (Mohammad, WorcestershireAcuteHospitalsNHSTrust
shown that this has a significant impact on 2009) and consequently a patient may not see
© 2013 MA Healthcare Ltd
their quality of life (Franks and Moffatt, 2001; the same practitioner on a regular basis, losing Submittedforpeerreview:20May2013;
Price et al, 2008). Wound-related pain affects the important element of continuity of care. acceptedforpublication30May2013
the physical, psychological, and social wellbe- The use of analgesia, and more importantly
ing of the patient, with the effects of pain the effectiveness of this, should be carefully Keywords:Chronicwounds,pain,wound
limiting physical activities, social contact and monitored to ensure that the patient is offered assessment, practice nursing
maximum relief for wound-related pain. contributing to wound pain, and can improve
Management of wound-related pain can the outcomes for patients by incorporating
offer complex challenges for the practitioner, early recognition and good assessment skills.
and in some cases patients with ongoing,
intractable wound pain may benefit from the Chronic inflammation
input of a specialist pain management team Chronic wounds are wounds which fail to
(Grey et al, 2006). progress through the normal stages of wound
In addition to analgesia, patients find strate- healing and often exhibit a prolonged inflam-
gies such as distraction, relaxation techniques, matory and proliferative stage of healing
information sharing, ‘time out’, and a compas- (Lazarus et al, 1994) (Figure 1). This can con-
sionate caring approach a helpful adjunct in tribute to wound-related pain (Acton, 2007). It
managing wound pain (Hollinworth, 2004). is important that nurses recognize chronic
All of these could be incorporated into wound inflammation; often it is confused with infec-
care practices as a matter of routine—compas- tion, and they can then reassure patients that
sion and caring are of course key aspects of this is part of the healing process, while taking
nursing. In some cases, patients prefer to appropriate measures to assess and monitor
remove the dressing themselves and where their pain. Informing patients of what to expect,
desired this could offer the patient a degree of together with an explanation of whatever meas-
participation and autonomy. ures are in place to minimize pain will help
There have been studies regarding the use of reduce fear and anxiety (Briggs et al, 2002).
Entonox (a gas mixture of 50% nitrous oxide
and 50% oxygen) to manage procedural pain Wound infection
(Pediani, 2003), with reported benefits for the There are subtle changes in pain when a wound
patients, including both a reduction in wound becomes clinically infected or critically colo-
pain and anxiety associated with anticipatory nized, during which patients report an increase
wound pain (Evans, 2004). Although Entonox in pain or a change in the nature of the pain
Figure 1 (top). Chronic is not used routinely in clinical practice, there (European Wound Management Association
inflammation is an opportunity to explore its use in the gen- (EWMA), 2005). A high bacterial load can
Figure 2 (bottom left). Wound eral practice setting following appropriate result in an increase in pain, even before the
critically colonized with training. signs of infection are observed (Bjarnsholt et al,
anaerobes Wound chronicity, infection, contact sensi- 2008). An increase in pain, unexpected pain, or
Figure 3 (bottom right). tivity, dressing trauma, wound exudate, wound change in the nature of pain is a key factor
Contact sensitivity cleansing, temperature fluctuations, compres- indicating the presence of infection (Gardner et
sion therapy and ischaemia al, 2001). These subtle changes have the poten-
can contribute to wound tial to go unnoticed when different practitioners
pain (Hollinworth, 2004; review the wounds, and an ongoing pain assess-
Price et al, 2008). From ment tool has not been utilized.
clinical practice experienc- Once assessment has been carried out and
es it is evident that patients the wound is considered to be critically colo-
with hypergranulating nized, or to have local or spreading infection,
wounds experience signifi- topical antimicrobial agents and/or antibiot-
cant wound pain. ics can be started (Wounds UK, 2010).
This article will consid- Patients with a wound that is critically colo-
er how practice nurses can nized with anaerobes often express an increase
help to identify factors in wound-related pain, as well as increased
distress and anxiety at the associated odour,
contributing to an adverse affect on their their
quality of life (Figure 2). Pain can be reduced
with the prompt treatment of the anaerobe
infection with topical metronidazole gel.
Some patients can develop a reaction to a
wound care product, which contributes to fur-
© 2013 MA Healthcare Ltd
wound care should be mindful that any wound on top of it. Ongoing assessment of the wound,
care product, emollient, or bandage can cause including dressing induced pain, should be
sensitivities, such sensitivities should be treated undertaken to identify and address areas of
promptly by discontinuing the particular prod- concern for the patient. As wounds progress
uct and applying topical corticosteroids (Bourke towards healing, and the exudate levels reduce,
et al, 2009; Joint Formulary Committee, 2013). the frequency of dressing changes should also
reduce to ensure minimal disturbance of the
Dressing trauma wound and disruption of wound healing.
Following a wound assessment, a wound care Inappropriate use of wound care products
product should be selected to meet the needs can have adverse effects for patients, the com-
of the wound bed, which includes reducing the bination of wound care products can cause
risk of infection and pain, and the manage- maceration and tissue damage and resultant
ment of wound exudate (Shorney and Ousey, pain for the patient (Figure 5).
2011). Wound care products can cause trauma
to the wound bed if they adhere or dry out, Exudate
which in turn causes pain for the patient and Chronic wound exudate contains elevated
can result in anticipatory wound pain, using levels of inflammatory mediators and acti-
atraumatic products significantly reduces pain vated matrix metalloproteinase (WUWHS,
and stress at dressing change (Upton and 2007) which can be detrimental to the peri-
Solowiej, 2012). wound area (Figure 6). The contact of chron-
A wound care product that has adhered to ic wound fluid with the skin can cause pain
the wound bed can be seen in Figure 4, interest- for the patient, and excessive exudate causes
ingly a non-adherent product has been placed maceration. This problem can be addressed
with the use of appropriate absorbent wound
care products, a skin barrier protective, and
where appropriate, elevation of the limb and
compression therapy.
Wound cleansing
Wound cleansing has been reported as one
of the most painful experiences associated
with wounds (Price et al, 2008). Routine
cleansing of wounds is considered to have
no beneficial effect on wound healing or in
reducing wound infection (Fernandez and
Griffiths, 2012) and it is advised that wounds
are only cleansed to remove debris from the
peri-wound area, rather than the wound
surface itself. If cleansing is required, it is
important to ensure the solution is warmed
to 37° C to maintain blood flow to the
wound bed (MacFie et al, 2005), in addition
patients report that when cold solutions are
used their pain is increased.
Moffatt CJ, Franks PJ, Hollinworth H (2002) EWMA role of dressings. A consensus document. http://tiny-
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trauma: an international perspective. http://tinyurl. World Union of Wound Healing Societies (2008)
com/26unm9q (accessed 23 May 2013) Principles of best practice. A World Union of Wound
Mohammed JH (2009) Skill mix development in gen- Healing Societies’ initiative: Compressionin venous leg
eral practice: a mixed method study of practice ulcers. A consensus document. http://tinyurl.com/
nurses and general practitioners. http://tinyurl.com/ orca2rq (accessed 23 May 2013)