Pain

Pain has been a prevalent health care challenge in the United States for some time, with data from the Centers for Disease Control and Prevention showing that approximately 16% of men and 20% of women experience pain on most days or even every day.¹ As health care providers, we understand that unrelieved pain and suffering have direct results on the healing cascade and impair both physical and mental health. The topic of pain is almost always addressed in the health care setting, with pain even at one time being recognized as the “fifth vital sign.” Pain associated with acute or chronic wounds may delay wound healing, impact overall recovery (physical, emotional, and cognitive), and affect quality of life. Chronic wound-related pain has a high prevalence, with up to 80% of patients who experience pain. Literature shows that wound-related pain is often underassessed and therefore may not be optimally managed.²

As with wound management principles, appropriate and accurate pain assessment is the first step in an effective treatment plan. We must first assess and understand the problem or cause before we can treat it. This method can sometimes pose a challenge, especially considering the opioid crisis. It is important to understand that every person with pain, including those suffering with substance use disorders, needs high-quality, appropriate pain assessment and management.³

Etiology Guides Treatment

As with many other wound management principles and wound etiologies, pain etiology often guides treatment. Two common types of pain relating to wounds are acute and chronic. Under the umbrella terms of acute pain and chronic pain are different types of pain. Nociceptive and neuropathic are commonly used terms to describe chronic pain, and they can be broken down further. It is important to understand whether our patient’s pain is acute or chronic and to determine whether topical treatment would be helpful or whether systemic management may need to be explored. If a wound fails to heal, persistent pain with neuropathic or nociceptive characteristics may develop, resulting in a chronic pain condition, greatly affecting the patient’s overall health and quality of life.² Pain is what the patient says—most of us have heard this before. Pain is experienced differently for almost everyone, and behaviors may vary.

It is important to complete a thorough pain assessment before beginning wound care or topical treatment and to ensure that pain is addressed to achieve optimal healing outcomes. Pain can certainly impede healing for a multitude of reasons. Pain assessment should be completed initially and then on an ongoing basis, using a standardized, evidence-based tool to consistently evaluate and manage pain. Verbal and nonverbal or observational cues should be incorporated into the pain assessment, documentation, and plan of care.

Topical Treatment Suggestions

When looking at wound pain, the initial focus should be determining the etiology, followed by the treatment plan. Initial strategies typically include localized pain control. Localized pain control can be managed in several different ways, and with different techniques, including:

• Ensuring treatments (especially those applied circumferentially) are not too tight: This is especially important with extremities when edema can increase throughout the day, thus possibly increasing the tension on the dressing.
• Using nonstick topical treatments when appropriate: Using a nonadherent layer can help with wound pain when a treatment is removed for the next dressing change. Additionally, using gentle adhesives vs heavier adhesives that adhere more aggressively to the skin is helpful, along with using adhesive remover when appropriate to remove dressings or securement devices.
• Certain topical products have mild analgesic properties and may be appropriate depending on the type of wound, characteristics, and patient assessment. Consult with your wound care clinician here—an interprofessional approach is important!
• Premedicating the patient for wound care as ordered or when appropriate is important. Pain should be assessed initially, on an ongoing basis, and before and after wound care is provided, including the accompanying, appropriate documentation.
• Different types of pain management techniques (nonpharmacologic therapies) can also be explored here; distraction, meditation, aromatherapy, music therapy, and mind-body techniques could be helpful.
• Identifying factors that increase and decrease pain levels is important, along with employing strategies to control extrinsic variables when able.

Interdisciplinary Approach and Referrals as Needed

Sometimes collaboration with other disciplines is needed to achieve optimal outcomes and healing, especially in patients with chronic wounds. Chronic wound management can be difficult, notably when unrelieved pain comes into play. Pain can and does impede healing. Involving the interdisciplinary team is important, along with making referrals to alternative or complementary therapists, therapies, and pain management specialists. Ensuring that comorbid conditions are controlled is also important because these conditions can all play into the picture of unrelieved pain, and they are the reason that an interdisciplinary approach is so important.

Conclusion

As mentioned in my previous blogs, treating the whole patient and not just the hole in the patient is an essential take-away here. Pain management is an important piece of the healing puzzle when caring for patients with chronic, and even acute, wounds. Taking a holistic approach, talking to the patient, and observing the cues and characteristics exhibited are very important components of the care plan for wound management. Etiology guides treatment, both for wound care and pain management, and working together as a team leads to success and optimal outcomes for our patients.

References

1. Centers for Disease Control and Prevention. Retrieved from: Centers for Disease Control and Prevention (cdc.gov) on January 4th, 2022.
2. Frescos N. Assessment of pain in chronic wounds: a survey of Australian health care practitioners. Int Wound J. 2018;15(6):943-949. https://doi.org/10.1111/iwj.12951
3. Scher C, Meador L, Van Cleave JH, Reid MC. Moving beyond pain as the fifth vital sign and patient satisfaction scores to improve pain care in the 21st century. Pain Manag Nurs. 2018;19(2):125-129. https://doi.org/10.1016/j.pmn.2017.10.010

About the Author

Holly is a Wound Care Coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our Veterans. Holly has been practicing in wound care nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an inter-professional approach with wound care and prevention overall, and involves each member of the healthcare team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.