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ISSUES IN WOUND CARE

Wound care pain in hospitalized adult patients


Nancy A. Stotts, RN, EdD, FAAN, Kathleen Puntillo, RN, DNSc, FAAN, Ann Bonham Morris, RN, MSN,
CPNP, Julie Stanik-Hutt, RN, PhD, ACNP, Carol Lynn Thompson, PhD, CCRN, ACNP, CCNS, Cheri
White, RN, PhD, CCRN, and Lorie Reitman Wild, RN, PhD, San Francisco, California

BACKGROUND: Wound care (WC) is an important part of treatment for hospitalized patients with
wounds. There is a paucity of data about the type or amount of pain patients experience during WC.
OBJECTIVES: The purpose of this study is to describe patients (n 412) WC-related pain perceptions
and responses, examine the relationships between patients WC pain and demographic variables, and
describe the distress associated with WC.
METHODS: A repeated-measures design was used to examine pain before, during, and after WC in
hospitalized patients (n 412) with wounds healing by secondary intention.
RESULTS: Pain intensity was greatest during WC. It was most frequently described as tender, sharp,
stinging, aching, and stabbing. Behaviors that occurred most often were no verbal response, no body
movement, grimace, and complaints of pain. There were no differences in pain between genders.
Nonwhites had significantly greater WC pain than whites. Pain during the procedure was the same in
younger and older patients, and procedural distress was mild.
CONCLUSION: Patients experience pain and distress with WC. Some behaviors and words consistently
describe WC pain. Further work is warranted to refine pain assessment and management in patients
undergoing WC procedures. (Heart Lung 2004;33:32132.)

INTRODUCTION
Wound care (WC) is an important part of the overall
treatment of hospitalized adults with wounds healing by secondary intention. Wound management
includes changing the dressing and packing the
wound as well as irrigation and debridement.1,2
Clinical observation has led practitioners to conclude that WC is a major source of pain for patients
with wounds, yet limited data support this assumption.3,4
As part of a major study on procedural pain,
supported by the American Association of Critical
Care Nurses,5 we examined pain perceptions and
responses of acutely or critically ill adults to WC.
Specifically, the research was designed to (1) describe patients pain perceptions and responses beFrom the University of California San Francisco, School of Nursing, San Francisco, California.
Reprint requests: Nancy Stotts, RN, EdD, FAAN, UCSF, School of
Nursing, 2 Koret Way 631, San Francisco, CA 94143-0610.
0147-9563/$ see front matter
Copyright 2004 by Elsevier Inc.
doi:10.1016/j.hrtlng.2004.04.001

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fore, during, and after WC; (2) compare patients


pain perceptions and responses across time for
each of 4 specific WC procedures (dressing change,
packing, irrigation, and debridement) and by wound
type (surgical/nonsurgical); (3) examine the relationships between patients pain perceptions and
responses to WC and the following factors: patients
age, sex, ethnicity, presence of chronic pain, chronic
opioid use, procedural analgesia and sedative use,
use of nonpharmacologic interventions, type of provider performing the procedure, and procedure duration; and (4) describe the distress associated with
WC.

BACKGROUND
Wound Care
A wound is a disruption of tissue integrity such
that structural and functional integrity of tissue is
disrupted.6 Wound healing by secondary intention
is characterized by tissue loss and bacterial contamination.2 Local care is an integral part of treatment
of wounds and is designed to reduce bacterial burden, contain exudate, protect the wound from iat-

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Wound care pain in hospitalized adults

