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magine going to the dentist and having a tooth filled without any local anesthesia. Does it evoke feelings of fear, discomfort, or worse? Would you complain to the dentist or “grin and bear it”? Would you go back and see that practitioner, stop going to the dentist altogether, or try to find other options?
       Pain management and wound care have not always gone hand in hand. Not too far in the distant past, people were expected to endure great pain in the dentist’s chair. Dental anesthesia is light years away from where it was back then. Thankfully, no one today has to endure pain in the dentist’s chair—or in the wound clinic, for that matter.
       Is the idea of caring for and treating patients with wounds while causing the least amount of pain and discomfort a realistic goal? As the primary advocates for our patients, we must strive for it in our clinical practices. If your goal is to provide your clients with pain-free wound care, you share one of my passions. This article will cover new ideas and the latest information regarding pain management and wound care, as well as some simple guidelines to prepare your facility to offer pain-free wound management.

The Patient’s View

       From the other side of the bedrail, the patient has many concerns. The patient views pain as the worst aspect of his or her chronic wound but will often suffer silently, not wanting to be viewed as someone with low pain tolerance.
       The literature tells us that patients rank pain control as more important than healing.¹ Pain has been shown to be a primary reason for why they fail to attend clinic visits.² Patients fail to request pain relief because of their own misconceptions and faulty assumptions. For example, I remember my own grandfather, a cancer patient, stating, “If the doctor wanted me to have something more for pain, he would have offered it to me.”
       Many barriers to pain management exist. Myths about the inevitability of pain, cultural and religious issues, and social and socioeconomic factors involved with the patient and the patient’s family sometimes block the control of pain. System-related challenges include a lack of specialized pain resources, a low priority given to pain management, and insufficient reimbursement or expense. Often, care providers lack education in pain management or fear that patients will develop dependency to pain medication. Only education will change these unfortunate facts.
       Therefore, our ultimate goal is to assess, measure, document, manage, and evaluate patients’ wound pain experience to their satisfaction. McCaffrey suggests that pain is whatever the experiencing person says it is and exists whenever he or she says it does.³ It is always a subjective experience.

Assessment

       All patients with wounds should be assessed for pain—no exceptions. The Department of Veterans Affairs considers pain assessment “the fifth vital sign” and collects pain data with each vital sign measurement.⁴ An easy pneumonic to remember the components of wound pain is the letters P-Q-R-S-T. Pain assessment should cover:
• Palliative/proactive factors: The question “What makes the pain better or worse?” is helpful.
• Quality of pain: Ask “What kind of pain are you experiencing?” and “How would you describe it: sore, burning, or throbbing?”
• Region and radiation of pain: Eliciting questions, including “Where is the pain right now?” and “Does it radiate?” can help pinpoint the pain.
• Severity of pain: Use one of the many quantitative scales, such as the visual analog scale, the numerical rating scale, or the Wong-Baker Faces Scale, to assess the severity of the patient’s pain. The verbal rating scale (VRS) is one the simplest scales to use and consists of no more than four words (none, mild, moderate, and severe).³
• Temporal aspects of pain: Questions, such as, “When does the pain stop and start?” and “Is it better or worse any particular time of day or night?” can help.
       Be aware of nonverbal cues, such as restlessness, guarding the area or wound, grimacing, sweating, muscle tightness, squinting, dilated pupils, and either constant sleep or inability to sleep, as indicators of pain. Caregivers may overlook infants and patients who are elderly, deaf, nonverbal, or cognitively impaired. Make sure their pain is assessed.

Wound Pain and Types

       Wound pain usually relates to the etiology or treatment of the wound. Etiology issues that can cause pain include inflammation, edema, ischemia, claudication, infection (cellulitis and osteomyelitis), venous hypertension, and malignancy. Treatment concerns consist of dressing adherence, debridement, cleansing, and manipulation of the wound bed and periwound skin.
       When first addressing wound pain, it is necessary to understand the etiology of the wound, treat the cause, and remove the noxious stimuli. Let’s look at the various wound types, the potential causes of pain, and the treatment recommendations.
       Pressure ulcer pain is often due to ischemia from pressure and shear leading to discomfort caused by inflammation. Langemo and associates found that half of all patients with pressure ulcers have pain, particularly those with stage 3 and stage 4 ulcers.⁵ Treatment is aimed at the cause: assessing risk for every potential client, providing appropriate pressure redistribution (support surfaces, both mattresses and cushions), supporting the host holistically, maximizing nutrition, mobilizing the immobile, treating bioburden and infection, and practicing appropriate preventative care.
       Venous ulcer pain is described as dull, aching heaviness that can continue after the ulcer heals. This pain is often secondary to edema and internal pressure. Venous ulcers were historically believed to be painless, but we now know that this is far from true. Seven recent studies determined most venous ulcer patients (63 percent or more) experienced pain.⁶ Addressing the pain involves treating the cause. For known venous insufficiency (with an ABI > 0.8), treatment includes compression, support stockings, and leg elevation.
       Neuropathy is the most common complication of diabetes. The amount of pain depends on the severity of the neuropathy and can interfere with the patient’s entire life, including the ability to sleep. The pain is often described as “pins and needles” or burning and itching. New pain can indicate a developing infection. Teach every patient with diabetes to report this important sign.
       We begin to address neuropathic wound pain by eliminating or controlling the source. Proper control of diabetes, preventative foot care, offloading, and pharmacologic intervention—often with tricyclics and antidepressants—are key.
       Arterial ulcer pain is frequently associated with peripheral vascular disease and intermittent claudication, which can occur at night, when the patient’s legs are elevated at periods of rest, or as a result of activity or exercise. It is usually described as burning, cramping, or aching.
       Treating the source of the arterial ulcer pain consists of teaching the patient to dangle his or her legs with unrelieved pain and, if medically necessary, bypass grafting or balloon angioplasty to revascularize the ischemic area.

