Clinical Focus WouNd CAre

Minimizing pain in
wound management
I
n response to the Francis report (2013),
commissioning groups have been advised to
utilise valuable resources to improve quality
and health outcomes, measure patient
satisfaction and promote equality in health
(The Mid Staffordshire NHS Foundation Trust
Inquiry, 2013; department of Health (dH),
2013). The ambition to improve health-related
quality of life for people with long-term
conditions, is of particular relevance. It has
been identified that to meet the health needs of
the population, competent staff are required
with the ability to understand an individuals
health and social needs, and with the expertise,
clinical and technical knowledge to deliver
effective care and evidence-based treatments
(NHS Commissioning Board et al, 2012).
Chronic wounds are considered to be a
long-term condition, with non-healing
wounds having an impact on both mortality
risk and quality of life (Posnett et al, 2009). It
is estimated that approximately 200 000 indi-
viduals have a chronic wound in the uK, of
which 68% are treated in the community
(Posnett and Franks, 2008).
The royal College of General Practitioners
(rCGP) (2012), together with an educational
advisory group of experienced practice nurs-
es, has devised a competency framework for
a nurse to become a general practice nurse.
This document includes the assessment and
care of uncomplicated wounds, the selection
and application of appropriate treatments
and wound care products, and the assessment
of wound-related pain.
Therefore, there is an opportunity to reflect
on current practices in relation to the man-
agement of wound pain and discuss evidence-
based practice in relation to the management
of wound-related pain.
Wound-related pain
Wound-related pain is a significant problem
for patients with wounds, and studies have
shown that this has a significant impact on
2013 MA Healthcare Ltd
having the potential to contribute to anxiety Julie M day
and depression (Wounds International, 2012).
The pain can arise from the wound itself (neu- discusses how the
ropathic pain), wound treatments or be antici-
patory in nature (Solowiej et al, 2010). assessment of
Wound assessment, undertaken by a skilled woundrelatedpain
and competent practitioner, is fundamental to
planning care, with outcomes for the wound should be an
identified and monitored by ongoing assess-
ment (Wounds uK, 2008). The assessment integralcomponent
should include the assessment of wound- of wound
related pain and the impact on the patients
quality of life. However, there is evidence to assessment
suggest that pain assessment is often consid-
ered to be a low priority (Moffatt et al, 2002).
The intensity of the patients pain should
be investigated using a simple pain scale, such
as a visual, numerical or verbal scale, or pain
diary ( World union of Wound Healing
Societies (WuWHS), 2004). The description
of the pain, frequency and duration should
also be recorded, as this can guide the practi-
tioner to the cause. Patients use various terms
to describe the pain for example, sharp,
stabbing, aching throbbing (enoch and
Price, 2004). The assessment of wound-relat-
ed pain should be an ongoing process, so that
the effects of analgesia can be monitored and
any subtle changes in pain can be identified.
Practice nurses undertaking university tissue
viability modules reflect that the use of elec-
tronic patient records make it difficult to record
all aspects of the wound assessment, and that
they have been unable to access an appropriate
wound assessment proforma that is compatible
with computer systems. They reflect that impor-
tant aspects of wound assessment are not
included, and opportunities for continuity of
care are missed.
In many cases practice nurses see patients in
10 minute time slots; thus limiting the poten-
tial for an in-depth exploration of the com- JulieMdayisclinicalnursespecialist,
plexities of wound pain. Furthermore, many department of Vascular Surgery,
practice nurses work part-time (Mohammad, WorcestershireAcuteHospitalsNHSTrust
2009) and consequently a patient may not see

their quality of life (Franks and Moffatt, 2001;
Price et al, 2008). Wound-related pain affects
the physical, psychological, and social wellbe-
ing of the patient, with the effects of pain
limiting physical activities, social contact and
the same practitioner on a regular basis, losing
the important element of continuity of care.
The use of analgesia, and more importantly
the effectiveness of this, should be carefully
monitored to ensure that the patient is offered
Submittedforpeerreview:20May2013;
acceptedforpublication30May2013
Keywords:Chronicwounds,pain,wound
assessment, practice nursing