rogenic damage, and lead to wound closure.1 Care


of wounds healing by secondary and tertiary intention includes dressing change, packing, irrigation,
and debridement.
Many types of dressings are available to treat
wounds. Historically, dressings have been conceptualized as having a contact layer, an absorptive
layer, and a binding layer.7 The contact layer is the
material that is closest to the wound, often a nonadherent layer. The absorptive layer usually is composed of gauze to wick away exudate from the
wound surface. The binding layer holds the dressing
in place. With the newer dressings, such as those
made of hydrocolloid or foam, the contact, absorptive, and binding layers often are combined.
Dressing change involves removal of a dressing
and reapplication with a new dressing. Dressing
changes may also include cleansing of the wound.
Dressing changes are performed on a scheduled
basis and when draining seeps through the dressing. Should the contact layer adhere to the wound,
it may be moistened before removal.8
Packing of a wound is performed to fill dead
space and prevent premature closure of the wound
to mitigate abscess formation. The wound is filled
with absorbent material and is packed lightly so it
does not inhibit blood flow to the area. Gauze is the
most commonly used packing material, and it is
opened to a single layer before insertion. Depending on how moist the wound is, packing is inserted
into the wound dry or after being moistened with a
physiologic solution.
Irrigation of a wound is performed to remove metabolic end products, debris, and contaminants.9 With
a physiologic solution, the fluid is applied to the
wound at 4 to 15 pounds per square inch (PSI). Low
pressures (4 PSI) are not effective in exceeding the
adhesive forces and so are not able to remove debris.
Higher pressures (15 PSI) push fluid into the tissues,
creating an environment that is theoretically supportive of infection.10 No experimental studies that examine the effectiveness of irrigation in reducing wound
infection are reported in the literature.
Sharp debridement is the removal of dead tissue
with a scalpel, scissors, or curette. It is a quick and
efficient method to reduce dead tissue in a wound,
but it is nonselective and healthy tissue can be
removed with the dead tissue.9 Surgical debridement demonstrates an increase in the rate of healing of diabetic foot wounds.11 Debridement can also
be accomplished with chemical and autolytic approaches as well as mechanical debridement with
wet-to-dry dressings and whirlpool.9

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Stotts et al

Pain and wound care


Some data indicate that pain is associated with
chronic wounds,12 yet little is known about WC pain.
Most of what we know about WC pain comes from
providers impressions of patients experiences. Using a Heideggerian hermeneutic approach, Krasner3
asked nurses (n 42) to provide an exemplar about
the pain experienced by persons with pressure ulcers. Major themes that emerged from the exemplars were related to nurses identifying and treating
the pain, ignoring the pain, and confronting the
challenge of pain.
In Great Britain, nurses views about the pain and
trauma experienced by patients during dressing
changes were explored.13 A survey, mailed to members of 2 national wound-care organizations, sought
to identify practitioners main concerns during
dressing change. They found that 47% of participants were most concerned about trauma and that
34% were most concerned about patients pain. The
nurses reported that most pain is experienced during dressing change (81%), a few identified cleansing (7%) as a source of pain, and some (6%) reported
that merely the presence of the wound caused pain.
These nurses reported that they prevented pain by
selecting a certain type of dressing, giving prescribed analgesia, and soaking the dressing before
its removal. Few participants reported involving the
patient in care to reduce pain.
Factors identified as most important in contributing to pain at dressing change were the dressing
drying out (33%) and wound products adhering to
the wound (29%). This research is important, because it is the largest study of nurses opinions
about the sources of pain at dressing change. The
response rate for the survey was 37%, and thus
these findings may reflect the response bias of the
subset who completed the survey.
This same survey was sent to nurses in Austria,
Germany, and Switzerland, and 499 responses were
received from the 3300 distributed.14 Adherent
dressings were identified as the most important
factor contributing to pain (35%). Strategies to reduce pain at dressing change focused on use of
products that do not cause pain or soaking the
dressing before its removal. Slightly more than 40%
of participants reported controlling pain with pharmacologic interventions. Low participation, as seen
in the less than 16% response rate, threatens the
validity of these data.
There is a need to understand the pain experience associated with WC. Because pain by definition is a subjective experience, data that are more

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accurate would be generated if research were focused on patients perceptions of their experience,
rather than those of the provider.

METHODS
A 1-group, repeated-measures design was used
to examine the pain response of patients who had
WC performed. The site coordinator for the study
determined whether institutional review board (IRB)
approval was necessary and, when needed, obtained approval from the sites IRB. In sites that
required IRB approval, informed consent was obtained from the patient. In sites that did not require
IRB approval, patients were directly enrolled in the
study.

Sample
A convenience sample of adults was enrolled
from the population of patients undergoing WC at
participating institutions. (Children aged 3-17 years
were included in the sample for the larger procedural pain study.5 Data about WC-related pain will
be reported in an article focused on procedural pain
in pediatric patients.) Adults were included after
their primary nurse determined that they were
awake, alert, oriented, and medically stable enough
to respond to questions. Patients had to be able to
see, hear, and communicate in English. Patients
were excluded if they were receiving neuromuscular
blockade; had disease processes or injury that impaired sensory transmission proximal to the WC
site; had WC that included the removal of drains,
sutures, or staples; or were receiving burn care.

Definition of terms
The major study terms are defined in Table I.

