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BACKGROUND: Wound care (WC) is an important part of treatment for hospitalized patients with
wounds. There is a paucity of data about the type or amount of pain patients experience during WC.
OBJECTIVES: The purpose of this study is to describe patients (n 412) WC-related pain perceptions
and responses, examine the relationships between patients WC pain and demographic variables, and
describe the distress associated with WC.
METHODS: A repeated-measures design was used to examine pain before, during, and after WC in
hospitalized patients (n 412) with wounds healing by secondary intention.
RESULTS: Pain intensity was greatest during WC. It was most frequently described as tender, sharp,
stinging, aching, and stabbing. Behaviors that occurred most often were no verbal response, no body
movement, grimace, and complaints of pain. There were no differences in pain between genders.
Nonwhites had significantly greater WC pain than whites. Pain during the procedure was the same in
younger and older patients, and procedural distress was mild.
CONCLUSION: Patients experience pain and distress with WC. Some behaviors and words consistently
describe WC pain. Further work is warranted to refine pain assessment and management in patients
undergoing WC procedures. (Heart Lung 2004;33:32132.)
INTRODUCTION
Wound care (WC) is an important part of the overall
treatment of hospitalized adults with wounds healing by secondary intention. Wound management
includes changing the dressing and packing the
wound as well as irrigation and debridement.1,2
Clinical observation has led practitioners to conclude that WC is a major source of pain for patients
with wounds, yet limited data support this assumption.3,4
As part of a major study on procedural pain,
supported by the American Association of Critical
Care Nurses,5 we examined pain perceptions and
responses of acutely or critically ill adults to WC.
Specifically, the research was designed to (1) describe patients pain perceptions and responses beFrom the University of California San Francisco, School of Nursing, San Francisco, California.
Reprint requests: Nancy Stotts, RN, EdD, FAAN, UCSF, School of
Nursing, 2 Koret Way 631, San Francisco, CA 94143-0610.
0147-9563/$ see front matter
Copyright 2004 by Elsevier Inc.
doi:10.1016/j.hrtlng.2004.04.001
BACKGROUND
Wound Care
A wound is a disruption of tissue integrity such
that structural and functional integrity of tissue is
disrupted.6 Wound healing by secondary intention
is characterized by tissue loss and bacterial contamination.2 Local care is an integral part of treatment
of wounds and is designed to reduce bacterial burden, contain exudate, protect the wound from iat-
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accurate would be generated if research were focused on patients perceptions of their experience,
rather than those of the provider.
METHODS
A 1-group, repeated-measures design was used
to examine the pain response of patients who had
WC performed. The site coordinator for the study
determined whether institutional review board (IRB)
approval was necessary and, when needed, obtained approval from the sites IRB. In sites that
required IRB approval, informed consent was obtained from the patient. In sites that did not require
IRB approval, patients were directly enrolled in the
study.
Sample
A convenience sample of adults was enrolled
from the population of patients undergoing WC at
participating institutions. (Children aged 3-17 years
were included in the sample for the larger procedural pain study.5 Data about WC-related pain will
be reported in an article focused on procedural pain
in pediatric patients.) Adults were included after
their primary nurse determined that they were
awake, alert, oriented, and medically stable enough
to respond to questions. Patients had to be able to
see, hear, and communicate in English. Patients
were excluded if they were receiving neuromuscular
blockade; had disease processes or injury that impaired sensory transmission proximal to the WC
site; had WC that included the removal of drains,
sutures, or staples; or were receiving burn care.
Definition of terms
The major study terms are defined in Table I.
Instruments
Study instruments were a pain intensity numeric
rating scale (NRS) (range 0-10), the Thunder Study
Modified McGill Pain Questionnaire-Short Form
(MPQ-SF) for pain quality, a behavioral observation
tool developed for this study, the procedural distress NRS (range 0-10), and the body outline diagram. The NRS, Thunder Study Modified MPQ-SF,
and procedural distress NRS, and their validity and
reliability are described in the main study report.5
The body outline to identify pain location has been
described by Puntillo.15 Data on the behavioral observation tool also have been reported.16
Table I
Definition of major study variables
Pain: An unpleasant sensory and emotional
experience arising from actual or
potential tissue damage or described in
terms of such damage. It is whatever the
experiencing person says it is, existing
whenever he or she says it does.
