Journal of Community Nursing - page 41

JCN
2013,Vol 27, No 4
41
WOUND CARE
WOUND CARE
causing pain (Morris et al, 2007), and
larval therapy is also known to cause
pain in some patients (Sherman,
2002). Honey dressings have also
been known to cause a stinging or
burning sensation, possibly caused by
the acidity level or the osmotic ‘pull’
they exert (Vuolo, 2009). Appropriate
assessment of patients for these
treatments is required as well, as the
provision of adequate analgesia to
manage any potential pain.
Wound cleansing, particularly with
antiseptics, has been identified as a
major cause of wound pain, as has
mechanical cleansing with gauze and
the use of cold solutions (Vuolo, 2009).
Analgesia
Analgesia must be given at least 30–60
minutes before any dressing change
(Lloyd-Jones, 2008), and can be
systemic, topical or local.Vuolo (2009)
has suggested that analgesia should
relate to the severity, frequency and
duration of pain and that background
pain requires medication provided
at regular intervals, supplemented
by appropriate analgesics before any
dressing changes.
Paracetamol
Paracetamol works on the central
and descending pain pathways. It is
a strong analgesic and will increase
the analgesic effects of non-steroidal
anti-inflammatory drugs (NSAIDS)
in both acute and chronic pain
(Richardson and Upton, 2011).
NSAIDS
The drugs have an analgesic and
anti-inflammatory mode of action.
There are potential problems of
gastric irritation and cardiac and renal
compromise, therefore, healthcare
professionals should check for
contraindications. There are no
compatibility issues with paracetamol
and they can be used together for
procedural pain and background pain
management (Richardson and
Upton, 2011).
Weak opioids
If a mixture of paracetamol and
NSAIDS is not effective for background
wound pain, a weak opioid (codeine,
tramadol) can be added at a dosing
frequency sufficient to control the pain
(Richardson and Upton, 2011).
Strong opioids
These drugs should only be
considered for wound care in the
case of insufficient relief from the
combined analgesia described
above. Morphine is flexible in that
it can be given via all routes with
no ceiling dose and is useful for
dressing changes. It should be given
at least an hour before any procedure
(Richardson and Upton, 2011).
Co-analgesics
Co-analgesics are used for the
treatment of non-nociceptive
elements of pain such as neuropathic
pain, allodynia and hyperalgesia. In
wound pain, anticonvulsants and
antidepressants, such as amitryptyline
and gabapentin, have been found to
be effective, but at lower levels than
for their original purpose (Richardson
and Upton, 2011).
Nitrous oxide
Nitrous oxide is a 50:50 mixture
of oxygen and nitrous oxide and
is effective in painful dressing
changes. It is self-administered by
the patient, has few side-effects
and can be used alongside other
analgesics (Acton, 2008).
Lidocaine/prilocaine cream
This is a topical anaesthetic that may
be suitable for use before painful
procedures. This is not a licensed use
and its effects on wound healing are
unclear (Vanscheidt et al, 2001).
PATIENT EMPOWERMENT
Educating patients about pain is a
necessary step as it helps to dispel
common misconceptions and myths,
that might lead to non-concordance.
By explaining procedures and how
they will be performed, healthcare
professionals can improve patients’
understanding of treatment and
reduce any anxiety and fear (Wright
and Shirey, 2003). For example, in the
author’s experience, patients often
misunderstand wound debridement
and fear that it may worsen tissue
damage. However, with education,
patients can learn that the removal
of necrotic tissue will in fact facilitate
wound healing.
Another technique is to ensure
that patients are involved in their
dressing changes, allowing them
to remove their own dressings and
have ‘time out’periods during the
procedure (Vuolo, 2009).
Pain can often result in non-
concordance with wound care.
Therefore, there is a need to ensure
that patients undergoing dressing
changes have their pain minimised
as much as possible. Fletcher (2010)
suggests some strategies that can be
used to achieve this (
Table 3
).
CONCLUSION
Patients put their trust in healthcare
professionals and should not have to
face the trauma of repeated painful
dressing changes (Gray, 2009).
Healthcare professionals need to
rise to the challenge of minimising
wound pain, selecting the appropriate
wound care products and having
an understanding of the uses,
indications and contraindications of a
wide range of products.
It is also vital that, in order
to provide evidence-based care,
they have a wider knowledge and
understanding of pain assessment
and management.
JCN
REFERENCES
Acton C (2008) Reducing pain during
wound dressing changes.
Wound
Essentials
3:
114–22
Bell C, McCarthy G (2010) The assessment
and treatment of wound pain at dressing
changes.
Br J Nurs
19(11):
S7–S10
Table 3:
Strategies for avoiding pain at
dressing change
Avoid use of adhesive products on fragile skin
where possible
Use skin protectants, i.e. barrier creams
Make sure appropriate dressings are selected
Include patients in their dressing changes
Follow the manufacturers’instructions for
application and removal of the dressing
Expose wounds for a minimum time
Use atraumatic dressings
Cleanse with warm solutions
Use silicone medical adhesive removers to
remove dressings
Utilise distraction techniques
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