Instruments
Study instruments were a pain intensity numeric
rating scale (NRS) (range 0-10), the Thunder Study
Modified McGill Pain Questionnaire-Short Form
(MPQ-SF) for pain quality, a behavioral observation
tool developed for this study, the procedural distress NRS (range 0-10), and the body outline diagram. The NRS, Thunder Study Modified MPQ-SF,
and procedural distress NRS, and their validity and
reliability are described in the main study report.5
The body outline to identify pain location has been
described by Puntillo.15 Data on the behavioral observation tool also have been reported.16

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Table I
Definition of major study variables
Pain: An unpleasant sensory and emotional
experience arising from actual or
potential tissue damage or described in
terms of such damage. It is whatever the
experiencing person says it is, existing
whenever he or she says it does.
Wound care: The process of removing dead
tissue, cleansing the wound, or providing
a protective environment. Wound care
procedures include dressing change,
packing, irrigation, debridement.
Types of wound care procedures
Dressing change: removal and
reapplication of a covering to the wound.
Packing: Insertion of material into a
wound cavity and covering of the wound
with a secondary dressing to prevent
ingress of organisms.
Irrigation: Applying fluid under pressure
to remove adherent materials and
byproducts of wound metabolism from
the surface of the wound.
Debridement: Removal of necrotic
material and slough from the wound.

Procedure
Before the study was initiated, nurses at each
study site participated in educational training sessions to ensure accuracy and consistency of procedures. The training included a videotape developed
by the research team that demonstrated each aspect of data collection including use of the behavior
observation tool. Drawings of facial expressions
with labels and defining characteristics were provided to assist data-collection nurses to master this
component of the pain assessment. After training,
the participating nurses screened patients who were
to undergo WC and collected study data on appropriate patients who consented to participate. A standard protocol was used for each data collection point.
Before the procedure. The patient was observed
for pain behaviors for 1 minute, and all facial responses and other behaviors observed were recorded on the behavior checklist. Pain intensity was
assessed using an NRS. Patients with a pain rating
of 1 or greater identified the location of pain using
a body outline diagram. Pain quality was assessed
by the nurse reading the MPQ-SF word list and the
patient selecting those words that described the

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Stotts et al

pain they were experiencing at the time. Patients


who were unable to speak nodded or pointed to the
terms that described their pain. The patients blood
pressure (BP) and pulse rate then were recorded if
instruments monitored these.
During the procedure. The patient was observed
for pain behaviors for 1 minute during the procedure. These behaviors were recorded on the data
collection sheet. Pain intensity, location, and quality were assessed using the same approach as described at baseline, before the procedure. Patients
were asked to report peak pain during the procedure. BP and pulse rate were recorded at the conclusion of the WC.
After the procedure. Ten minutes after the completion of the WC, pain intensity was elicited, and
pain location and quality were assessed again as
before and during the procedure. Procedural distress was recorded. Patients were queried about
their prior experience with the procedure. The patients BP and pulse rate were recorded.
The patient, nurse, and others present during the
procedure were asked what nonpharmacologic measures they used during the procedure. Demographic
data and procedure-related data were retrieved from
the patients chart. Data regarding analgesia and
sedatives administered within the 1 hour before the
procedure and during the procedure were recorded.
The trained registered nurse who participated
returned the data collection forms to the site coordinator. All forms from the site were returned to the
American Association of Critical Care Nurses national office where data were entered into the Statistical Package for the Social Sciences (version
10.0, SPSS Inc, Chicago, IL).

RESULTS
The sample

Data analysis

Pain and wound care

Descriptive statistics were generated for pain location, pain intensity, pain-related behaviors, words
that described the quality of the pain, heart rate,
and BP for the 3 pain assessment times. Descriptive
statistics were also generated for the data concerning analgesics, sedatives, nonpharmacologic interventions, and procedural distress.
Repeated-measures
analysis
of
variance
(ANOVA) was used to examine the main effect of
pain intensity across the 3 times (before, during,
and after the procedure) by wound type (surgical
and nonsurgical) and the related interactions. Three
repeated measures ANOVAs were performed: one
for dressing change, one for packing, and one for 2
or more dressing change procedures. The simple

WC procedures included dressing change, packing, irrigation, and debridement. Dressing change
was the most frequent WC procedure (n 293;
71.1%). Packing was performed in 54.6% of patients
(n 205). The packing was removed moist in 80% of
the cases and dry in 20%. Irrigation was performed
in 107 patients (27.6%), and debridement was performed in a small portion (n 15; 3.6%). The
cleansing agents and dressings that were used on
these wounds are listed in Table IV.
No patient reported a history of chronic pain or
chronic opioid use. Across the 3 time periods, patient pain intensity was not different between men
and women (P .05). Pain intensity reports before
and after WC were not different by ethnicity; how-

