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Dealing with pain at wound dressing

Una Adderley
DN RGN BA BSc
Community Tissue Viability Nurse
Scarborough, Whitby and Ryedale PCT

As a child, the worst part of scraping your knee was often when the plaster had to be removed. Dressing removal can be just as traumatic for a patient with a chronic wound. There is evidence that clinicians are increasingly aware that patients regard pain as a major issue in wound care.(1) An international survey that sought to identify practitioners' views on pain and trauma in relationship to woundcare products found that "preventing trauma" was regarded as the most important factor to consider when changing a wound dressing. "Pain prevention" was the next most highly ranked factor, and clinicians consistently rated "dressing removal", closely followed by "wound cleansing" as the time at which patients with wounds experienced greatest pain.(2)

Pain with procedures
The theory of pain has been studied for many years but has only relatively recently been receiving significant attention in wound care. Pain is defined as an unpleasant sensation associated with actual or potential tissue injury.(3) It generally has a protective function, but when pain becomes chronic the normal pain pathways can become altered. This can result in the nerve endings that transmit pain signals becoming inflamed and damaged, leading to nociceptive (inflammatory) pain. Damage to the peripheral nerves can also be associated with abnormal sensory function or loss of sensory function, which can result in neuropathic pain.
Any procedure that can be sensed by the patient can be painful, but repeated painful dressing changes can damage nerve endings. This can lead to increased sensitivity so that even benign sensations can become painful, such as when a patient flinches during gentle, warmed irrigation of the wound. Although the stimulus is minimal and benign, the patient perceives the sensation as painful.

Managing pain
Management strategies to prevent pain at dressing changes are inevitably complex since there are many factors that impact on the experience of pain. Pain is a complex subject that is affected by physical, social and psychological issues. The sensation of pain will be affected by the degree of physical damage and the biochemical response to that damage. However, in addition, the attitudes and beliefs of the patient will also affect their perception of pain. There are known links between pain and anxiety,although the exact relationship is currently unclear.(4)
Therefore, assessment of pain should be broad and holistic. A pain assessment should include qualitative information, such as the patient's description of their pain (in their own words) as well as quantifiable information, such as the severity of pain and details regarding analgesia. A validated pain scale that is appropriate to the age and ability of the patient should be used to provide a systematic and objective approach to measuring pain. A selection of validated pain scales in a variety of languages are available at www.britishpainsociety.org
Good pain management, based on the principles of the World Health Organization's analgesic ladder, should be offered to all patients in pain (see Box 1).(5) Although analgesia will reduce pain, it will not eliminate all unpleasant sensation, and additional measures will be required to minimise pain. Neuropathic pain, characterised by an abnormal, unpleasant sensation, which may include pricking, tingling, burning or pins and needles, can be particularly difficult to manage and may require referral to a pain specialist. Chronic, constant wound pain will need 24-hour analgesia, but pain that is principally experienced at wound change will be reduced if oral analgesia is given up to an hour before.

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Other forms of analgesia include topical anaesthetics and inhaled anaesthetics. There is evidence that EMLA cream is effective in reducing pain during wound debridement for venous leg ulcers.(6) Entonox (inhaled oxygen and nitrous oxygen) has been used for many years for procedure-related pain but should be used only for the duration of the procedure.
Analgesia is an important part of pain relief, but other factors such as reducing anxiety and appropriate dressing selection also play a key role in minimising wound pain. Although the relationship between anxiety and pain is unclear, it is known that autonomic responses, such as muscle tension and heart rate, are affected by anxiety, and it is possible that these may increase the sensation of pain. Therefore, careful discussion with the patient to identify what the patient regards as the specifics that may trigger pain should help reduce anxiety and thus lessen pain, as well as providing useful practice pointers. Some patients may find that pain is reduced if they are allowed to remove the dressing themselves, at their own pace. If this is impractical, establishing good communication so that the procedure can be undertaken at the patient's pace should increase patient confidence and reduce anxiety. Although dressing selection will be influenced by many factors, including absorbency and protection from trauma and bacteria, comfort and low adherence are essential for minimising pain. There is evidence that practitioners perceive "modern" dressings, such as hydrogels, hydrofibres, alginates and soft silicones, as less likely to cause pain at dressing changes than traditional wound dressings such as gauze.(2)
A dressing should be selected that is able to maintain high humidity at the wound site while removing excess exudate, thus reducing friction and adherence at the wound surface and enabling gentle, easy removal at wound dressing change. Ideally the dressing should be capable of remaining in situ as long as possible so as to reduce the frequency of painful dressing changes. If a wound contact layer leads to pain or bleeding on removal or requires soaking off then the dressing choice should be re-evaluated. Some adhesive dressings may have specific techniques for low trauma removal, so it is important to read the manufacturer's instructions.

Conclusion
Minimising pain at wound dressing change is a humane approach to wound care. It requires good assessment techniques to plan a multifaceted approach that considers pharmacological, psychological and physical aspects that impact upon the patient. Focusing on pain minimisation from the beginning of an episode of care reduces the risk of a chronic long-term pain problem developing that can be distressing for the patient and difficult for the clinician to resolve.

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References

  1. Briggs M, Hofman D. Pain management. 9th European Conference on Advances in Wound Management. Harrogate; 1999.
  2. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. Pain at wound dressing changes. EWMA position document. Available from http://www.tendra.com/index.asp?id=1321
  3. Wulf H, Baron R. The theory of pain. Pain at wound dressing changes. EWMA Position Document. Available from http://www.tendra.com/index.asp?id=1321
  4. Briggs M, Torra I, Bou JE . Pain at wound dressing changes: a guide to management. Pain at wound dressing changes. EWMA Position Document. Accessed at www.ewma.org, 18.01.06.
  5. World Health Organization. Cancer pain relief. 2nd ed. Geneva: WHO; 1996.
  6. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev 2003;1:CD001177.

Resources
British Pain Society
For information on pain and a selection of validated pain scoring systems in many languages
W:www.britishpain society.org

European Wound Management Association Has produced a "Position Document" on minimising pain at wound dressing-related procedures 
W:www.ewma.org