Janice Reynolds works at Mid Coast Hospital in Brunswick Maine. She is a Certified Oncology and Certified Pain Management Nurse. This interview is based on her presentation "Taking the Ouch Out of Wound Care" at the American Society for Pain Management Nursing in March, 2007.

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Questions

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Evelyn Corsini:

What led you to develop expertise in wound care and pain?

Janice Reynolds, RN, C, OCN: Taking care of wounds is an activity that is commonly done by health care providers but research has shown that the assessment, management, and documentation of pain related to wound care is inadequate. Pain and wounds are always connected as damaged nociceptors are exposed to air, damage is caused to neurons, and in healing the inflammatory response takes place. Patients who experience wound pain are very much an underserved population among pain sufferers. I became interested in this problem in the course of my work as an oncology and pain management nurse. Several years ago I was asked to reactivate the skin and wounds team at my hospital and found that there was no place in my region where a provider could learn more about the topic. As a result, we initiated an annual symposium at the hospital. Although I am no longer part of the team, the experience has led to my doing more research on and teaching about the problems of wound care and pain.

EC: Why should health care providers learn more about wound care and wound pain?

JR: Many providers still do not have a good understanding of pain management. There is a lack of understanding as well regarding the long term effect of even short term pain. There is the belief pressure sores or venous ulcers do not cause pain. Sometimes health care providers believe that pain is inevitable and don’t feel they should be doing anything to prevent it. Some patients believe they must tolerate pain or there isn’t any thing which can be done. Recently I observed a patient screaming while a nurse did a dressing change. This should not happen! This can be an especially great problem for older patients, who have fragile skin to start with, may experience some confusion, or don’t think they should speak up. They may assume that suffering is part of what they need to endure. Patients may deny pain when asked, but if you ask how a wound feels or "Tell me about your wound", you may then get a more accurate answer.

EC: What may be the effect of poorly treated wound pain?

JR: Pain is damaging. It decreases the supply of oxygen and stress hormones lead to vasoconstriction. This causes wound hypoxia which leads to delayed wound healing. A loss of ability to do activities of daily living can occur with pain. With loss of function in the older adult, morbidity and mortality increase. With pain, “Quality of Life” is greatly diminished. There is an increase in depression as well. Short term pain can become persistent pain. Research on post mastectomy and post thoracotomy patients has shown pain that was not well-controlled at the time of surgery is more likely to create a chronic pain syndrome. In a study on post mastectomy pain, patients who achieved better pain control with PCAs and increased use of opioids experienced fewer problems with persistent pain later. The same phenomenon is true with post herpetic neuralgia (PHN); better pain control with shingles results in less problems with PHN.

It is very important to continuously assess and reassess for pain related to wounds. With wounds there is non-cyclic incident pain (or pain associated with debridement), cyclic pain which occurs at the time of dressing changes, and persistent (or background) pain that can always be there. Knowing how to treat the pain requires understanding the kind of pain it is.

Pain at the time of dressing changes is the most common problem, and taking adequate preparation is an important way to control the pain. This can be challenging in busy health care setting but taking the time will prevent many problems.

Most patients need pre-medication before a dressing change. It needs to be given at an appropriate interval before, 15 minutes for IV, an hour for oral medication. It is also important to understand if there are anticipatory pain triggers, as controlling these triggers can reduce anxiety and fear. Patients can be helped to get into a more relaxed mood in many ways: having a family member provide a gentle massage; playing music or other distractions; using simple breathing exercises, or guided imagery. Some patients will feel more comfortable if they are allowed to use their own home folk remedies if they are not contraindicated, or are allowed to participate in removing a dressing, or given the option of a "time out". For some people, prayer is very helpful.

There are many tips to improve dressing changes besides premedication; do the change when the patient is less fatigued; dampen a dried out dressing before removing; avoid aggressive packing; use warm cleansing solutions; protect the periwound area; minimize the number of dressing changes; use pain friendly dressings such as hydrogel, calcium alginate, hydrocolloidal, transparent, foam, or silicone, and most importantly if a dressing change is painful or causes damage, re-evaluate your materials and plan.

EC: What treatment methods are successfully used for wound pain?

JR: Use of the well studied available non-pharmacological and pharmacological pain treatments can avoid, lessen, or alleviate wound pain. For persistent or back ground pain a systemic analgesic needs to be used. Having pain 12 out of 24 hours requires around the clock medication. Most often this will be an opioid. Patients, caregivers, and providers may worry about side effects or have concerns about addiction, but patient education regarding good pain management can reassure them. Side effects such as sedation may be a problem –however patients usually develop a tolerance to side effects. If not, trying a different opioid may help. Addiction is rarely a problem with someone taking opioids for pain relief. Always remember, with around the clock or long acting medications, you still have to have breakthrough medication as well. Patients with pressure ulcers, arterial ulcers, venous ulcers, neuropathic ulcers, or fungating lesions, can have persistent pain problems. In someone who is unable to report pain such as the cognitively impaired the only indication of pain, may be a change in behavior. Many long term care facilities are now initiating a trial of analgesics with their cognitively impaired patients who are unable to accurately describe pain, to see if this leads to an overall improvement in functioning or cognition. There are off label uses of analgesics in wound care that have reported good success but are primarily anecdotal at this time. The most common one is the use of morphine "gel"in the wound. There are studies being done but the ones currently available are small. Wounds and pain management is an area in great need of research to enhance evidenced based practice.