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effects post hoc test compared the difference in


pain intensity across the 3 times between surgical
and nonsurgical patients. Pearson product moment
correlations were used to examine the relationships
between patients pain perceptions and age, procedure duration, and procedural distress. ANOVA also
was used to compare patients mean procedural
distress scores among 4 medication regimes (preprocedure, pre-procedure and during the procedure,
during the procedure only, none); t tests were used
to examine differences in patients pain intensity
reports at the time of the procedure according to
sex (male/female), ethnicity (white/nonwhite), procedural analgesia (use/no use), sedative use, and
type of provider performing the procedure.

WC was performed on 412 adults whose mean


age was 56.3 years (SD 17.13). Demographic data on
the sample are presented in Table II.
Patients had 1 to 12 wounds with a mean length
of 11.8 cm (SD 11.77) and a mean depth of 2.1 cm
(SD 2.61). Most wounds (73.9%) were surgical, and
the majority of patients (84%) had previously undergone WC. The modal WC procedure time was 5
minutes, and the median WC completion time was 9
to 10 minutes. The median time that WC was performed was 4 days after hospital admission, and the
modal day was 1 day after admission; 1 to 6 persons
participated in the WC, and usually 1 person (64.6%)
or 2 persons (28.2%) provided the care. Table III
shows the frequency with which various health care
providers performed the WC procedure.

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Table II
Demographic data for the sample
Variable

Sex (n 396)
Male
Female
Race and ethnicity (n 410)
White
African American
Other
Number of wounds (n 412)
1
2
2
Location of wound (n 412)
Abdomen
Leg
Other
Type unit where procedure performed (n 396)
Specialty unit (eg, cardiac surgery)
Other units
Critical care unit (medical or surgical)
Emergency department
Procedure room

Table III
Personnel who performed wound care*

Professional title

Registered nurse
Advanced practice
nurse
Physician
Assistive personnel
Physician assistant
Other

Number of
subjects
(n 412) Percentage

304
36

73.8
8.7

32
26
5
57

7.8
6.3
1.2
13.8

*May have had more than one person performing


wound care.

ever, during the procedure, nonwhites had greater


pain intensity than whites (t 2.12, P .034).
Patients physiologic response to pain was measured with their BP and pulse rate (Table V). All 3 of
these measures increased during the procedure.
When the 3 time periods were compared, there was

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Number of subjects

Percentage

207
189

52.3
47.7

303
79
28

73.9
19.3
6.8

245
126
41

59.5
30.6
9.9

236
131
45

57.3
31.8
10.9

167
127
84
10
8

40.5
32.1
21.2
2.5
2.0

a significant difference over time in BP (systolic [F


3.38, P .035], diastolic pressure [F 5.35, P
.005]), and pulse rate (F 5.92, P .003). Approximately a quarter of the patients (23.5%) were receiving hemodynamic medications. When BP and
pulse rate were compared for those receiving hemodynamic medications and those not receiving hemodynamic medications, no significant difference
was noted (P .05).
Complete data for pain intensity available on 375
patients at the 3 time periods show that the mean
pre-procedure pain was 3.0 (SD 2.85), during procedure pain was 4.4 (SD 3.20), and post-procedure
pain was 2.7 (SD 2.74). Repeated-measures ANOVA
was used to test whether there was a difference in
pain intensity within subjects across all 3 time periods by wound type (surgical/nonsurgical). Findings
showed a significant interaction between time and
wound type (F 3.93, P .023). Simple effects post
hoc test showed that pain intensity during the procedure was significantly different between surgical
and nonsurgical patients. Nonsurgical patients had
significantly higher pain intensity than surgical patients during WC (F 10.04, P .002). Although not
statistically significant, perhaps because of the

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Table IV
Wound cleansing agents and wound contact materials
Variable

Number of subjects
(n 412)

Percentage

267
50
25
18
11
10
39

64.8
12.1
6.1
4.4
2.7
2.4
9.5

317
25
22
19
11
9
9
8

76.9
6.1
5.3
4.6
2.7
2.2
2.2
1.9

Wound cleansing agents


Normal saline
Povidone iodine
Hydrogen peroxide
Acetic acid
Dakins solution
Isopropyl alcohol
Other
Wound contact layer
Gauze
Telfa
Enzymatic debridement
Medicated gauze
Vasoline gauze
Film barriers (skin prep)
Hydrogels
Hydrocolloids

