Addressing the Pain: Pain Doesn`t Have to be a Part of Wound Care

  The pain experience is an unpleasant sensory and emotional response to injury - only the person enduring the sensation can provide an accurate description. We have learned from the field of psychoimmunology that emotions strongly influence the body's response to illness, infection, and recovery. Only recently has the healthcare community begun to connect the dots between wound trauma, pain, emotions, and delayed wound healing. The outcome? Pain doesn't have to be a part of wound care.

The Emotional Experience of Pain

  The most common components of local chronic wound care are wound cleansing, dressing changes, and debridement. Because most patients with wounds have experienced pain, they often harbor feelings of fear and anger, believing that all such procedures have to be painful and feeling skeptical about future wound treatments and the clinicians providing care. As a result, patients often do not report wound pain verbally or cognitively; instead, they communicate pain through behaviors. Expression of pain may include body language, signs of anxiety and depression, lack of compliance with therapy, and missed appointments. Depression is a common component of patients with chronic health conditions, including chronic pain and chronic wounds. Rebuilding trust is extremely difficult because of the negative expectations of patient and clinician. If problems of depression and anxiety persist and the clinician seems unable to help the patient recuperate, referring the patient for psychiatric help is appropriate.

  In addition, social and cultural factors such as religion, the meaning of pain, and the desire to be a "good patient" all are contributing factors for patients and caregivers underreporting pain. Myths abound regarding the negative side effects and addictive tendency of pain medications. Thus, many individuals just believe that they are better off to "tough out" wound pain.

Changing the Paradigm

  Pain is a personal matter - only the individual can accurately evaluate and report his/her pain Therefore, the patient must be brought into the process from the beginning. The clinician should:
  * Determine the patient's goal for managing his/her pain
  * Empower the individual by letting him/her know that appropriate pain relief is a right
  * Teach the patient that less pain means more gain in wound healing
  * Assure the patient that he/she will be part of the team effort to develop a pain relief plan and that the plan can change if the pain is not under control.

  The goal is to provide the patient with a sense of personal control over the pain by changing myths and misconceptions through education and noticeable results.

The Pain Control Plan

  Pain assessment. Use a pain assessment tool to develop the pain control plan. A good tool should allow the patient and clinician to determine the location of the pain (with body diagrams to mark), the intensity as rated on a pain scale (including the scale used), the effects of interventions on the pain (worse, better), the quality of the pain in the patient's own words (eg, stabbing, burning, throbbing, itching), onset (what causes pain?), duration, variations, aggravating and relieving factors of pain, previous treatment and results, attitudes towards medications, coping strategies, preferences, and expectations.

  Using a tool such as a numeric pain rating scale (NPRS), visual analog scale (VAS), or faces scale to quantify a patient's pain level has become standard for assessing pain. All three have been validated - a numeric pain scale has been shown to be a more appropriate choice for elderly patients and a faces scale is effective for children and people with cognitive problems. Have the patient select a pain scale that he/she feels best describes the pain. Be sure to include one scale in the selection with figures or terms in the patient's native language (eg, Spanish). Also, enhance the meaning of the numbers on a pain scale by explaining the subtle difference between 4- and 5-level pain (pain noticed at rest or during activity; this may be a warning of worse pain to come), 6- and 7-level pain (you may be gritting your teeth to carry out activities), and 8- and 9-level pain (pain that makes you stop an activity or not be able to start it at all). This helps the patient recognize what triggers increased pain and what corrects it. Feedback from the pain scale can reassure the patient that the pain is lessening.

  Consider keeping a patient pain management diary to track the results of pain interventions. The diary provides the patient and healthcare provider feedback and a documented record of the pain treatment and its effectiveness. A pain scale at the top of the diary page will assist the patient in quantifying pain. Other items to include on the diary are the date, time, and medication or non-drug pain control method used, the activity being performed at the onset or exacerbation of the pain, and the severity of the pain 1 hour after the pain control intervention is used. The patient should be instructed to bring the pain management diary to clinic visits or to refer to the dairy during a phone conference to report problems with the pain control plan between visits, should a problem arise.

  Preventing wound trauma and pain. External causes of wound pain often are associated with wound trauma occurring during wound cleansing, dressing changes, sharp debridement, and turning and repositioning. Instruct the patient to clean the wound with warm fluids that are soothing - not cytotoxic to cells of repair or caustic to the wound or surrounding skin. Encourage the patient to participate in wound dressing changes. Time outs called by the patient during dressing changes allow the patient to control the situation. Premedicate before sharp debridement. Anti-anxiety medication may be as, if not more, effective as analgesics. Remember to teach the patient to support injured tissues during turning and repositioning.

