Journal of Community Nursing - page 38

38 JCN
2013,Vol 27, No 4
WOUND CARE
supported byVuolo (2009) who cited
the psychological impact of having
a wound, which, depending on its
location, can cause issues with body
image and self-esteem as well as
embarrassment at exudate and odour.
All these elements can lead to loss of
sleep and appetite, anxiety, and loss
of independence.
TYPES OF PAIN
Pain is intrinsic in origin, arising from
the person experiencing it, although
sources are varied and can be
categorised in different ways.
Acute pain is usually nociceptive
and caused by stimulation of
peripheral nerve fibres, which send
a‘pain message’to the brain when
they are activated or damaged (Acton,
2008). Acute pain is a symptom of
injury or illness and usually ceases
when the underlying problem is
resolved. Acute pain performs an
important protective function, warning
of injury or harm and the need to limit
further tissue damage, but it is how
this pain is managed that is important.
Acute pain is an appropriate response
to a painful stimulus and may involve
acute or chronic inflammation.
Chronic pain can be nociceptive
and/or neuropathic in origin, typically
continuing longer after the original
tissue damage has resolved. Chronic
pain involves an alteration of normal
pain transmission pathways (Wulf
and Baron, 2002). Three common
altered pain transmission pathways
are ‘wind-up’pain, allodynia and
hyperalgesia:
Wind-up pain: repeated stimulus
of the same intensity can lead
to increased pain response to
the same stimulus, i.e. wound
cleansing
Allodynia: an area of increased
sensitivity can develop near to
the site of an original injury. This
area produces extreme pain in
response to minimal stimulus, i.e.
the breeze from a fan
Primary hyperalgesia: tissue injury
resulting from inflammation,
infection and ischaemia produces
chemical mediators that activate
or sensitise nociceptors.
Pain can also be categorised by
when, and for how long it occurs
(
Table 1
). Anticipatory pain is of
particular significance as patients may
remember the pain of a procedure
for decades, thereby making
them reluctant to undergo certain
interventions (Moffat et al, 2002).
In the case of wound care
specifically, Laterjet (2002) has
suggested that it is essential to
recognise the significance of
patients’ first experience of having a
wound dressed — inadequate pain
management at this stage could have
lasting effects, with patients dreading
subsequent dressings and losing
confidence in the care team.
This is something the author
sees regularly, particularly when dry
dressings are applied to burns and
have to be soaked off, with patients
refusing to be treated by the same
healthcare professional thereafter.
Woo (2010) has suggested that
anxiety can also increase wound
pain at dressing change, stating that
patients with higher levels of anxiety
anticipate more pain and, therefore,
experience more intense pain.
PAIN ASSESSMENT
There are various assessment
tools that can be used in pain
management, with effective
assessment usually involving self-
report methods. The advantages of
self-report are that there will be a
consistent and clearly measurable
record of any changes to patients’
pain levels.
The same tool should always be
used and pain should be measured
before, during and after the dressing
change (Acton, 2008) (
Table 2)
.
In older people, communication
may be a problem due to their
medical condition or mental state.
Alternative pain tools can be used
(such as the Oucher Scale
Figure
1
), or assessments should also
include visual observations of non-
verbal signs such as facial colour
or expression, increase in pulse
rate, moaning, tension, and body
movements, which could all be signs
of pain (Lloyds Jones, 2008).
For neuropathic pain,
assessment could be made by
using the neuropathic pain scale
(Galer and Jensen, 1997), or the
Leeds Assessment of Neuropathic
Symptoms and Signs pain scale
(S-LANSS) (Bennett et al, 2005).
PAIN MANAGEMENT
Dressing selection
Dressings that have dried out are
identified as the most common factor
contributing to wound pain (Bell
Table 1:
Different types of pain
Type of pain
Onset and duration
Background
Is felt intermittently or continuously and may be exacerbated by
certain events
Breakthrough/incident
Often occurs as a result of sudden movement or activity such
as standing
Procedural
Relates to specific procedures, i.e. wound cleansing and often
continues for some time afterwards
Anticipatory
Is described as incurring or intensifying pain through expectation.
Is of particular significance as patients can remember it for decades
Table 2:
Different types of pain assessment tools
Visual analogue tool (VAS)
A 10cm line with‘no pain’at one end and‘worst pain imaginable’at
the other. Patients mark where on the line represents the intensity
of their pain
Numerical rating scale (NRS)
This includes numbers from 0–10, with patients stating which
number represents their pain intensity
Verbal rating scale (VRS)
This usually consists of five words, which are used to describe pain,
e.g.‘none’,‘mild’,‘moderate’,‘severe’or‘excruciating’. Patients state
which word best describes their pain intensity
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