Clinical Focus WouNd CAre

Minimizing pain in
wound
management
I
n response to the Francis report (2013), pain limiting physical activities, social having the potential to
commissioning groups have been advised to contact and contribute to anxiety and
utilise valuable resources to improve quality depression (Wounds
and health outcomes, measure patient International, 2012). The pain
satisfaction and promote equality in health can arise from the wound
(The Mid Staffordshire NHS Foundation itself (neu- ropathic pain),
Trust Inquiry, 2013; department of Health wound treatments or be
(dH), antici- patory in nature
2013). The ambition to improve health-related (Solowiej et al, 2010).
quality of life for people with long-term Wound assessment,
conditions, is of particular relevance. It has undertaken by a skilled and
been identified that to meet the health needs of competent practitioner, is
the population, competent staff are fundamental to planning
required with the ability to understand an care, with outcomes for the
individual’s health and social needs, and with wound identified and
the expertise, clinical and technical knowledge monitored by ongoing
to deliver effective care and evidence-based assess- ment (Wounds uK,
treatments (NHS Commissioning Board et al, 2008). The assessment should
2012). include the assessment of
Chronic wounds are considered to be a wound- related pain and the
long-term condition, with non-healing impact on the patients
wounds having an impact on both mortality quality of life. However, there
risk and quality of life (Posnett et al, 2009). It is evidence to suggest that
is estimated that approximately 200 000 indi- pain assessment is often
viduals have a chronic wound in the uK, of consid- ered to be a low
which 68% are treated in the community priority (Moffatt et al, 2002).
(Posnett and Franks, 2008). The intensity of the
The royal College of General Practitioners patient’s pain should be
(rCGP) (2012), together with an educational investigated using a simple
advisory group of experienced practice nurs- pain scale, such as a visual,
es, has devised a competency framework for numerical or verbal scale, or
a nurse to become a general practice nurse. pain diary ( World union
This document includes the assessment and of Wound Healing
care of uncomplicated wounds, the selection Societies (WuWHS), 2004).
and application of appropriate treatments The description of the pain,
and wound care products, and the assessment frequency and duration
of wound-related pain. should also be recorded, as
Therefore, there is an opportunity to reflect this can guide the practi-
on current practices in relation to the man- tioner to the cause. Patients
agement of wound pain and discuss evidence- use various terms to describe
based practice in relation to the management the pain for example,
of wound-related pain. ‘sharp’,
‘stabbing’, ‘aching’
Wound-related pain ‘throbbing’ (enoch and Price,
Wound-related pain is a significant problem 2004). The assessment of
for patients with wounds, and studies have wound-relat- ed pain should
shown that this has a significant impact on be an ongoing process, so
their quality of life (Franks and Moffatt, 2001; that the effects of analgesia
Price et al, 2008). Wound-related pain can be monitored and any
affects the physical, psychological, and social subtle changes in pain can be
wellbe- ing of the patient, with the effects of identified.
 Practice nurses undertaking university tissue
viability modules reflect that the use of elec- Julie M day discusses how
tronic patient records make it difficult to record
the assessment of
all aspects of the wound assessment, and that
they have been unable to access an appropriate woundrelatedpain should be
wound assessment proforma that is compatible
with computer systems. They reflect that impor- an integralcomponent of
tant aspects of wound assessment are not
wound assessment
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- JulieMdayisclinicalnursespecialis
plexities of wound pain. Furthermore, many t, department of Vascular
practice nurses work part-time (Mohammad, Surgery,
2009) and consequently a patient may not see WorcestershireAcuteHospitalsN
the same practitioner on a regular basis, losing HSTrust
the important element of continuity of care.
The use of analgesia, and more importantly Submittedforpeerreview:20May20
the effectiveness of this, should be carefully 13;
monitored to ensure that the patient is offered acceptedforpublication30May201
3

Keywords:Chronicwounds,pain,
wound assessment, practice
nursing

Practice Nursing 2013, Vol 24, No 6 269

© 2013 MA Healthcare Ltd
 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
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 routine—compas- 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
Figure 1 (top). Chronic wound pain (evans, 2004). Although
inflammation entonox is not used routinely in clinical
Figure 2 (bottom left). practice, there is an opportunity to explore its
Wound critically colonized use in the gen- eral practice setting following
with anaerobes appropriate training.
Figure 3 (bottom right). Wound chronicity, infection, contact
Contact sensitivity 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
a (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.
© 2013 MA Healthcare Ltd
Some patients can develop a reaction to a
wound care product, which contributes to fur-
ther tissue damage, inflammation and pain
(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
270 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 patient’s
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
Clinical Focus WouNd CAre
Hypergranulation tissue In severe cases compression
Hypergranulation tissue is usually visible as therapy may have to be dis-
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 (o’Meara
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
patient’s 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.
continued to allow patients should be referred urgently for correctly. This should incorporate the
the damage to vascular assessment. important aspect of wound-related pain and
resolve. how to minimize this to improve the patient’s
Conclusion overall experience and quality of life. It is of
I s course an opportunity for practice nurses to
s The examples above demonstrate that a raise the awareness of their role in the
c lack of skill and competence has management of wounds and identify and
h resulted in adverse events for patients, address their learning needs. There should also
a unnecessary suf- fering and delayed wound be a commitment from general practices and
e healing. developing skills and competence clinical commissioning groups to ensure that
m in all aspects of wound management, nurses have access to education in this
i including the complexities of pain important aspect of clinical care.
a assessment has the potential to improve The development of wound assessment doc-
Patients with progressing outcomes for patients. umentation should take into consideration the
arterial insufficiency will The introduction of wound management compatibility of a tool with electronic records
complain of increased pain competencies for practice nurses is a step so that practice nurses can undertake holistic
and will often report pain for- ward. However, one could consider that wound assessments and identify problems
at rest or on elevation these do not go far enough. The through ongoing patient assessment.
(Beard, competencies are for uncomplicated wounds
2000). Prompt action only and it is somewhat challenging to define Conflicts of interest: none

should be taken if the what would be an uncom- plicated wound.

patient develops clinical
signs of ischaemia and
resultant pain, these
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
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