Journal of Community Nursing - page 40

40 JCN
2013,Vol 27, No 4
WOUND CARE
and McCarthy, 2010). Davies and
Rippon (2008) have supported this,
suggesting that the most common
causes of wound pain are dressings
that have adhered to the wound
bed, skin stripping of the periwound
area, and tissue maceration and
excoriation of periwound skin due
to inadequately managed exudate.
Benbow (2010) has stated that
accurate assessment should inform
the healthcare professional’s choice
of dressing, based on exudate levels
and tissue type. The challenge lies in
correctly identifying the needs of the
wound and matching the dressing to
these needs.
Woo (2010) identified that
dressing changes are painful when
the contact layer adheres to the
wound bed due to dried out materials
and aggressive adhesives; granulation
tissue and capillary loops growing
into the product matrix; or the glue-
like nature of dehydrated exudate.
Woo (2010) added that the enzymes
in the wound exudate can cause
maceration and tissue erosion, which
leave the periwound skin at increased
risk of trauma.
The World Union of Wound
Healing Societies (WUWHS, 2004) has
suggested that healthcare practitioners
select products that are appropriate
for the wound type, promote moist
wound healing and are atraumatic
on removal. Modern dressings are
designed not to adhere to the wound
surface or skin and, therefore, should
not cause trauma or pain due to skin
stripping (Benbow, 2010). White
(2008) reported that conventional
dressings caused higher pain ratings
at dressing change than atraumatic
dressings, a finding supported by
Upton and Soleweij (2012), who
found that patients using atraumatic
dressings reported lower levels of pain
and psychological stress.
Blackburn-Munro (2004)
identified high levels of background
pain in macerated periwound
areas. Therefore, dressings should
be changed before they become
saturated and allow the spread of
potentially corrosive wound exudate
onto periwound skin. Application
of a skin barrier before dressing
application will help to prevent
periwound skin trauma and prolong
wear time, particularly on difficult
anatomical areas.
If soaking is required to aid
removal, there is bleeding or trauma
to the wound or surrounding skin, or
if there is pain on removal, another
dressing should be considered (Briggs
et al, 2002).
Some dressings contain
aggressive adhesives that strip
skin cells on removal (Rippon et al,
2007), which causes unnecessary
suffering and can result in delayed
wound healing. However, retention
of dressings is problematic in some
anatomical areas and adhesives
are required to keep them in place.
Therefore, the development of
atraumatic dressings made from
soft silicone has been significant in
preventing wound pain. Timmons
et al (2009) used a series of case
studies to demonstrate that the
use of silicone-based treatments
provided effective treatment of
patients’wounds, without causing
excessive trauma to the wound
bed or surrounding skin. Timmons
et al (2009) added that the use of
these dressings helped to improve
the patient’s quality of life, reduce
anxiety and improve outcomes.
A number of authors have
suggested that the use of soft
silicone dressings reduces wound
pain at dressing change (Acton,
2008; Benbow, 2010; Upton, 2011).
Benbow (2010) stated that this is
because the soft silicone does not
adhere to the wound’s surface or the
skin and, therefore, does not cause
trauma or pain due to skin stripping
on removal. Therefore, soft silicone
dressings should be considered in
patients who have anticipatory pain
or are at high risk of periwound
trauma.
There are some dressings that
have a known potential to cause
pain. For example, alginate dressings
should not be applied to wounds
with low levels of exudate as they are
highly absorbent and likely to dry
out and adhere. Similarly, mesh-type
dressings, could lead to trauma on
removal as granulation tissue can
grow through the mesh pores.
In the author’s experience,
appropriate removal is important
in avoiding trauma and can be
aided by stretching some dressings
(particularly hydrocolloids and films),
which causes the adhesive to break
down. Another technique is to apply
a swab moistened with saline or
water to the underside of the dressing
as it is lifted (useful in adhesive
foam dressings).
Topical negative pressure has also
been cited in a number of studies as
Answer the following questions
about this article, either to test the
new knowledge you have gained or
to form part of your ongoing practice
development portfolio.
1 – What are the main symptoms of
wound pain?
2 – Name some of the primary causes
of wound pain.
3 – What types of pain might patients
experience at dressing change?
4 – Outline the main techniques
for helping to minimise pain at
dressing change.
5 – Can you explain the principles
behind pain assessment?
Five-minute test
Figure 1.
The Oucher scale.
0
No hurt
2
Hurts
little bit
4
Hurts
little more
6
Hurts
even more
8
Hurts
whole lot
10
Hurts
worst
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