Relieving Pain during Dressing Changes in the Elderly

Some practical measures can reduce pain during dressing changes, making the experience tolerable for residents in long-term care. Here are some important tips to remember:

• Wounds that are immobilized hurt less. Dressings that adhere well to healthy tissue without adhering to the wound reduce pain and trauma. Avoid all sticking, pulling, bleeding, and tearing of the wound bed. Trauma not only increases pain, but it also keeps the wound in the inflammatory phase and causes increased drainage.

• All dressings should be moist when they are removed from the resident. The wound bed should be kept moist. The drying of exposed nerve endings and air flowing against nerve endings is very painful. Removing adherent dressings requires soaking until the dressing is saturated. Using lotion on the caregiver’s hands as the edges of the dressing are gently removed helps break the adhesive-type dressing. Painful dressings should be replaced by the newer silicone and polymer-type dressings. The attachment breaks when in contact with water, resulting in reduced pain.

• Exudating wounds requires absorptive dressings and timely dressing changes. Exudate that remains in and on the wound bed increases cellular pressure, causes pain, and erodes the periwound surface.

• The periwound surface must be protected throughout the healing process. Trauma, excoriation, erythema, maceration, and dermatitis of intact skin delay epithelial activity and increase pain. All re-epithelialization is orchestrated from the edges. Special attention to the periwound should be part of all dressing changes. Using fillers to collect exudate is helpful. The frequency of dressing changes should be based on the amount of drainage. Many absorptive foams cue the clinician when dressing saturation is 70-75%.

• When cleaning wounds, use warm solution and only noncytotoxic materials. Avoid using cleansers or products that produce burning, stinging, or bleeding. Any trauma to the wound is damaging to the cellular matrix.

• Pressure relief must always be part of the treatment regimen. Wounds must be offloaded, loosely packed, and protected from pressure. This can be achieved by using appliances, foams, specialty mattresses/cushions, and positioning devices. Patient education in the use of these products is necessary for success. If the device is not comfortable, the resident will not use it consistently. Follow up with the residents and ask how the device is working.

• Allow residents to assist and participate in dressing changes. Suggest that residents call time-outs if they are feeling uncomfortable. As residents know their own tolerance level, they may want to remove the dressings themselves or assist in cleaning the wound. • Prepare the resident for the dressing change. Explain what is taking place during the dressing change. Instruct residents in deep-breathing techniques. Utilize calming imagery. Constantly check with the resident throughout the procedure.

• If analgesics are needed, administer them at a time that will provide relief to the resident during the dressing change. Consider the resident holistically. Failure to treat pain effectively is no longer acceptable and should be considered a prime indicator of poor quality medical care.

Resources

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Dykes PJ, Heggie R, Hill SA. Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care 2001;10(2):7-10.

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Krasner D. Chronic wound pain. In: Krasner D, Kane D, eds. Chronic Wound Care: A Clinical Sourcebook for Healthcare Professionals. 2nd ed. Wayne, PA: Health Management Publications; 1997:336-343.

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Melding PS. Is there such a thing as geriatric pain? Pain 1991;46:119-121. Adapted and reprinted with permission from Ostomy/Wound Management 2002;48(5):20-21.