  Select nontraumatic, moisture-retentive wound care dressing products and perform fewer dressing changes. Dried out wound dressing (eg, gauze) and tissues irritate local nerve endings. Wound dressings that do not dry out and adhere to the moist wound base are available. Wound environment-friendly dressings include products such as hydrogels, hydrofibers, alginates, and soft silicones. Some dressing adhesives (eg, hydrocolloids) become sticky after initial application to effect tighter adhesion, reduced dressing movement, longer placement, and gradual release after several days. Premature removal of such dressings can result in skin tears, damage to wound tissues, and pain. Manufacturer recommendations concerning duration of application before removal should be reviewed and followed. If dressings need to be changed often due to heavy exudate, infection, or other treatment needs, the dressing of choice would need to meet those criteria, as well as be nontraumatic to the wound and surrounding tissues when removed. Frequent dressing changes are not only uncomfortable but also biologically undesirable - during dressing changes, wound tissues are chilled and nerve endings are irritated, a combination that slows healing. Timely removal of dressings is also important so the dressing will not dry out and adhere to the wound bed.

Self-care Patient Pain Strategies

  Teach the patient self-care strategies for pain. Preventing pain is better than trying to stop or chase it. Pain medication requires 45 to 60 minutes to achieve the desired effect, so the patient should be instructed to take a pain pill 30 minutes before a clinic visit involving a procedure. Splinting or immobilizing the wound area can decrease drag on injured tissues during moving or repositioning. To get more mileage out of pain medication, the patient should be instructed to 1) take pain medication on a regular schedule, setting an alarm clock as a reminder, and/or 2) use complementary therapies such as relaxation techniques, heat or cold on the painful or opposite area, transcutaneous electrical nerve stimulation therapy, music, and guided imagery to reduce emotional stress and calm the nervous system. Persistent pain, including pain at the wound base and the periwound tissues when nothing is being manipulated, may be attributed to other factors such as ischemia or infection. Diagnostic testing (eg, laboratory tests and noninvasive vascular testing) may be indicated for chronic wound or periwound pain. Above all, patients need to know that they should focus on what they can do to stop pain rather than on what they cannot do. They should be encouraged to keep asking for help and trying to alleviate the pain.

Making the Plan Work

  Assessment is a key word for healthcare providers. One area often not assessed is the patient's learning readiness. Is the patient in a state of comfort and energy conducive to learning? Is the patient asking questions or receptive to new information when teaching is suggested? If the answers to such questions are No, postpone the teaching, speak with the family, and look for other teaching opportunities. One sign that the patient is comfortable with learning is when he/she is asking questions and venting concerns.

  Engaging the patient in learning is an important part of patient education. Determine the patient's motivation: Ask if he/she would like to learn about the topic you had in mind and if this seems important. What is the patient's learning capability? Is literacy a problem (ie, difficulty with written instructions)? Is language or visual impairment a barrier? If the patient is not capable of learning, instruction would be inappropriate and alternative methods of communication involving family and caregivers would be necessary. The ability to follow through with direction is directly related to the person's receptiveness to learning and the ability to understand materials presented. Health professionals can select from a number of patient education materials written at different levels for ease of understanding. Larger type and simple terminology enhance readability. Try to select materials that contain only essential information about the topic. Few healthcare professionals have the necessary skills or time to accurately assess a patient's literacy and comprehension; offer the patient several different samples of education materials on the same subject and allow him/her to choose which ones are most helpful.

  Additional factors that influence patient behavior and treatment outcomes that often are overlooked include the patient's knowledge, skill, attitude, and past experiences. Social factors (social support system and attitudes and beliefs of his/her the family, peers and employer); environmental factors (living arrangements and financial status, daily schedule including employment, and family or child care obligations); and the demands of the medical regimen (wound care, complexity of the healthcare plan, side effects, costs, duration, and time) also must be considered. By identifying the factors that may hinder the success of the teaching and by learning about and addressing them early in the wound care process, you can help the patient reach the targeted goals.

  Patient education is an ongoing part of quality patient care. Continuous feedback from patients and their families is necessary on a regular basis. Part of the Pain Control Plan should include a scheduled assessment of the pain plan itself. Plan format assessment, suggested by the Agency for Health Care Policy and Research Clinical Practice Guideline for Pain Management, includes questions such as: Is the pain plan hard to follow? Are you pleased with your pain control? Is it hard to take your medicine? Is the pain plan causing a problem for you or your family? Are the non-medicine treatments working for you?

  Educate the patient and caregiver on the importance of reporting conditions that may be contributing to pain, including excessive or foul smelling drainage, itching or redness, severe emotional distress, bleeding, fever, unusual wound appearance, inability to follow the treatment regimen, or need for additional supplies.

  Not all wounds will heal and not all patients have an expectation of a healed wound, but controlling wound pain so the patient can have the best possible quality of life is doable.

Conclusion

  Managing and preventing wound pain is morally, ethically, and medically the right thing to do. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has incentivized pain management by making it a standard to be met by all healthcare organizations. This includes prevention and treatment of wound pain. Another JCAHO standard is for patient education. A pain control plan that includes patient education would meet both standards. In addition, documenting pain assessment, pain management results, and education is also a way to reduce liability and to remain in compliance with health facility licensing requirements. But the biggest incentive is the impact of less pain on your patients and you as a concerned care provider.

 Addressing the Pain is made possible through the support of Molnlycke Health Care, Newtown, Pa.