Addressing the Pain: Plain Talk about Wound Pain

   To some degree, almost every person with an open wound experiences pain. The pain may occur during wound cleansing or debridement (noncyclic pain), during repeated treatments such as daily dressing changes or repositioning (cyclic wound pain), or during quiet time without manipulation (persistent pain).¹ The pain experience might even be one of anticipation; the anxiety of a painful event potentially is as disabling and as real as physical pain.

   The manner of dealing with the pain and the condition varies with the individual, the circumstances, and the level of the tissue injury. Healthcare professionals are responsible for recognizing the person in pain, assessing the type of pain, and determining appropriate interventions for relieving/easing the pain.

   Pain is the reaction to signals transmitted throughout the body but more importantly, pain is what the person says it is. It is an experience that cannot be separated from the patient’s mental state, environment, and cultural background. These factors can cause the brain to trigger or abolish the experience of pain, independent of what is occurring elsewhere in the body. When assessing pain, investigating relevant mental and environmental factors is critical.²

   The pain experience is dynamic and variable and has been categorized in different ways. Acute pain is described as an identified event that resolves in minutes, hours, days or weeks. Acute pain is usually nociceptive — nociceptive (from the word noxious meaning harmful) pain is caused by an injury or disease outside the nervous system. Nociceptors are specialized nerve endings in skin and deeper tissue. The pain may originate from direct nerve stimulation of the intact fibers.³ The pain is often an ongoing dull ache or pressure, rather than the sharper pain characteristic of neuropathic pain. The severity of pain usually correlates with the level of tissue damage. Nociceptive pain triggers a protective reflex (eg, to move your hand immediately if you touch a hot object). The pain is a symptom of injured or diseased tissue — when the underlying problem is cured, the pain usually goes away. Nociceptive pain is usually finite and responds well to treatment with opioids.

   With persistent (chronic) pain, the cause is not usually identified or may be multifactorial and often is of undetermined duration. The pain can be nociceptive and/or neuropathic. The nerves continue to send pain messages to the brain even though tissue damage has ceased.

   Neuropathic pain is a form of chronic pain. Neuropathy is any functional and/or pathological change in the peripheral nervous system. The three types of neuropathy are sensory, motor, and autonomic. They may occur individually or combined. Neuropathic pain is caused by damage to nerve tissues/fibers and is often felt as a burning or stabbing pain (eg, the pain experienced with a pinched nerve). The pain is often chronic and does not respond well to opioids. Neuropathic pain may respond to antiseizure and antidepressant medications. Nerve irritation (burning and/or stinging pain) may respond to tricyclics (amitriptyline or nortriptyline). The shooting/stabbing pain of nerve damage responds well to anti-epileptic medication (eg, gabapentin).

The Chronic Wound Pain Experience

   According to Krasner’s¹ description of the chronic wound pain experience (see Figure 1), cyclic pain may be experienced when turning the patient or during routine dressing change, and non-cyclic pain may occur with wound debridement or suture removal. The healthcare professional should minimize procedural pain — the best intervention is a combination of pharmacological and non-pharmacological techniques. The clinician should medicate the patient before the procedure, use non-pharmacological interventions (see Table 1), use local anesthesia, and select atraumatic dressings such as soft silicone.⁴ These dressings have a non-adherent wound contact layer but adhere readily to intact skin with a gentle adhesion capacity that decreases skin stripping. Absorbent silicone dressings help prevent skin maceration.

Asking the Right Questions

   Understanding the patient’s pain experience begins with involving the patient and significant others in the physical and social assessment. Their description of the pain situation will give clues as to how to manage the problem. Because many patients find it difficult to describe the pain, giving them descriptive words to choose from and using a pain measuring tool help them articulate their experience. Asking the patient to complete a pain assessment profile and document their pain experience for 3 to 5 days in a 24-hour diary (see Figure 2) will help provide a complete picture of the experience and allow the clinician to implement specific pain strategies to diminish or relieve the pain.

