Nonpharmacologic pain control

Many nonpharmacologic pain control measures are essential when caring for a patient with a wound. A simple and effective intervention is acknowledging a patient’s pain and making a commitment to the patient to address the pain. Explaining the potential harmful effects of pain on healing, along with a careful explanation of how to manage pain, will help to shape the patient’s expectations as well as increase the individual’s sense of control. Both of these strategies may reduce the pain experienced (Acute Pain Management Panel [APMP], 1992). Additional interventions related to pain control begin with controlling and reducing procedural pain or cyclic acute pain through appropriate and conscientious topical care.

Wound cleansing

Avoiding cytotoxic topical agents (e.g., antiseptics, antimicrobials), harsh chemicals, and highly concentrated agents for wound cleansing can significantly reduce wound pain. In general, use of these agents should be avoided unless the wound warrants such intervention (e.g., traumatic wound) and the patient has been adequately anesthetized (van Rijswijk, 1999).

Wound cleansing can also be used as a strategy for reducing wound pain. The buildup of exudate in a wound bed can cause pressure and pain. Pain can be relieved by removing exudate with gentle flushing, low-pressure irrigation, or, in selected patients, cautious use of whirlpool.

Periwound skin care

Eroded or denuded wound margins can contribute significantly to the pain experienced by the patient with a wound (National Pressure Ulcer Advisory Panel [NPUAP]-European Pressure Ulcer Advisory Panel [EPUAP], 2009). Use of skin sealants on intact skin can prevent painful denuding of skin or skin stripping. Use of ointments or skin barriers on open areas can prevent and/or minimize the pain secondary to damaged wound margins.

Debridement

Although many factors are considered when a method of debridement is selected, pain is a frequently neglected consideration. Regardless of the method of debridement selected, pain assessment and management must be considered. Wet-to-dry dressing changes for debridement (nonselective and painful) should be avoided. Using autolysis for debridement, when feasible and appropriate, can significantly reduce the pain associated with debridement (NPUAP-EPUAP, 2009; Robson et al, 2006; Whitney et al, 2006).

Conservative or surgical sharp debridement provokes acute noncyclical pain, which leads patients to ask the clinician to stop the debridement unless they are given additional analgesia or anesthesia (Briggs and Nelson, 2003; Evans and Gray, 2005; Hansson et al, 1993). When sharp debridement is indicated, pharmacologic interventions are an important consideration and are described in detail later in this chapter.

Inflammation and edema

Inflammation and edema contribute to wound pain, so any measures that reduce inflammation and edema likely will provide pain relief. This includes elevation of edematous extremities, appropriate edema-reducing dressings and devices (e.g., compression bandaging and sequential compression pumps), and systemic medications.

Support and positioning

Binders, splints, body positioners, and other devices that stabilize a wound can significantly reduce pain, especially pain related to mobilization. Care must be taken to fit these devices properly so that the wound dressing is appropriately accommodated and increased pressure on the wound does not result. However, certain medical devices, such as immobilizers and negative pressure therapy devices, can become a source of pain. Various methods can be used to reduce that pain, including pressure relief and use of nonadherent dressings at the device–wound interface (NPUAP-EPUAP, 2009).

Positioning patients for comfort and off their wound can reduce pain at the wound site. If this is not possible, judicious use of support surfaces can offer pain relief to bed- or chair-bound patients. Individuals should be encouraged to request a “time-out” during any procedure that causes pain. Patients should be premedicated, if needed, prior to activities that cause or trigger pain. Using lift sheets (to lift and move) instead of draw sheets (that drag) to move patients in bed prevents friction and shear, which can cause painful injuries to the skin and deeper tissues (NPUAP-EPUAP, 2009).

Wound dressings

Many commercially available moisture-retentive dressings are designed for the care of wounds. The main analgesic efficacy of these products appears to stem from their ability to keep the wound moist and protected from the environment, reduce inflammation, and stimulate healing. Moisture-retentive dressings have at least some capacity to reduce pain associated with wounds (NPUAP-EPUAP, 2009; Steed et al, 2006; Whitney et al, 2006). Thus, dressings can be selected with the aim of reducing pain in a particular patient. The most effective dressing will depend on patient factors such as volume of exudate, condition of surrounding skin, wound depth, and necrotic tissue. Dry, wet-to-dry, or wet-to-damp dressings are not moisture retentive and consequently are the most painful. As the gauze dehydrates, it tends to become attached to the wound surface and, along with damaging new granulation tissue, is painful to remove (NPUAP-EPUAP, 2009; Robson et al, 2006; Whitney et al, 2006). The trauma that patients must endure then is multiplied because wet-to-damp or dry dressing must be changed three times per day.

The patient with a wound often dreads the dressing change procedure, which is cyclic in nature. Box 26-1 lists several interventions for pain control during dressing changes. Dressings should be selected that will, upon removal, minimize the degree of sensory stimulus to the wound area (European Wound Management Association [EWMA], 2002).

BOX 26-1 Interventions for Pain Reduction During Dressing Changes

• Minimize degree of sensory stimulus (e.g., drafts from open windows, prodding and poking).

• Allow patient to perform own dressing changes.

• Allow “time-outs” during painful procedures.

• Schedule dressing changes when patient is feeling best.

• Give an analgesic and then schedule dressing change for time of drug’s peak effect.

• Soak dried dressings before removal.

• Avoid use of cytotoxic cleansers.

• Avoid aggressive packing.

• Minimize number of dressing changes.

• Prevent periwound trauma.

• Position and support wounded area for comfort.

• Consider using low-adhesive or nonadhesive dressings.

• Offer and use distraction techniques (e.g., headphones, TV, music, warm blanket).

Pharmacologic interventions

The World Health Organization (WHO) Pain Clinical Ladder, a three-step analgesic ladder approach for the treatment of cancer pain, can also been used to guide the treatment of nonmalignant pain (Boxes 26-2 and 26-3 and Figure 26-1). This approach uses a combination of pain control medications based on assessment of pain intensity. If pain persists after reassessment, the ladder guides the clinician in adding a medication or combination of medications to effectively control pain (McCaffery and Portenoy, 1999). Pharmacologic interventions can be topical, subcutaneous or perineural injectable, or systemic (McCaffery and Beebe, 1989; McCaffery and Portenoy, 1999).

BOX 26-2 World Health Organization Analgesic Ladder (see Figure 26-1)

Step 1

Patients with mild to moderate pain should be treated with a non-opioid analgesic, which should be combined with an adjuvant drug if an indication for one exists.

For example: Nonsteroidal antiinflammatory drugs, acetylsalicylic acid, acetaminophen.

Step 2

Patients who have limited opioid exposure and moderate to severe pain or who fail to achieve adequate relief after a trial of a nonopioid analgesic should be treated with an opioid conventionally used for moderate pain.

For example: Step 1 medications plus codeine, tramadol, and so forth.

Step 3

Patients who have severe pain or who fail to achieve adequate relief after appropriate administration of drugs in step 2 of the analgesic ladder should receive an opioid conventionally used for severe pain.

For example: Step 1 medications and morphine (discontinue step 2 medications).

Note: Unrelieved pain should raise a red flag that attracts the clinician’s attention.

From McCaffery M, Portenoy RK: Overview of three groups of analgesics. In McCaffrey M, Pasero C, editors: Pain clinical manual, ed 2, St. Louis, 1999, Mosby.

BOX 26-3 Examples of Opioid, Nonopioid, and Adjuvant Medications