Table V
Mean (SD) blood pressure and pulse before, during, and after wound care

Before
During
After

Systolic N 236
Mean (SD) mm Hg

Diastolic N 235
Mean (SD) mm Hg

Heart rate N 241


Mean (SD) beats/min

128.4 (24.23)
131.0 (24.01)
127.7 (25.81)

71.1 (12.55)
72.3 (13.58)
70.2 (13.12)

89.5 (17.13)
92.0 (19.39)
88.8 (18.34)

small sample size of 15, pain in surgical patients


undergoing debridement as part of their wound care
was substantially higher than in nonsurgical patients (8.2 [SD 2.06] vs 6.5 [SD 2.84], respectively).
Pain intensity by wound care procedure was explored. Of the 412 patients, 124 underwent a single
procedure while the remainder (n 288) had two or
more wound care procedures completed at one
time. Dressing change was the most frequent single
procedure performed (n 61), followed by packing
(n 41). Few subjects had only irrigation or wound
debridement.
Repeated measures ANOVA was used to test
whether there was a difference in pain intensity
across the 3 time periods by wound type for (1)

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dressing change, (2) packing, and (3) 2 or more


wound care procedures. Included were patients that
had complete data for all 3 time periods (prior to,
during, and after the procedure). Findings showed
that pain intensity for the dressing change procedure was significantly different between the surgical
and nonsurgical patients during the procedure (F
6.57, P .013). Also pain intensity within the nonsurgical group was significantly different across
time (F 16.41, P .001).
For packing, there was no difference in pain over
time (F 2.20, P .133) or pain intensity interaction between pain and the surgical and nonsurgical
patients (F 0.22, P .732). In patients that underwent 2 or more procedures, pain increased sig-

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Table VI
Mean pain intensity (SD) for surgical and nonsurgical patients prior to and during dressing change,
packing, and 2 or more wound care procedures

Prior to the procedure


Surgical patients
Nonsurgical patients
During the procedure
Surgical patients
Nonsurgical patients
After the procedure
Surgical patients
Nonsurgical patients

Dressing change
(n 61)

Packing
(n 41)

>2 Procedures
(n 258)

3.1 (2.73) (n 42)


2.9 (3.23) (n 19)

2.4 (2.77) (n 37)


4.5 (3.42) (n 4)

2.9 (2.93) (n 194)


3.3 (2.51) (n 64)

3.6 (3.16) (n 42)


5.9 (3.53) (n 19)

4.0 (3.53) (n 37)


5.3 (4.11) (n 4)

4.2 (3.15) (n 194)


5.3 (2.58) (n 64)

3.3 (2.83) (n 42)


2.8 (3.28) (n 19)

2.1 (2.44) (n 37)


4.3 (3.10) (n 4)

2.6 (2.80) (n 194)


3.1 (2.31) (n 64)

nificantly during the procedure (P .000), regardless of whether they had a surgical or nonsurgical
wound (P .088). Table VI shows mean pain scores
over time for wound procedures by type of wound.
Data on pain quality, assessed with the Thunder
Study Modified MPQ Quality Word List, showed that
some terms were used consistently to describe pain
across the specific WC procedures. Terms most frequently used were tender (53.6%), sharp (38.9%),
stinging (32.1%), aching (27.7%), stabbing (25.5%),
bad (24.2%), hot-burning (24%), throbbing (22.1%)
and shooting (22.1%). The 20 terms on the scale
were examined to see which changed by 10% or
more from baseline to during the procedure. Ten
percent was selected as an arbitrary amount. Three
words increased in use by 10% or more across the 4
specific WC procedures: stabbing, sharp, and stinging. No term decreased by 10% (Table VII).
In a similar manner, pain behaviors were examined. Behaviors that occurred most frequently during the wound care procedures were no verbal response (46.1%), no body movements (42.2%),
grimace (30.8%), verbal complaints of pain (26%),
frown (23.8%), wince (21.6%), no facial response
(21.6%), eyes closed (21.1%), and moaning (20.4%).
When the behaviors were examined to see which
increased by 10%, the behaviors were grimace,
wince, moaning, verbal complaints of pain, rigid,
and clenched fist. Those that decreased by 10% or
more included no facial response, no verbal response, and no body movement (Table VIII).

