Practical pain relief: Drugs not the only answer
Some fundamental suggestions for reducing pain
Clinicians attempting to relieve the pain suffered by patients who have chronic wounds often rely on medications ranging in strength from over-the-counter anti-inflammatories to opioids. Drugs are certainly essential components in the pain relief equation, but they are not the only measures available to wound care professionals.
"We’re so focused on popping pills that we’ve forgotten lots of fundamental things to alleviate pain," says Lia van Rijswijk, RN, ET, a nurse consultant in Newtown, PA. Rijswijk says there are many simple measures clinicians can take to help alleviate pain, but that unfortunately have not become common practices in the field.
Listed below are suggested actions for providers to help reduce pain for chronic wound patients. The suggestions were compiled from interviews and writings from three sources: Frank Ferris, MD, a palliative care physician at the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital in Toronto; Diane Krasner, PhD, RN, CETN, CWS, a postdoctoral fellow at the Johns Hopkins University School of Nursing in Baltimore who has focused her research on pain related to venous ulcers; and Rijswijk.
• Immobilize the wound. Postoperative patients automatically hold their wounds when they get out of bed, because that action reduces their pain. Immobilization can be achieved with dressings that adhere well to healthy tissue surrounding the wound, but not to the wound itself.
• Don’t let the dressing adhere to any part of the wound itself. When this occurs, pain can increase a great deal because every time the patient moves, the dressing pulls at the inside of the wound.
• Keep wounds moist and don’t expose them to air. Drying exposed nerve endings and air flowing against exposed nerves can cause great pain. Think of the relief that a simple adhesive bandage provides for a minor cut or abrasion.
• Clean wounds regularly to eliminate the build-up of exudate in the wound bed, which can cause pressure and pain. Remove exudate by gentle flushing, low-pressure irrigation, or in selected cases with a whirlpool bath.
• Use lift sheets instead of draw sheets to move patients.
• Use gentle wound cleansers. Avoid antiseptics such as hydrogen peroxide and povidone iodine unless the patient has been anesthetized. Heat cleansers to body temperature before use.
• Remove dead tissue because it can produce chemicals that irritate nociceptive nerve terminals.
• Protect wound margins with skin sealants, ointments, or skin barriers.
• Choose debridement options carefully, keeping in mind the need to assess and control pain regularly. There are many topical anesthetics available for use before sharp debridement. Use autolytic debridement when feasible. Avoid enzymatic debridement, which has the potential to cause a great deal of pain.
• Reduce pressure on wounds. For example, pack deep wounds lightly with soft, nonadherent materials, and position the patient to reduce pressure on wounds from their support surfaces.
• Allow patients to perform their own dressing changes when possible, or to call "time out" when the procedure becomes painful.
• Time dressing changes to coincide with periods when the patient will be most prepared for the procedure. Talk to the patient to find out if there is a particular time of day when he or she would prefer to have dressings changed.
• Prior to dressing changes, give patients an analgesic, then start the procedure when the medicine’s effect reaches its peak.
• Finally, consider patients holistically and try to understand and empathize with what they are going through. Even small measures can have a powerful effect, such as holding a person’s hand during a procedure, hugging regularly, offering words of encouragement, or just listening. All of these responses can ease a patient’s feelings of frustration, depression, helplessness, and anguish, all of which often accompany chronic wounds.
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