Wound care: The process of removing dead
tissue, cleansing the wound, or providing
a protective environment. Wound care
procedures include dressing change,
packing, irrigation, debridement.
Types of wound care procedures
Dressing change: removal and
reapplication of a covering to the wound.
Packing: Insertion of material into a
wound cavity and covering of the wound
with a secondary dressing to prevent
ingress of organisms.
Irrigation: Applying fluid under pressure
to remove adherent materials and
byproducts of wound metabolism from
the surface of the wound.
Debridement: Removal of necrotic
material and slough from the wound.
Procedure
Before the study was initiated, nurses at each
study site participated in educational training sessions to ensure accuracy and consistency of procedures. The training included a videotape developed
by the research team that demonstrated each aspect of data collection including use of the behavior
observation tool. Drawings of facial expressions
with labels and defining characteristics were provided to assist data-collection nurses to master this
component of the pain assessment. After training,
the participating nurses screened patients who were
to undergo WC and collected study data on appropriate patients who consented to participate. A standard protocol was used for each data collection point.
Before the procedure. The patient was observed
for pain behaviors for 1 minute, and all facial responses and other behaviors observed were recorded on the behavior checklist. Pain intensity was
assessed using an NRS. Patients with a pain rating
of 1 or greater identified the location of pain using
a body outline diagram. Pain quality was assessed
by the nurse reading the MPQ-SF word list and the
patient selecting those words that described the
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RESULTS
The sample
Data analysis
Descriptive statistics were generated for pain location, pain intensity, pain-related behaviors, words
that described the quality of the pain, heart rate,
and BP for the 3 pain assessment times. Descriptive
statistics were also generated for the data concerning analgesics, sedatives, nonpharmacologic interventions, and procedural distress.
Repeated-measures
analysis
of
variance
(ANOVA) was used to examine the main effect of
pain intensity across the 3 times (before, during,
and after the procedure) by wound type (surgical
and nonsurgical) and the related interactions. Three
repeated measures ANOVAs were performed: one
for dressing change, one for packing, and one for 2
or more dressing change procedures. The simple
WC procedures included dressing change, packing, irrigation, and debridement. Dressing change
was the most frequent WC procedure (n 293;
71.1%). Packing was performed in 54.6% of patients
(n 205). The packing was removed moist in 80% of
the cases and dry in 20%. Irrigation was performed
in 107 patients (27.6%), and debridement was performed in a small portion (n 15; 3.6%). The
cleansing agents and dressings that were used on
these wounds are listed in Table IV.
No patient reported a history of chronic pain or
chronic opioid use. Across the 3 time periods, patient pain intensity was not different between men
and women (P .05). Pain intensity reports before
and after WC were not different by ethnicity; how-
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Table II
Demographic data for the sample
Variable
Sex (n 396)
Male
Female
Race and ethnicity (n 410)
White
African American
Other
Number of wounds (n 412)
1
2
2
Location of wound (n 412)
Abdomen
Leg
Other
Type unit where procedure performed (n 396)
Specialty unit (eg, cardiac surgery)
Other units
Critical care unit (medical or surgical)
Emergency department
Procedure room
Table III
Personnel who performed wound care*
Professional title
Registered nurse
Advanced practice
nurse
Physician
Assistive personnel
Physician assistant
Other
Number of
subjects
(n 412) Percentage
304
36
73.8
8.7
32
26
5
57
7.8
6.3
1.2
13.8
Number of subjects
Percentage
207
189
52.3
47.7
303
79
28
73.9
19.3
6.8
245
126
41
59.5
30.6
9.9
236
131
45
57.3
31.8
10.9
167
127
84
10
8
40.5
32.1
21.2
2.5
2.0
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Table IV
Wound cleansing agents and wound contact materials
Variable
Number of subjects
(n 412)
Percentage
267
50
25
18
11
10
39
64.8
12.1
6.1
4.4
2.7
2.4
9.5
317
25
22
19
11
9
9
8
76.9
6.1
5.3
4.6
2.7
2.2
2.2
1.9
Table V
Mean (SD) blood pressure and pulse before, during, and after wound care
Before
During
After
Systolic N 236
Mean (SD) mm Hg
Diastolic N 235
Mean (SD) mm Hg
128.4 (24.23)
131.0 (24.01)
127.7 (25.81)
71.1 (12.55)
72.3 (13.58)
70.2 (13.12)
89.5 (17.13)
92.0 (19.39)
88.8 (18.34)
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Table VI
Mean pain intensity (SD) for surgical and nonsurgical patients prior to and during dressing change,
packing, and 2 or more wound care procedures
Dressing change
(n 61)
Packing
(n 41)
>2 Procedures
(n 258)
nificantly during the procedure (P .000), regardless of whether they had a surgical or nonsurgical
wound (P .088). Table VI shows mean pain scores
over time for wound procedures by type of wound.
