Perceptions about pain

A patient’s expectation of pain can be largely dependent on his or her cultural and ethnic background, social support system, medical history, and prior pain experience (Morris, 1991). When a patient cannot communicate in the language of the care provider, effective management of his or her pain becomes more difficult and often leads to undertreatment. Erroneous assumptions and perceptions on the part of the provider about pain tolerance based on traits such as age, gender or ethnic background, can result in inadequate analgesia (Lasch, 2002). However, studies indicate that when patients control their own analgesia (e.g., with patient-controlled analgesia pumps), patients self-administer similar doses for similar injuries independent of race or cultural background. Health care providers must be aware of obstacles such as language and cultural barriers and use more care and time in assessing and treating such patients. Interventions that alter a patient’s expectation of pain may positively affect the pain experienced by that patient.

A long-held myth in wound care is that venous ulcers and pressure ulcers are not painful. Ironically, in a study of patients with venous ulcers, patients often did not request pain medication because they expected their wounds to be painful (Krasner, 1997). Therefore health care professionals often do not even assess for venous ulcer pain, which then contributes to the undertreatment of venous ulcer pain. In a study conducted by Dallam et al (1995) involving 132 patients with pressure ulcers, 68% reported some type of wound pain, yet only 2% were given analgesics for pressure ulcer pain within 4 hours of pain measurement.

In a 2008 review of the literature on pain with pressure ulcers, reported pain prevalence ranged from 37% to 100%, and ulcer stage was reported to most consistently affect pain (Girouard et al, 2008). In 2009, the National Pressure Ulcer Advisory Panel (NPUAP) published a systematic literature review and white paper on pressure ulcer pain advocating the importance of pressure ulcer pain and the need for further research in all populations across all settings (Pieper et al, 2009).

In a qualitative study of nurses providing care to patients with a pressure ulcer who experienced pain, nurse generalists and advanced practice nurses were asked to reflect and write a story about the phenomenon of caring for the patient with wound pain (Krasner, 1996). Text analysis of the reflections from the 42 participants revealed three patterns of responses by the caregivers. By examining and understanding these patterns of response and the examples of behaviors relative to each response, valuable insight can be gained into the delivery of more sensitive care that is patient focused rather than wound focused.

The first pattern of response is described as “nursing expertly.” With this type of response, the nurse uses a set of skills and behaviors that make a qualitative difference in the patient’s care. Skills commonly used include (1) read the pain, (2) attend to the pain, and (3) acknowledge the presence of or potential for pain (i.e., empathize with the patient). “Reading” the pain is a critical aspect of assessing for the presence of pain that extends beyond simply asking patients if they are experiencing pain. It is the recognition of signs associated with pain, such as increased anxiety, sweating, bulging eyes, increased respirations, and exaggerated movement in bed. Unfortunately, these signs are easily overlooked by the caregiver when the patient is nonverbal. Attending to the pain indicates that the nurse has taken steps to control pain with medications, positioning, distraction, and so on. Acknowledging the presence of pain or the potential for an intervention or procedure to trigger pain demonstrates empathy for the patient and creates an opportunity to discuss the nature of the pain and identify strategies to minimize or relieve the pain. Empathic care for the patient with pain is demonstrated by using a slower pace in performing procedures, conducting dressing changes in a gentle fashion, allowing short “breaks” during painful procedures, providing careful explanations for every step of the procedure, providing words of encouragement, and offering a menu of pain control interventions.

The second pattern of caregiver response reported in the study is to actually “deny the pain.” In this type of response, the caregiver essentially fails to recognize or treat pain and leaves the patient to deal with the pain alone. Ultimately, to “deny the pain” is associated with the care provider who is trying to cope with personally uncomfortable situations, such as those in which the provider feels powerless, feels as though nothing else can be done to ameliorate the patient’s pain, or feels that the situation is “not the best” but is acceptable and somewhat expected. Three key behaviors exhibited by the nurse are typical of this pattern of response. (1) Assuming pain does not exist. This behavior is common, along with the erroneous but previously held belief that venous and pressure ulcers are not painful despite the twinges of pain or other verbal or nonverbal signs the patient would manifest. (2) Ignoring the patient’s cries of pain. This behavior could be characteristic of situations where the patient continues to report the presence of pain with a dressing change or sharp debridement despite the analgesic given. (3) Avoidance of personal failure. This behavior is characterized by the nurse who simply avoids interacting with the patient or limits the extent of contact with the patient because the patient continues to experience discomfort and all possible interventions for this patient have been exhausted.

The third and final pattern of response observed by this group of nurses was to “confront the challenge of pain” as exemplified by coping with the frustrations and “being with” the patient. A central benefit to this type of response by the nurse is the insight gained into the meaning of the pain experience to the patient. For example, the challenge of the pain may be triggered more by anxiety rather than pain. This insight then can be used to develop a more individualized plan of care. A hermeneutic phenomenologic study by Kohr and Gibson (2008) suggests that although nurses want to do the right thing and protect the patient from physical and psychic wound pain, many barriers to optimal pain management exist.

Consequences of wound pain

Wound pain negatively affects quality of life and impacts physiologic processes, including oxygenation and infection control. Unfortunately, many patients with a wound suffer these negative consequences because undertreatment of patients with chronic wound pain is far too common.

Pain physiology

Although pain is a subjective experience, objective physiologic mechanisms control how pain is initiated, transmitted, and perceived. The objective neural response to a painful stimulus (e.g., at the wound) is called nociception. Nociception is defined as the detection of impending or actual tissue damage and is accomplished by specialized sensory nerve terminals (nociceptors) derived from Aδ (delta) and C fibers. All nerve endings in the epidermis are considered nociceptors (Popescu and Salcido, 2004). When cells are damaged, chemicals are released, triggering the nerve fibers to transmit the pain impulses along nerve sheaths to the spinal cord. The spinal cord transmits the information to the brain, where it is centrally processed. Synaptic junctions in the spinal cord and brain will either attenuate or amplify the pain signal and thus affect how the intensity of the pain signal will be perceived or interpreted.

In addition to the actual tissue injury that triggers the pain episode, psychological, physical, emotional, and cultural factors as well as the patient’s expectations collectively define an individual’s pain experience. Thus the same type of injury in two different individuals often generates a very different pain experience in terms of severity, quality, and impact (Turk, 1993). Reported pain may appear to be either less than expected or excessive given the degree of tissue injury. Distress out of proportion to the injury is often ascribed to anxiety as well as “catastrophizing” (Sullivan and Neish, 1999; Sullivan et al, 1998).

Catastrophizing is significantly correlated with mood and personality variables such as depression, fear of pain, coping strategies, and state and trait anxiety (Rosenstiel and Keefe, 1983; Sullivan et al, 1995). These variables have been shown to be important predictors of the pain experience. Preoperative levels of anxiety and catastrophizing can be predictive of postoperative pain intensity. A study by Granot and Ferber (2005) found that moderately anxious surgical patients are at greater risk for developing greater postoperative pain.