Management of chronic wound pain 2014

Sabo Y. Machudo,

Senior Nurse Educator;

KAUH. KSA.

Pain is a major issue for patients suffering from many different wound types.

The last decade has focused on healing as the principal outcome of wound management.

At the end of this lecture, participants will be able to:

understand the guide to pain management during wound dressing.

be aware of the options of product range and ability to select dressings that reduce pain and provide comfort.

Wounds require complex care because they have many causes & complications:

Pain can affect everyone; the psychological impact of pain cannot be measured nor underestimated and is likely to affect wound healing.

Poor techniques in wound care can further traumatize wounds resulting in an increased pain for the patient & slowed healing.

Strategies can be adopted through which pain can be avoided or minimized.

‘Wound bed management paradigm’ previously developed by Sibbald et al, 2003b) is a basis for the management of chronic wounds and has been used extensively by wound care specialists.

It consists of four major principles:

Treating the cause.

Addressing patient-centred concerns.

Providing local wound care.

Using advanced therapies when the wound is not healing at the expected rate.

Treating the cause of a chronic wound may involve removing the source of the problem, for example with a venous ulcer edema can be reduced with compression therapy.

Pain in chronic wounds is a major concern for patients and healthcare professionals (Sibbald, 1998; Neil and Munjas, 2000).

Pain was identified as the third biggest issue after time to healing and limb preservation (Eager, 2005).

Pain control is often more important to patients than it is to healthcare professionals (Queen et al,2005).

Pain friendly dressings:

Hydrogel.Calcium alginate.Hydrocolloidal.Foam.Transparent.

Dressings

Debridement

Infection/inflammation and

Moisture balance

Dressing removal is usually cited as the time when the most pain occurs.

Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes, with gauze removal being the most common cause of this pain.

Newer products, such as soft silicone dressings, hydrogels, Hydrofiber® (ConvaTec, Ickenham), and alginates are less likely to cause pain (Hollinworth and Collier, 2000).

Wound debridement by surgical autolytic, enzymatic, and or mechanical means (Davies et al. 2005).

The more aggressive the debridement regimen (e.g. surgical and mechanical), the more potential pain for the patient.

For surgical debridement, application of topical local anaesthetics, such as 4% topical lidocaine, amethocaine 4% gel or EMLA, 30–60 minutes before the procedure may be helpful.

Infection and inflammation can be painful in themselves (Gardner et al, 2001).

Superficial infections may be treated with topical antimicrobials, while deeper infections require systemic agents (Krasner and Sibbald, 1999).

Many topical preparations, both pharmacological and non -pharmacological (e.g. antibacterial dressings), exist to treat both infection and inflammation. Silver-containing dressings are both anti-inflammatory and antimicrobial (Wright et al, 2002).

Moist wound healing has been demonstrated to result in faster healing, less scarring, and less pain (Rovee, 1991; Kannon and Garrett, 1995).

The pain reduction has been attributed to the bathing of the exposed nerve ending in fluid, preventing dehydration.

Fibrous products (eg. alginates, Hydrofiber®) are excellent primary contact layers.

In the presence of wound fluid, these fibres transform into gels to facilitate a moist interactive local wound bed environment and result in a soothing sensation.

Products or techniques used to cleanse wounds.

Lack of empathy.

Skin excoriation from exudates or wound drainage .

Failure to record patient’s earlier reports of pain.

Poor techniques when using compression bandaging .

Dressing removal is considered to be time of most pain.

Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes.

Gauze is most likely to cause pain.

Products designed to be non-traumatic are most frequently used to prevent tissue trauma.

Awareness of product range and ability to select appropriate dressings.

Use of valid pain assessment tools is considered a low priority in assessment, with greater reliance on body language and non-verbal cues.

Prevent trauma.

Prevent pain.

Prevent infection.

Prevent skin damage.

The most important strategy to avoid wound damage was the use of non-traumatic dressing.

Importance of dressing characteristics.

Awareness of products.

Ability to choose the dressing

Regularly scheduled interventions such as dressing changes.Perform dressings when patient is less fatiguedPre-medicateIf dressing has dried out, dampen itConsider alternatives to sharp surgical Debridement:Hydrogels, hydrocolloids, Hypertonic

saline solution, or enzymatic agents.Medicate before, during, and after as appropriate.

Infection and inflammation can be painful in themselves (Gardner et al, 2001).

Increased pain in the area of an ulcer is a sign of possible deep infection.

Superficial infections may be treated with topical antimicrobials, while deeper infections require systemic agents (Krasner and Sibbald, 1999).

Many topical preparations, both pharmacological and non pharmacological (e.g. Antibacterial dressings), exist to treat both infection and inflammation. Silver-containing dressings are both anti-inflammatory & antimicrobial (Wright et al, 2002).

Skin adhesives play an important role in keeping wound dressings in place.

Tissue trauma caused by the removal of adhesive tapes and dressings is known to increase the size of wounds, exacerbate wound pain and delay healing (Hollinworth & White, 2006).

Silicone and nonsilicone adhesives offer low-trauma alternatives for wound-care applications.

Monitor for pain during the intervention(s).

Minimize daily dressing changes.

Avoid tape on fragile skin.

Montgomery straps if appropriate.

Avoid aggressive packing.

Avoid drying out wound or wound bed

Consider Ostomy appliance forheavily draining wound.

Time-out.

Provide analgesia as needed whenrepositioning.

Protect peri-wound area (Skin protectant, barriers).

Careful wound assessment is required, as selecting the correct dressing can ensure comfort can reduce pain.

Emotional responses can also influence the perception of pain.

Pain should be assessed prior to each dressing change and appropriate action taken.

Campbell 1995

Analgesics should be given in anticipation prior to dressing/care.

Give careful consideration to any activities that exacerbate pain.

Patients be closely observed throughout dressing procedure for reaction.

Instruct Pt. to inform when pain is worse at any particular time during dressings.

WHO analgesic ladder forms the basis of many approaches to the use of analgesic drugs.

Suggested methods of dressing product removal are: (local guidelines to be followed)

Removal in shower (if applicable) .

Soaking with normal saline (Sodium Chloride 0.9%) .

Syringe with warm saline through blunt needle.

Utilization of adhesive removal wipes (alcohol free wipes should be used if wound skin is excoriated or

broken) .

Harmful effects of pain (including impaired healing).

Pain management.

Addiction fears.

Non-pharmacological treatment.

What’s new?Lidocaine patches (Lidoderm).Use of Actiq or Fentora during dressingchanges.

It is not always possible to heal a chronic wound, but the activities of daily living and quality of life of patients can be improved through optimal wound and pain management.

Dressing removal is considered to be the time of most pain.

Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes.

Gauze is most likely to cause pain. New products such as hydrogels, hydrofibres, alginates and soft silicone dressings are least likely to cause pain.

Awareness of product range and ability to select dressings is highly recommended.

Choice of products designed to be non-traumatic to prevent tissue trauma.

1. Baxter H (2000) A comparison of two hydrocolloid sheet dressings. Br J Community Nurs 5(11): 572–7

2. Fletcher J (2005) Understanding wound dressings: hydrocolloids. Nurs Times 101(46): 51

3. Davies CE, Turton G, Woolfrey G, ElleyR, Taylor M (2005) Exploring debridement options for chronic venous leg ulcers.

4. Br J Nurs 14(7): 393–7

5. Medical management of chronic wound pain. Wounds UK, 2006, Vol 2, No 4; last accessed on 29/8/2013.