Data on pain quality, assessed with the Thunder
Study Modified MPQ Quality Word List, showed that
some terms were used consistently to describe pain
across the specific WC procedures. Terms most frequently used were tender (53.6%), sharp (38.9%),
stinging (32.1%), aching (27.7%), stabbing (25.5%),
bad (24.2%), hot-burning (24%), throbbing (22.1%)
and shooting (22.1%). The 20 terms on the scale
were examined to see which changed by 10% or
more from baseline to during the procedure. Ten
percent was selected as an arbitrary amount. Three
words increased in use by 10% or more across the 4
specific WC procedures: stabbing, sharp, and stinging. No term decreased by 10% (Table VII).
In a similar manner, pain behaviors were examined. Behaviors that occurred most frequently during the wound care procedures were no verbal response (46.1%), no body movements (42.2%),
grimace (30.8%), verbal complaints of pain (26%),
frown (23.8%), wince (21.6%), no facial response
(21.6%), eyes closed (21.1%), and moaning (20.4%).
When the behaviors were examined to see which
increased by 10%, the behaviors were grimace,
wince, moaning, verbal complaints of pain, rigid,
and clenched fist. Those that decreased by 10% or
more included no facial response, no verbal response, and no body movement (Table VIII).
Pain intervention
Both pharmacologic and nonpharmacologic
strategies were used to prevent and treat pain in
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Table VII
Percentage of patients who identified specific pain quality words at baseline and during the wound
care procedure
Pain quality
words
Percentage of patients
who described their
pain with this term
during the procedure
Throbbing
Shooting
Stabbing*
Sharp*
Cramping
Gnawing
Hot-burning
Aching
Heavy
Tender
Splitting
Tiring-exhausting
Sickening
Fearful-frightening
Punishing-cruel
Awful
Bad
Stinging*
Dull
Numb
25.6%
13.8%
13.2%
26.4%
12.4%
14.6%
19.4%
31.2%
16.0%
44.7%
6.5%
16.0%
11.2%
10.7%
6.5%
13.2%
19.1%
19.4%
25.4%
14.0%
22.1%
22.1%
25.5%
38.9%
9.2%
14.7%
24.0%
27.7%
13.7%
53.6%
9.5%
15.3%
11.8%
10.8%
10.5%
19.2%
24.2%
32.1%
17.4%
10.3%
*Items that increased by 10% or more from baseline to during the wound care procedure.
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Table VIII
Percentage of patients who displayed behaviors when pain was assessed at baseline and during the
wound care procedure
Pain behaviors
Grimace*
Frown
Wince*
Eyes closed
Eyes wide open
Looking away
Grin/smile
Mouth wide open
Clenched teeth
No facial response**
Moaning*
Screaming
Whimpering
Crying
Using protest words
Verbal complaints of pain*
No verbal response**
No body movements**
Rigid*
Arching
Clenched fist*
Shaking
Withdrawing
Splinting
Flailing
Picking/touching site
Restlessness
Rubbing/massaging
Repetitive movement
Defensive grabbing
Pushing
Guarding
10.4%
18.0%
4.6%
11.4%
5.8%
3.6%
12.9%
0.5%
2.4%
45.1%
4.9%
0.5%
1.7%
0.7%
0.5%
15.5%
69.4%
62.4%
5.3%
1.5%
1.7%
1.5%
1.7%
2.4%
0.2%
1.7%
5.8%
5.3%
1.7%
0.2%
1.0%
5.8%
30.8%
23.8%
21.6%
21.1%
7.8%
10.0%
7.0%
1.0%
8.5%
21.6%
20.4%
1.7%
4.6%
2.2%
8.0%
26.0%
46.1%
42.2%
16.7%
3.4%
11.7%
3.4%
9.7%
2.4%
0.7%
2.4%
9.2%
3.9%
2.2%
3.2%
1.5%
8.3%
*Items that increased in 10% or more from baseline to during the wound care procedure. **Items that decreased in 10% or more
from baseline to during the wound care procedure.