Pain intervention
Both pharmacologic and nonpharmacologic
strategies were used to prevent and treat pain in

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this sample. Pharmacologic treatment was used in


23.8% (n 98) of patients. Nonpharmacologic treatment was used in 88.3% (n 364). A total of 20.6%
(n 85) had both pharmacologic and nonpharmacologic treatments. Approximately two thirds of the
patients (n 279) received no drug but did receive
nonpharmacologic treatments, and 3.2% (n 13)
received drugs only. In the sample, 8.5% (n 35)
did not receive pharmacologic or nonpharmacologic
treatment for pain.
Pharmacologic treatments included opioids,
sedatives, nonsteroidal antiinflammatory drugs
(NSAIDs), or other, and local treatment included
lidocaine injection and topical eutectic mixture of
local anesthetic (EMLA) cream. A total of 93 patients received medications before WC, and opioids
were used the most frequently to premedicate patients (n 75). Only 19 patients received medication during WC, and opioids were administered to
most of them (n 17). The mean dose expressed in
equivalent doses of morphine was 6.3 mg (SD 6.07).
To determine whether opioids contributed to differences in pain intensity between the surgical and
nonsurgical patients, the number of patients in each
group who received an opioid was examined. Treatment with any opioid was provided in only 7.3% of
the surgical patients and 5.9% of nonsurgical patients. There was no difference in whether or not a
patient received an opioid by whether they were in
the surgical or nonsurgical group (P .821).
Opioid doses were examined across the 3 time
periods. Those who received opioid pre-procedure
or during the procedure had more pain at those
times than those who received no opioids (P
.001). Pain intensity was greatest during the proce-

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Table VII
Percentage of patients who identified specific pain quality words at baseline and during the wound
care procedure

Pain quality
words

Percent of patients who


described their pain
with this term prior
to the procedure

Percentage of patients
who described their
pain with this term
during the procedure

Throbbing
Shooting
Stabbing*
Sharp*
Cramping
Gnawing
Hot-burning
Aching
Heavy
Tender
Splitting
Tiring-exhausting
Sickening
Fearful-frightening
Punishing-cruel
Awful
Bad
Stinging*
Dull
Numb

25.6%
13.8%
13.2%
26.4%
12.4%
14.6%
19.4%
31.2%
16.0%
44.7%
6.5%
16.0%
11.2%
10.7%
6.5%
13.2%
19.1%
19.4%
25.4%
14.0%

22.1%
22.1%
25.5%
38.9%
9.2%
14.7%
24.0%
27.7%
13.7%
53.6%
9.5%
15.3%
11.8%
10.8%
10.5%
19.2%
24.2%
32.1%
17.4%
10.3%

*Items that increased by 10% or more from baseline to during the wound care procedure.

dure and decreased after WC was completed. After


WC, there was no difference in pain intensity in
those who had and had not received opioids (P
.05).
There were similar findings with the use of sedatives. Those with greater pain received sedatives
pre-procedure or during the procedure. However,
the number of patients who received sedatives was
small (n 10). Their mean pain intensity was higher
for those who received sedatives versus those who
did not receive sedatives before the procedure (6.6
vs 3.0), during WC (8.2 vs 4.3), and after WC (3.9 vs
2.7).
NSAIDs also were used in a small sample (n
10). Data showed no difference in pain intensity
when NSAIDs were used pre-procedure or during
the procedure (P .05). Injected lidocaine also was
used in a small number of patients (n 9). No
difference was seen in the pain before or during the
procedure for these patients, but a significant decrease in pain intensity was reported after the pro-

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cedure for those who received lidocaine (P .001).


The mean pain intensity of those receiving lidocaine
was 3.1 (SD 3.37) during the procedure and 0.3 (SD
0.71) after the procedure. Only 1 patient received
topical local anesthetic.
Nonpharmacologic interventions were recorded
when they were performed by the patient, nurse, or
other. A total of 364 patients received 1 to 8 nonpharmacologic treatments. Both the median and
the mode for nonpharmacologic treatment are approximately 2 treatments per patient.
The nonpharmacologic interventions initiated
most often by patients were humor (18.9%), distraction (15.5%), and deep breathing (12.1%). Nurses
most often provided information (59.0%), used a
calming voice (47.6%), and used distraction (31.8%).
Other members of the health care team or family
members rarely (7.0%) used nonpharmacologic interventions. When nonpharmacologic interventions
were examined across patients, nurses, and others,
those most frequently used were the same as used

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Table VIII
Percentage of patients who displayed behaviors when pain was assessed at baseline and during the
wound care procedure