Wound Pain Basics

       Assume that every wound is painful and every patient who has a wound is in pain. Patients frequently experience pain during dressing changes (e.g., from dried dressings, strong adhesives, debridement, and the pressure of exudate), around wound edges, and in infected or inflamed wounds. Wound pain can serve as an important indicator of inadequate wound management, untreated underlying cause, and/or infection.
       Moist wound healing has been demonstrated to result in faster healing, less scarring, and less pain. The pain reduction is attributed to the bathing of nerve endings in fluid, preventing dehydration of the nerve receptors.⁷
       Edema, swelling, and inflammation can cause or contribute to the pain experience. Infection and inflammation alone can be painful. Superficial infection may cause local pain or discomfort due to the release of mediators by the bacteria and the host. The exudate of chronic wounds has abnormally high concentrations of proteases, particularly matrix metalloproteinases.⁸ These increased proteases shift the wound healing balance into a continuing chronic-inflammatory phase. The use of compression bandages, hosiery, and binders can offer relief. Also, look to newer dressings, such as activated polyacrylates, which diminish edema at the wound site.
       The following pain relief strategies are intuitive but sometimes forgotten: handle every wound gently; avoid unnecessary stimuli, such as drafts; protect wound edges; allow patients to change their own dressings if possible and allow them to call “time out” with a pre-arranged signal, word, or phrase; encourage imagery and slow, rhythmic breathing; and premedicate 30 to 60 minutes prior to dressing change, considering the use of local anesthesia, such as EMLA Cream (AstraZeneca Pharmaceuticals, Wayne, Pennsylvania) or Lidoderm® (Endo Pharmaceuticals, Chadds Ford, Pennsylvania).

Dressing and Treatment Strategies

       Dressing removal is considered to be the time of most pain.⁹ Dried dressing and adherent products are most likely to cause pain and trauma at dressing changes. Products designed to be nontraumatic should be used to prevent tissue trauma. Gauze is most likely to cause pain and should be avoided. Clinicians should avoid wet-to-dry regimens, as well.
       Consider novel alternatives, such as polyacrylate debriding. This method of debridement debrides at an average rate of 38 percent and produces no discomfort,¹⁰ compared to papain/urea, with a debridement rate of 17.75 percent, and collagenase, with a debridement rate of 0 percent.¹¹
       The latest products, such as hydrogels (sheet, strands/cavity, and amorphous), hydrofibers, alginates, soft silicones, cellulose, “smart” foams—advanced foam dressings that can absorb large amounts of fluids while protecting against contaminants—and polyacrylates, are the least likely to adhere and cause pain. Be sure to select dressings with absorbency that matches exudate levels. Choose dressings that can remain in situ for longer periods of time, thus minimizing the chances of wound manipulation and a harmful aggravation of the pain cycle (see Table 1).
       Contact layers or dressings that remain in close proximity to the wound bed during dressing changes also have proven beneficial in the pain arena. Don’t neglect pain management during wound cleansing, either. Appropriate noncytotoxic wound cleansers used at body temperature (~100°F) at 4-15 psi are best to keep discomfort at bay.¹² Avoid cytotoxic solutions, such as povidone iodine or hydrogen peroxide, when cleaning the wound.¹³
       Simple measures, such as the use of skin preparations (especially the no-sting varieties), to strengthen and prepare the skin for adhesive application provide less trauma to tender periwound skin. Use them whenever you dress a wound. Consider tape alternatives, such as netting, tubular dressings, Velcro wraps, and Montgomery straps, to attach dressings. If the dressing gets dry, moisten it with wound cleanser or normal saline to soak it prior to removal.
       Silver dressings, especially ionic silver hydrogels, could be one of the most ideal pain-free dressings. The dressings provide a broad-spectrum antimicrobial action with no known resistance and maintain moisture balance with pain-free application and removal. They also provide for autolytic, thus pain-free, debridement and display anti-inflammatory actions while eliminating any offensive odors.¹⁴ Think about adding one of these versatile dressings to your protocols.