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Table IX
Mean distress scores by type of wound and
medication use
Distress
Mean (SD)
Overall (N 379)
Type of wound
Surgical (N 270)
Nonsurgical (N 89)
Medication use
Before and during (N 14)
Before only (N 73)
During only (N 5)
None (N 287)
2.8 (3.26)
2.5 (3.17)
3.7 (3.32)
6.4 (3.27)
3.5 (3.34)
6.4 (3.05)
2.4 (3.08)
DISCUSSION
Patients who underwent WC had mild-to-moderate pain intensity present before manipulation of
the wound. Presumably this pain was caused by
stimulation of nociceptors by tissue trauma with
varying reported levels of pain because of differences in processing through the central and peripheral nervous system.17
Even with mean pain intensity that was mild to
moderate at baseline (Table VI), pharmacologic
treatment was initiated in less than a quarter of
patients in this study. In those who received medication, it is not clear whether they were adequately
medicated. The possibility of inadequate medication of those who received opioids is supported by
the fact that they had greater pain during the pro-
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sample, yet their mean pain scores during the procedure increased to a severe level and returned to
only a mean moderate level post-procedure. This
high level of pain may be caused by inadequate pain
management combined with the nonselective nature of sharp debridement in that healthy tissue
often is removed with the debris. Data are not available that indicate whether the injected local anesthetic was allowed to reach peak effect before debridement was performed. Data from a review of
randomized clinical trials of EMLA to treat the pain
associated with debridement in the chronic wound
literature indicate that EMLA is effective in reducing
the pain associated with debridement23; however, a
slower rate of healing and higher incidence of burning and itching were reported in 1 trial. EMLA was
used in only 1 patient in this study; further examination of its use in the critical care setting is warranted.
Two studies indicate that nurses believe that the
dressing used can prevent trauma and pain with
WC. Yet in these studies, nurses did not know what
types of dressings could be used to reduce pain and
trauma.13,14 In the current study, most wounds were
dressed with gauze, and therefore comparison of the
pain associated with various types of dressings could
not be performed. Further research comparing pain
intensity with various dressings using patient report
rather than nurses estimate of pain is needed.
Data from this study provide the clinician with
terminology to assess the presence of pain. The
terms tender, sharp, stinging, aching, and stabbing
were frequently reported. The terms stabbing, sharp,
and stinging were experienced more frequently during WC than before it. Further work is needed in
nonEnglish-speaking populations to identify the
terms associated with procedural pain.
Behaviors that occurred most frequently were no
verbal response, no body movements, grimace, and
complaints of pain. Those behaviors that increased
10% or more from baseline to during the procedures
were grimace, wince, moaning, verbal complaints of
pain, rigid, and clenched fist. Also during the procedure, there was a 10% or more decrease in the
categories of no facial responses, no verbal responses and no body movements. Observation of
these behaviors may help clinicians identify those
in pain, especially those who are not able to verbalize their needs (eg, the patient with an endotracheal
tube). Few studies have been performed in populations who are not able to verbalize their pain-related needs during procedures.
LIMITATIONS
The findings from this study were limited to alert,
oriented, English-speaking patients. Those who
were excluded because they were sedated or not
alert may have had a different pain experience than
those who were studied. Further work is needed in
this area. In addition, specific interventions were
not tested in this study. Although training was given
in use of the data-collection tools, interrater reliability among raters and sites was not formally established.
CONCLUSION
Hospitalized patients with wounds healing by
secondary intention experience pain before, during,
and after WC. Peak pain is during the procedure.
Specific terms and behaviors were used consistently
with pain across procedures. Providers need to
adopt these often-used terms to assess pain and
observe patients for frequently occurring behaviors,
especially in patients who are not able to verbalize
their pain needs. Patients in this study were given
little pain medication. Nonpharmacologic treatment was used in more than 80% of patients.
There is a need for further research in the area of
pain control with WC. Additional testing is needed
to determine whether the terms and behaviors reported in this study are consistent across populations. More work is needed to evaluate strategies to
increase the amount of medication administered
and to compare the effectiveness of various medications. The effectiveness of nonpharmacologic
therapies also needs to be explored and compared
for efficacy. Combination pharmacologic and nonpharmacologic therapy deserves further study.
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