Pain control in wound

Pain  Control  In  Wound  Management

Most  wounds  cause  a  certain  amount  of  pain  (Casey  1998)  but  pain  management,  a  key  function  of  all health  professionals,  is  often  poorly  managed. 

Sometimes  pain  can  be  severe  and  ongoing,  such  as with  chronic  wounds,  while  at  other  times  it  may  only  occur  with  initial  injury,  or  during  infection  or during  dressing  change.
Patients  may  experience  pain  as  a  result  of:
•  Products or techniques  used  to  cleanse  wounds  
•  Trauma to the tissues  and  surrounding  skin  when  products  are  removed  
•  Skin excoriation  from  exudates  or  wound  drainage   •  Lack of empathy 
•  Failure to record  patient’s  earlier  reports  of  pain  
•  Infection,  which  can  exacerbate  existing  wound  pain
•  Poor techniques when  using  compression  bandaging. Careful  wound  assessment  is  required,  as  selecting  an  inappropriate  dressing  can  result  in considerable  pain  and  discomfort  (Dealey  1999). 
The  correct  dressing  can  ensure  comfort  and  reduce pain,  especially  during  dressing  change. Emotional  responses  can  also  influence  the  perception  of  pain  and  the  distress  of  having  a  wound. The  way  patients  detect  pain  appears  to  be  related  to  the  type  of  damage  causing  it  (Campbell  1995). Clinically,  pain,  like  wound  types,  can  be  classified  as  acute  or  chronic,  but  will  be  related  to:
•  The type of injury  
•  The location of  the  wound
•  Patient perception  and  previous  experience  
•  The healing process  and  approaches  to  wound  management,  e.g.  choice  of  dressing  and   provision  of  analgesia.
Assessment  Of  Pain Pain  should  be  assessed  prior  to  each  dressing  change  and  appropriate  action  taken  to  address  the identified  cause.  Accurate  assessment  depends  on  subjective  reporting  by  the  patient.  Pain  can  be assessed  effectively  during  ongoing  therapy  by  asking  the  patient  to  rate  his/her  pain.  It  is recommended  that  a  simple  visual  analogue  scale  is  used.

The  patient  should  be  asked  if  the  pain  is  worse  at  any  particular  time  or  during  a  particular  activity  so that  analgesic  doses  can 
be  timed  appropriately.  Patients  should  be  closely  observed  throughout  the dressing  procedure  for  reaction  to  treatment.  

Analgesia Whatever  analgesia  is  used  in  wound  care,  its  effectiveness  should  be  evaluated  continuously.  Failure to  achieve  pain  relief  may  contribute  to  the  depression  and  anxiety  associated  with  chronic  pain.   The  type  of  analgesia  to  be  used  depends  upon:
•  The type  of  wound
•  Whether  the  wound  is  acute  or  chronic
•  The level  of  pain  reported  by  the  patient.
•  Patients  individual  circumstances  e.g.  other  medicines,  co-morbidities Effective  doses  of  analgesics  should  be  given. 

In  chronic  pain,  treatment  should  be  given  often  enough and  regularly  to  provide  continuous  pain  relief.  This  is  preferable  to  giving  analgesics  only  when necessary,  ie  allowing  pain  to  recur  before  giving  further  treatment.

Analgesics should also be given in anticipation of pain, giving careful consideration to any activities which exacerbate pain. In the case of acute pain there is little time to titrate the dose against the patient’s response. Analgesics should be chosen according to assessment of the factors mentioned above.  

The use of non-steroidal anti-inflammatory drugs (NSAIDs) eg aspirin, ibuprofen, diclofenac etc., is common in treating minor injuries and in long-term inflammatory conditions. This is due to their action of inhibiting the production of prostaglandins (inflammatory mediators). If wound pain is ongoing it may not be appropriate to use an NSAID due to their side effects.   The WHO analgesic ladder forms the basis of many approaches to the use of analgesic medicines. There are three essential steps on this ladder.

The Who Analgesic Ladder

REFERENCES

Campbell, J. (1995) Making sense  of pain management. Nursing Times 91, 34-35. Casey, G. (1998) The management of pain in wound care. Nursing Standard 13, 49-54. Dealey, C. (2005) The Care of Wounds, 3rd  ed. Oxford: Blackwell Science.  World Health Organization (1996) WHO Guidelines: Cancer Pain Relief, 2nd ed. Geneva, World Health Organization.