Pain behaviors

Percent of patients who


demonstrated the behavior
prior to the procedure

Percentage of patients who


demonstrated the behavior
during the procedure

Grimace*
Frown
Wince*
Eyes closed
Eyes wide open
Looking away
Grin/smile
Mouth wide open
Clenched teeth
No facial response**
Moaning*
Screaming
Whimpering
Crying
Using protest words
Verbal complaints of pain*
No verbal response**
No body movements**
Rigid*
Arching
Clenched fist*
Shaking
Withdrawing
Splinting
Flailing
Picking/touching site
Restlessness
Rubbing/massaging
Repetitive movement
Defensive grabbing
Pushing
Guarding

10.4%
18.0%
4.6%
11.4%
5.8%
3.6%
12.9%
0.5%
2.4%
45.1%
4.9%
0.5%
1.7%
0.7%
0.5%
15.5%
69.4%
62.4%
5.3%
1.5%
1.7%
1.5%
1.7%
2.4%
0.2%
1.7%
5.8%
5.3%
1.7%
0.2%
1.0%
5.8%

30.8%
23.8%
21.6%
21.1%
7.8%
10.0%
7.0%
1.0%
8.5%
21.6%
20.4%
1.7%
4.6%
2.2%
8.0%
26.0%
46.1%
42.2%
16.7%
3.4%
11.7%
3.4%
9.7%
2.4%
0.7%
2.4%
9.2%
3.9%
2.2%
3.2%
1.5%
8.3%

*Items that increased in 10% or more from baseline to during the wound care procedure. **Items that decreased in 10% or more
from baseline to during the wound care procedure.

by the nurses: information (62.4%), calming voice


(50.2%), and distraction (40.8%). Heat and cold
(0.5% and 0.2%) and hypnosis (0.2%) were rarely
used. Transcutaneous electrical stimulation and
acupressure were not used to relieve pain in patients in this study.
Of the nonpharmacologic treatments, deep
breathing significantly reduced pain before the procedure compared with during the procedure (t
2.65, P .01), as did using a calming voice (t

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3.17, P .002). Other interventions (ie, gentle


touch, humor, or information) did not reduce pain.

Relationship between pain and age


and procedure duration
When the relationship between patients pain
perception and responses to WC and specific variables was explored, data showed that there was a
small significant inverse relationship between age

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Table IX
Mean distress scores by type of wound and
medication use
Distress
Mean (SD)

Overall (N 379)
Type of wound
Surgical (N 270)
Nonsurgical (N 89)
Medication use
Before and during (N 14)
Before only (N 73)
During only (N 5)
None (N 287)

2.8 (3.26)
2.5 (3.17)
3.7 (3.32)
6.4 (3.27)
3.5 (3.34)
6.4 (3.05)
2.4 (3.08)

and pain intensity before (r .252, P .001) and


after the procedure (r .138, P .006). Younger
patients had greater pain than older patients before
and after the procedure, but pain was equal by age
during the WC procedure. Also, there was no significant relationship between procedure duration and
pain (P .05).

Distress associated with wound care


procedure
For subjects who reported distress (n 379), the
mean distress associated with WC was 2.8 (SD 3.26).
Nonsurgical patients had significantly more distress
(t 3.07, P .002) than surgical patients (Table
IX). Of those who received medication (n 92),
distress was least in those who received medication
before the procedure (Table IX).

DISCUSSION
Patients who underwent WC had mild-to-moderate pain intensity present before manipulation of
the wound. Presumably this pain was caused by
stimulation of nociceptors by tissue trauma with
varying reported levels of pain because of differences in processing through the central and peripheral nervous system.17
Even with mean pain intensity that was mild to
moderate at baseline (Table VI), pharmacologic
treatment was initiated in less than a quarter of
patients in this study. In those who received medication, it is not clear whether they were adequately
medicated. The possibility of inadequate medication of those who received opioids is supported by
the fact that they had greater pain during the pro-

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Stotts et al

cedure versus those who had not received opioids.


