Prior to dressing changes, patients deal with the anxiety related to the thoughts of pain and suffering. Clinicians can help reduce anxiety by meeting with the patient and discussing the patient’s concerns. The World Union of Healing Societies Initiative paper (Minimising pain at dressing-related procedures: “Implementation of pain relieving strategies”) provides useful non-pharmacological recommendations for reducing patient fear, anxiety, and pain. The pre-dressing removal anxiety reduction strategies include (WUWHS, 2008):
1. Talking and communicating with the patient (include family, friends, or care givers if permissible).
2. Inviting patient involvement.
3. Reducing anxiety by creating a sense of patient control.
4. Providing ongoing education .
Here are some of the ways to address patients and their pain issues:
Starting a dialog with the patient.
Ask the patient to describe their sensations during the last dressing change (e.g., does it hurt a little or a lot?). Try and separate what type of pain the patient is experiencing. Is it acute pain that is very intense, but only lasts a short period of time? Or is the patient experiencing long lasting pain throughout the day? Ask them what has been successful in reducing their pain in the past (including improving environmental conditions, pain medications, or adjunct pain therapy). Talk with them about how incorporating non-pharmacological and pharmacological strategies can help reduce chronic wound and dressing removal related pain. Focus on providing education that not only highlights the patient’s etiology-related condition, but how the dressings and treatments can benefit or resolve that condition.
Reassure the patient that you will be sensitive to their needs during dressing changes. Including incorporating time out procedures. Time-outs allow the patient to regulate how much pain they can tolerate at one time and gives them breaks as needed. Ask the patient how you can best reduce environmental stimuli to help reduce anxiety levels. Consider discussing several adjunct pain reduction strategies (WUWHS, 2008).
What to consider if the patient remains highly anxious.
If anxiety persists regardless of these strategies consider anti-anxiety medications (e.g. benzodiazepines or hydroxyzine). Also consider antidepressants, which are not only helpful in elevating mood but can relieve some types of pain. Use caution combining administering benzodiazepines and other sedatives to patients who are opioid sensitive for risk of adverse respiratory side effects (American Pain Society, 2003).
What to consider if the clinician is unable to reasonably control the patient’s pain during dressing changes.
If you have gone though a dressing change in which you were unable to provide reasonable pain control, consider talking with the patient and arranging other pain control options. If you have a patient that has extraordinary pain during dressing changes, one option for relieving pain may be a surgical dressing change with anesthetic. Please note that this assumes that the patient is healthy enough to tolerate anesthesia.
What to consider if the clinician is unable to reasonably control the patient’s pain between dressing changes.
For patients in the acute care setting consider placing the patient on instill VAC therapy with a lidocaine drip over the wound bed. Lidocaine irrigation concentrations are 1:200,00; 25cc of 1% lidocaine in 250cc NS or2% Lidocaine in 500cc of NS (Wolvos, 2004).
Note: Many contraindications, possible reactions, or side effects may exist including (but are not limited to): 1. contraindications with anticoagulation therapy and Infection, 2. Cautions including impaired cardiovascular or hepatic function, and 3. side effects of EKG variations at toxic levels of absorption (Wolvos, 2004).
For chronic wound related pain, if adjunct therapy is ineffective, consider referring the patient to a multidisciplinary pain clinic. Pain clinics can integrate psychological assessments and counseling with a treatment plan. Treatment options outside of normal opoid ladder may include surgery, nerve blocks, trigger-point injections, physical/occupational therapy, and muscle relaxants.
Note that chronic wound pain may result from many wound related etiology types. Often resolving or controlling the condition (say revascularizing an arterial wound) can completely solve the chronic wound pain. Sometimes, however, there may be chronic wound etiologies that are unsolvable including: arterial ulcers in patients who may not tolerate revascularization or patients who have untreatable malignancy related wounds.
The next article will discuss several alternative therapies that can reduce pain levels in patients with chronic or acute wound related pain.
References
American Pain Society, 2003. Principles of analgesic use in the treatment of acute pain and cancer pain (Fifth Edition).
The World Union of Healing Societies, 2008. Initiative paper: Minimising pain at dressing-related procedures:“Implementation of pain relieving strategies” retrieved from http://woundpedia.info/pdf/PainMolnlyckeSupplement.pdf
Wolvos T. 2004. Wound Instillation — The Next Step in Negative Pressure Wound Therapy. Lessons Learned from Initial Experiences. Ostomy/Wound Management – ISSN: 0889-5899 – Volume 50 – Issue 11 – November 2004 – Pages: 56 – 66
Matthew Livingston R.N. C.W.S.