Practice Nursing 2013, Vol 24, No 6 269


Figure 1 (top). Chronic
inflammation
Figure 2 (bottom left). Wound
critically colonized with
anaerobes
Figure 3 (bottom right).
Contact sensitivity
270
Clinical Focus WouNd CAre
maximum relief for wound-related pain.
Management of wound-related pain can
offer complex challenges for the practitioner,
and in some cases patients with ongoing,
intractable wound pain may benefit from the
input of a specialist pain management team
(Grey et al, 2006).
In addition to analgesia, patients find strate-
gies such as distraction, relaxation techniques,
information sharing, time out, and a compas-
sionate caring approach a helpful adjunct in
managing wound pain (Hollinworth, 2004).
All of these could be incorporated into wound
care practices as a matter of routinecompas-
sion and caring are of course key aspects of
nursing. In some cases, patients prefer to
remove the dressing themselves and where
desired this could offer the patient a degree of
participation and autonomy.
There have been studies regarding the use of
entonox (a gas mixture of 50% nitrous oxide
and 50% oxygen) to manage procedural pain
(Pediani, 2003), with reported benefits for the
patients, including both a reduction in wound
pain and anxiety associated with anticipatory
wound pain (evans, 2004). Although entonox
is not used routinely in clinical practice, there
is an opportunity to explore its use in the gen-
eral practice setting following appropriate
training.
Wound chronicity, infection, contact sensi-
tivity, dressing trauma, wound exudate, wound
cleansing, temperature fluctuations, compres-
sion therapy and ischaemia
can contribute to wound
pain (Hollinworth, 2004;
Price et al, 2008). From
clinical practice experienc-
es it is evident that patients
with hypergranulating
wounds experience signifi-
cant wound pain.
This article will consid-
er how practice nurses can
help to identify factors
contributing to wound pain, and can improve
the outcomes for patients by incorporating
early recognition and good assessment skills.
Chronic inflammation
Chronic wounds are wounds which fail to
progress through the normal stages of wound
healing and often exhibit a prolonged inflam-
matory and proliferative stage of healing
(Lazarus et al, 1994) (Figure 1). This can con-
tribute to wound-related pain (Acton, 2007). It
is important that nurses recognize chronic
inflammation; often it is confused with infec-
tion, and they can then reassure patients that
this is part of the healing process, while taking
appropriate measures to assess and monitor
their pain. Informing patients of what to expect,
together with an explanation of whatever meas-
ures are in place to minimize pain will help
reduce fear and anxiety (Briggs et al, 2002).
Wound infection
There are subtle changes in pain when a wound
becomes clinically infected or critically colo-
nized, during which patients report an increase
in pain or a change in the nature of the pain
(european Wound Management Association
(eWMA), 2005). A high bacterial load can
result in an increase in pain, even before the
signs of infection are observed (Bjarnsholt et al,
2008). An increase in pain, unexpected pain, or
change in the nature of pain is a key factor
indicating the presence of infection (Gardner et
al, 2001). These subtle changes have the poten-
tial to go unnoticed when different practitioners
review the wounds, and an ongoing pain assess-
ment tool has not been utilized.
once assessment has been carried out and
the wound is considered to be critically colo-
nized, or to have local or spreading infection,
topical antimicrobial agents and/or antibiot-
ics can be started (Wounds uK, 2010).
Patients with a wound that is critically colo-
nized with anaerobes often express an increase
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-
ther tissue damage, inflammation and pain
2013 MA Healthcare Ltd
(Figure 3). Some patients are more prone to
sensitivities to products, for example patients
with leg ulceration (rCN, 2006), and the eld-
erly (Wingfield, 2012). Nurses undertaking
Practice Nursing 2013, Vol 24, No 6
 Clinical Focus WouNd CAre
wound care should be mindful that any wound
care product, emollient, or bandage can cause
sensitivities, such sensitivities should be treated
promptly by discontinuing the particular prod-
uct and applying topical corticosteroids (Bourke
et al, 2009; Joint Formulary Committee, 2013).
dressing trauma
Following a wound assessment, a wound care
product should be selected to meet the needs
of the wound bed, which includes reducing the
risk of infection and pain, and the manage-
ment of wound exudate (Shorney and ousey,
2011). Wound care products can cause trauma
to the wound bed if they adhere or dry out,
which in turn causes pain for the patient and
can result in anticipatory wound pain, using
atraumatic products significantly reduces pain
and stress at dressing change (upton and
Solowiej, 2012).
A wound care product that has adhered to
the wound bed can be seen in Figure 4, interest-
ingly a non-adherent product has been placed
Figure 4 (top). Incorrect
application of wound care
products
Figure 5 (middle). Maceration
and tissue damage
Figure 6 (bottom). Chronic
wound exudate
272
on top of it. ongoing assessment of the wound,
including dressing induced pain, should be
undertaken to identify and address areas of
concern for the patient. As wounds progress
towards healing, and the exudate levels reduce,
the frequency of dressing changes should also
reduce to ensure minimal disturbance of the
wound and disruption of wound healing.
Inappropriate use of wound care products
can have adverse effects for patients, the com-
bination of wound care products can cause
maceration and tissue damage and resultant
pain for the patient (Figure 5).
exudate
Chronic wound exudate contains elevated
levels of inflammatory mediators and acti-
vated matrix metalloproteinase ( WuWHS,
2007) which can be detrimental to the peri-
wound area (Figure 6). The contact of chron-
ic wound fluid with the skin can cause pain
for the patient, and excessive exudate causes
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.
Leaving wounds exposed
The provision of a moist environment has
been shown to accelerate wound healing and
reduce pain (Palamand et al, 1992). Wounds
that are allowed to dry out or left exposed
to the air can become painful. If wounds
have to be left exposed for a short period of
time they can be covered with cling film to
2013 MA Healthcare Ltd
maintain both the wound temperature, and
moisture level, and thus reduce the patients
experience of wound-related pain (real First
Aid, 2013).
Practice Nursing 2013, Vol 24, No 6