   Assessing pain for those patients with mental confusion or cognitive impairment often is difficult. Signs of pain in a non-responsive person may include change in function or activity, alteration in mood, facial grimacing, moaning, groaning, crying, or fidgeting. Direct observations by care providers augment the patient’s description of the pain experience. When diseases associated with significant pain (eg, arthritis, cancer, or ischemia) are present, the clinician should suspect pain, even if the patient is non-verbal.

Treating the Patient with Pain

   When persistent pain is experienced, long-acting drugs are preferable. If the pain is not relieved, breakthrough dosing may be necessary. Whenever possible, clinicians should avoid medications that have adverse effects or if their use is necessary, anticipate and address side effects. One of the most common problems with pain medication is constipation. Increasing the fiber in the diet may resolve the problem.

   Helping the patient learn non-pharmacologic techniques for relieving pain is encouraged (see Table 1). For those experiencing incident pain (cyclic or non-cyclic), many strategies can be employed: warming solutions before use, using lubricious cleansers, wetting dressings before removal, allowing the patient to remove the dressing, using time outs to allow the patient to regain composure, and using a gentler hand.⁵ When the patient is aware of the possibility of pain, offering pain medications before the procedure is helpful. Local analgesics given before sharp debridement will relieve the pain (eg, lidocaine soak, see Table 2 and Figure 3). Even though evidence supporting use of topical analgesics is limited, clinician expertise teaches the importance of relieving pain associated with sharp debridement.

Odor

   Some wounds have an odor that can add to the psychological pain of the pain experience. The odor may originate from infection or the presence of necrotic tissue. The first step is to remove the causative factors — treat the infection, and when possible, debride the necrotic tissue. Odor may be alleviated through wound cleansing, wound irrigation, topical antimicrobial agents, using topical metronidazole, applying dressings with activated charcoal, burning candles, and using kitty litter near the patient area. Advanced wound dressings may need to be changed sooner due to the odor from excessive drainage.

Conclusion

   When feasible, clinicians should empower and educate patients and their families to take control of the pain experience. A basic educational booklet on the pain experience should be provided to the patient. Usually, when people understand what triggers pain and what can be done to relieve it, they will have more control over the situation and it will be less painful for everyone involved.

1. Krasner D. The chronic wound pain experience. Ostomy/Wound Management. 1995;41(3):20–25.

2. Richeimer SH, Bajwa ZH, Kahraman SS, Ransil BJ, Warfield CA. Utilization patterns of tricyclic antidepressants in a multidisciplinary pain clinic: a survey. Clin J Pain. 1997;13(4):324–329.

3. Reddy M, Kohr R, Queen D, Keast D, Sibbald RG. Practical treatment of wound pain and trauma: a patient-centered approach. An overview. Ostomy/Wound Management. 2003;49(4 Suppl):2S–13S.

4. Thomas S. Atraumatic dressings. World Wide Wounds. 2003; January. Available at www.worldwidewounds.com/2003/january/thoma/atraumatic-dressings.html. Accessed May 11, 2003.

5. Krasner D. Using a gentler hand: reflections on patients with pressure ulcers who experience pain. Ostomy/Wound Management. 1996;42(3):20–29.

Additional Resources
1. Paice JA. Understanding nociceptive pain. Nursing. 2002;32(3):74–75.

2. Moffat CJ, Franks P, Hollinworth H. Understanding wound pain and trauma: an international perspective. In: EWMA Position Document: Pain at Wound Changes. Medical Education Partnership LTD. London, UK 2002;2–7.

3. Kundu S, Achar S. Principles of office anesthesia: part II. Topical anesthesia. Am Fam Physician. 2002;66(1):99–102.

4. Menefee LA, Katz NP. The Pain EDU.org Manual: A Clinical Companion. Newton, Mass.: Inflexxion, Inc.;2003.