Adjunctive Tactics

       What other pain-relieving tactics can we integrate into our advanced wound caring practice? Dallum and associates showed that pain was significantly lower in patients using support surfaces for pressure reduction.¹⁵ Support surfaces take pressure off of the body’s frame and soft tissue, promote a healthy microclimate, and conform to body contours.
       For gentle skin care, use a four-pronged approach: clean, moisturize, protect, and nourish the skin of every patient—every time. Consider going soap-free. Newer products without harsh surfactant-type cleansers use phospholipids to clean, leaving the skin healthier and more comfortable. Look for ingredients like MSM, or methylsulfonylmethane, which slows the conduction of pain fibers and helps to reduce inflammation.¹⁶
       Do you ever utilize negative pressure wound therapy (NPWT) or Vacuum Assisted Closure® Therapy™ (V.A.C.® Therapy™, KCI, San Antonio, Texas)? Reality is that although this high-tech therapy can help treat difficult wounds, it often produces pain. Consider premedicating the client 30 to 60 minutes prior to removal. Instillation of normal saline and/or a physician or nurse practitioner’s order for lidocaine solution injected 30 to 60 minutes prior to dressing or sponge removal can dramatically reduce pain.
       Line the wound bed with an amorphous hydrogel or powder with ionic silver—it not only helps relieve pain on initiation and removal but can also cut offensive odor and number of days on NPWT—or a nonadherent gauze.¹⁷ Also, be sure to apply a skin prep or sealant to the periwound skin prior to applying the occlusive drape.
       Other strategies include keeping exposed tissue moist with normal, saline-soaked gauze or impregnated hydrogel gauze. Ensure that adequate personnel participate in the dressing change to minimize the time. More than one clinician is usually necessary to change these complex dressings.
       Increased cortisol levels lead to immunosuppression and poor wound healing. Delayed healing is associated with emotional stress, higher anxiety, and depression.¹⁸ Help your patients relax and cope with stress by referring them to mental health professionals who can offer appropriate therapy and pharmacologic intervention when required.
       What does the future hold? The lidocaine 5-percent patch (Lidoderm® Patch, Endo Pharmaceutical) was recently approved by the Food and Drug Administration for local anesthesia of neuropathic pain. Experimental use of lidocaine-infused amorphous hydrogels, compounded for sustained release into painful wounds, is being undertaken. Additionally, exploration of the effects of topical opioids, such as morphine-infused hydrogels, on treatment of painful wounds continues.

Standards and Evidence

       Still not convinced that wound pain is an issue with your clients? Consider the following:
• The Agency for Healthcare Research and Quality (AHRQ) recommends that pressure ulcers be routinely assessed by healthcare workers who should not assume the absence of pain in patients who cannot express or manifest it. Assess all patients for pain related to the pressure ulcer or control the source of pain (e.g., cover wounds, adjust support surfaces, reposition the patient). Provide analgesia as needed and appropriate. Prevent or manage pain associated with debridement as needed.¹⁹
• Szor and Bourguignon reported that 87.5 percent of patients with wounds reported pain at dressing change, and 84.4 percent of patients with wounds reported pain at rest.²⁰
• Dallum, et al., reported that only two percent of patients with pressure ulcers who reported pain or discomfort received pharmacologic treatments.²¹
• Krasner found that 42 percent of patients reported pain as continuous, occurring both at rest and at dressing changes.²² Only six percent of these patients were prescribed analgesics.
• The American Geriatric Society (AGS) Panel on Persistent Pain in Older Persons found that up to 80 percent of nursing home residents with pressure ulcers have significant pain that is undertreated.²³
       Lastly, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released revised pain management standards.²⁴ Among the requirements: pain must be assessed and reassessed regularly; routine and as needed analgesics must be administered; and discharge planning and teaching must include continuing care based on the patient’s needs at the time of discharge, including pain management. Additionally, it requires that patients:
• Have the right to appropriate assessment of their pain
• Will be treated for pain or referred for treatment
• Will be taught the importance of effective pain management
• Will be taught that pain management is a part of treatment
• Will be involved in making the care decisions.

Take it Home

       To assess how your facility addresses wound pain, ask yourself the following questions. Do your protocols include the pain management components of wound care? Do you have a pain specialist on your wound care team? Are you using appropriate wound management techniques and dressings to help alleviate pain? Are you offering your patients a pain-free wound care experience? Make sure these goals extend to your wound care practices, and you’ll be performing 21st century care with a gentle hand!

Helpful Websites

• Agency for Healthcare Research and Quality:http://www.ahrq.gov
• American Pain Society:http://www.ampainsoc.org
• Joint Commission on Accreditation of Healthcare Organizations: http://www.jcaho.org
• American Society for Pain Management Nursing: http://www.aspmn.org
• American Academy of Hospice and Palliative Medicine: http://www.aahpm.org
• American Academy of Pain Management:http://www.aapainmanage.org
• American Chronic Pain Association:http://www.theacpa.org
• Nursing Leadership Consortium on End-of-Life Care: http://www.palliativecarenursing.net
• Association for the Advancement of Wound Care: http://www.aawcone.com