Figure 7 (top).
Hypergranulation tissue
Figure 8 (bottom). results of
incorrect application of
compression bandage systems
274
Clinical Focus WouNd CAre
Hypergranulation tissue
Hypergranulation tissue is usually visible as a
pale or light purple uneven mass rising above
the level of the skin (Harris and rolstad, 1994),
or as a bright glossy red colour (Figure 7). The
presence of such tissue prevents epithelial
migration across the wound, which delays
wound healing (dealey 1999; dunford, 1999).
Hypergranulation tissue is thought to be
related to prolonged inflammation caused by
infection or foreign body irritant, including
dressing fibres, (Nelson, 1999) or by external
friction (Hanlon and Heximer, 1994).
Clinically inexperienced nurses may not iden-
tify this abnormality in wound healing (Vuolo,
2010), and the resultant pain is not addressed.
Although there is scant evidence to support
treatment options, in clinical practice the use of
topical steroids has proved beneficial in both
resolving hypergranulation and reducing pain.
Compression therapy
Compression therapy is clinically proven to
effectively treat venous leg ulcers (oMeara et
al, 2012). However, it is apparent in clinical
practice that the appropriate skills and compe-
tence in applying compression bandage systems
is often lacking, with resultant
tissue damage. This can range
from bandage ridges, pockets
of oedema, to extreme damage
(Figure 8), where the tibial crest
was palpable within the wound
bed. Compression bandage
damage is a significant cause of
pain for patients and affects
their ability to concord with the
treatment plan.
There are opportunities to
reduce the risk of compression
bandage damage; nurses
applying compression should
be skilled and competent in the
procedure (WuWHS, 2008).
Careful observation of the
limb, and the patients pain at
each dressing change, will
identify the early stages of
compression damage, such as
erythema or increased pain.
extra protection with wool
padding, or a temporary
reduction in the level of com-
pression, can be used to pro-
tect the limb and the patient.
In severe cases compression
therapy may have to be dis-
continued to allow the damage to resolve.
Ischaemia
Patients with progressing arterial insufficiency
will complain of increased pain and will often
report pain at rest or on elevation (Beard,
2000). Prompt action should be taken if the
patient develops clinical signs of ischaemia
and resultant pain, these patients should be
referred urgently for vascular assessment.
Conclusions
The examples above demonstrate that a lack
of skill and competence has resulted in
adverse events for patients, unnecessary suf-
fering and delayed wound healing. developing
skills and competence in all aspects of wound
management, including the complexities of
pain assessment has the potential to improve
outcomes for patients.
The introduction of wound management
competencies for practice nurses is a step for-
ward. However, one could consider that these
do not go far enough. The competencies are for
uncomplicated wounds only and it is somewhat
challenging to define what would be an uncom-
plicated wound. Chronic wounds tend to be
more complex, and it could be argued that
practice nurses should undertake a recognized
wound management course to ensure that the
patients are assessed and managed correctly.
This should incorporate the important aspect of
wound-related pain and how to minimize this
to improve the patients overall experience and
quality of life. It is of course an opportunity for
practice nurses to raise the awareness of their
role in the management of wounds and identify
and address their learning needs. There should
also be a commitment from general practices
and clinical commissioning groups to ensure
that nurses have access to education in this
important aspect of clinical care.
The development of wound assessment doc-
umentation should take into consideration the
compatibility of a tool with electronic records
so that practice nurses can undertake holistic
wound assessments and identify problems
through ongoing patient assessment.
Conflicts of interest: none
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