MDS Alert

Identify and address these underlying causes, including 2 psychosocial factors.

There's no magic formula for vanquishing residents' wound pain, but the right assessment and treatment approaches can go a long way toward promoting optimal comfort and wound healing.

The painful reality: "Pain has an impact at the cellular level of the wound," says Jayne Eidle, RN, BSN , CWOCN, a wound care expert in Middlebourne, W.Va. "Chemicals released there in response to pain or stress can rob the wound of oxygen, causing hypoxia at the cellular level" and diminishing wound healing. This "even affects the quality of the tissue being regenerated."

"Generally speaking, the deeper the wound, the more pain receptors are involved," says Eidle. For example, "the pain with a stage 4 pressure ulcer is generally more severe and constant," she says. A person with a pressure ulcer on the leg who has neuropathy may not experience pain, however, she points out. "Arterial ulcers are generally more painful than venous ulcers," adds Peggy Dotson, RN, a wound care specialist in Yardley, Pa., "although there's quite a bit of pain associated with chronic wounds overall."

"Determine if the pain is constant or intermittent," advises Dotson. If it is intermittent, look at what appears to be associated with the pain when it does occur, she adds. This may give you clues about potential underlying causes of the pain, including pain that's "directly associated with the wound itself, the surrounding tissues, exposed nerve endings, infection, or cellulitis." Use a validated, standardized pain scale to assess the level of pain the person is experiencing, advises Dotson. And pay close attention to any increase in pain as a potential danger signal. "Any worsening of pain requires timely physician examination and blood tests to rule out systemic infection," advises Jeffrey M. Levine, MD, a wound care expert in New York, N.Y. Increasing pain could also indicate deep tissue injury, he adds.

Also: Keep in mind that ischemic pain related to atherosclerotic vascular disease is included in the differential diagnosis for wound pain involving wounds in the lower extremity, adds Levine.

Take a look at the condition of the skin around the wound. "Sometimes patients experience periwound pain due to skin irritation or erosion from wound fluid or reaction to adhesives," Dotson says. "In that case, choose a dressing, such as a hydrogel dressing, to cool and soothe the tissue around the wound," she advises. Or "use another occlusive dressing to protect the peri-wound area, if that is causing the pain."

Another possibility: Suppose the wound has a moderate-to-high amount of exudate. Consider using a dressing to absorb the drainage, Dotson advises. For example, use "an alginate or gelling fiber dressing or a foam dressing that can absorb the excess wound fluid. You can also use protective ointments or specialty dressings that protect the surrounding area and help soothe and heal the skin." "If the pain is due to exposure of the nerve endings, occlusive dressings  not only protect the nerve endings, but also provide moist wound healing to make sure the wound doesn't dry out, which may cause more pain," Dotson adds.

Good question: Does the pain occur primarily during dressing changes? Consider using dressings that can be left on for a number of days without changing them, advises Mary Arnold Long, MSN , RN, CRRN, CWOCN-AP, A CNS -BC, a wound care consultant in Cincinnati, Ohio. Warming the wound cleansing solution in a tub of water may decrease pain due to using cold (room temperature) saline or other wound cleanser, adds Long. But do not heat the cleanser in the microwave, she cautions.

Resource: Long suggests reviewing the consensus document, "Minimizing Pain at Wound Dressing-Related Procedures," by the World Union of Wound Health Societies at

www.wuwhs.org/datas/2_1/2/A_consensus_document_-_Minimising_pain_at_wound_dressing_related_procedures.pdf.

Other ideas: "Repositioning and pressure-relieving devices, as well as activities that distract the person can help reduce pain," says Eidle. "You really have to work with the individual to identify what works for him or her," she adds. "Diathermy, which the therapy department provides, can increase circulation to the wound area, which shortens healing time."