These data are consistent with other data that show
undermedication of critical care patients18 and patients in simulated situations19; however, neither of
these situations was WC specific. In addition, nonpharmacologic treatment often was initiated. A
meta-analysis of studies of acute pain treated with
nonpharmacologic interventions could not identify
a difference between treatment and control
groups.20 Moreover, the combination of pharmacologic and nonpharmacologic therapy was not effective in mitigating pain intensity as seen by the
increase in mean pain during the procedure. Future
research is needed to determine the type of treatment that provides the best pain control with WC.
Also needed are strategies to enhance clinician use
of assessment data to treat existing pain and anticipate wound procedure pain.
Older patients had less baseline and post-procedure pain than did younger patients. These findings
are in contrast with those of Gagliese and colleagues,21 who found no difference in pain intensity
at rest or with movement between younger and
older surgical patients who were managing their
pain with patient-controlled analgesia. The administration of the medication by patient-controlled
analgesia may account for these differences in pain
intensity. It should be noted that a large series of
animal studies, largely rat studies, also are equivocal regarding the effect of age on pain nociception.22
Procedural pain intensity was significantly
greater for those with nonsurgical wounds than for
those with surgical wounds. It is possible that surgical patients had lingering effects of anesthesia
and so experienced less pain. Another possibility
was that surgical patients had received medication
for surgical pain that was provided more than 1 hour
before the procedure or that was continuous. The
study design did not provide for measure of time of
surgery or type of anesthesia and measured pain
medication only for 1 hour before the procedure, so
such comparisons could not be made. This finding
of differences in pain during WC procedures in nonsurgical versus surgical patients suggests that more
attention should be paid to those not receiving
regularly scheduled analgesics because they may be
more vulnerable to WC pain.
When pain intensity of surgical versus nonsurgical patients wounds was examined for dressing
change, packing, or 2 procedures, nonsurgical patients had significantly greater pain only during
dressing change.23,24
Debridement in this study was performed as part
of wound care on a small portion (4%) of the study

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sample, yet their mean pain scores during the procedure increased to a severe level and returned to
only a mean moderate level post-procedure. This
high level of pain may be caused by inadequate pain
management combined with the nonselective nature of sharp debridement in that healthy tissue
often is removed with the debris. Data are not available that indicate whether the injected local anesthetic was allowed to reach peak effect before debridement was performed. Data from a review of
randomized clinical trials of EMLA to treat the pain
associated with debridement in the chronic wound
literature indicate that EMLA is effective in reducing
the pain associated with debridement23; however, a
slower rate of healing and higher incidence of burning and itching were reported in 1 trial. EMLA was
used in only 1 patient in this study; further examination of its use in the critical care setting is warranted.
Two studies indicate that nurses believe that the
dressing used can prevent trauma and pain with
WC. Yet in these studies, nurses did not know what
types of dressings could be used to reduce pain and
trauma.13,14 In the current study, most wounds were
dressed with gauze, and therefore comparison of the
pain associated with various types of dressings could
not be performed. Further research comparing pain
intensity with various dressings using patient report
rather than nurses estimate of pain is needed.
Data from this study provide the clinician with
terminology to assess the presence of pain. The
terms tender, sharp, stinging, aching, and stabbing
were frequently reported. The terms stabbing, sharp,
and stinging were experienced more frequently during WC than before it. Further work is needed in
nonEnglish-speaking populations to identify the
terms associated with procedural pain.
Behaviors that occurred most frequently were no
verbal response, no body movements, grimace, and
complaints of pain. Those behaviors that increased
10% or more from baseline to during the procedures
were grimace, wince, moaning, verbal complaints of
pain, rigid, and clenched fist. Also during the procedure, there was a 10% or more decrease in the
categories of no facial responses, no verbal responses and no body movements. Observation of
these behaviors may help clinicians identify those
in pain, especially those who are not able to verbalize their needs (eg, the patient with an endotracheal
tube). Few studies have been performed in populations who are not able to verbalize their pain-related needs during procedures.

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LIMITATIONS
The findings from this study were limited to alert,
oriented, English-speaking patients. Those who
were excluded because they were sedated or not
alert may have had a different pain experience than
those who were studied. Further work is needed in
this area. In addition, specific interventions were
not tested in this study. Although training was given
in use of the data-collection tools, interrater reliability among raters and sites was not formally established.

CONCLUSION
Hospitalized patients with wounds healing by
secondary intention experience pain before, during,
and after WC. Peak pain is during the procedure.
Specific terms and behaviors were used consistently
with pain across procedures. Providers need to
adopt these often-used terms to assess pain and
observe patients for frequently occurring behaviors,
especially in patients who are not able to verbalize
their pain needs. Patients in this study were given
little pain medication. Nonpharmacologic treatment was used in more than 80% of patients.
There is a need for further research in the area of
pain control with WC. Additional testing is needed
to determine whether the terms and behaviors reported in this study are consistent across populations. More work is needed to evaluate strategies to
increase the amount of medication administered
and to compare the effectiveness of various medications. The effectiveness of nonpharmacologic
therapies also needs to be explored and compared
for efficacy. Combination pharmacologic and nonpharmacologic therapy deserves further study.

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