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Painful Dressings
Journal of Tissue Viability 1996 Vol6 No 3
69
PAINFUL DRESSINGS Clare Williams Tissue Viability Nurse, Maelor Hospital NHS Trust (A paper presented at the Society's 26th Conference) INTRODUCTION Pain and ·wound healing are closely linked through the process of inflammation and hyperalgesia1• The stress response which is increased by unrelieved pain promotes platelet aggregation. At a cellular level, stress hormones such as cortisol interfere with wound healing and hypoxia, (the result oflimited painful breathing and peripheral vasoconstriction), reduces oxygen at the wound site 2 • Despite this, the control of pain has been very much under-estimated within wound managemene. It is unacceptable nowadays, with modem dressings and available information, for patients to suffer pain other than minimal discomfort from dressings and the wound dressing procedure. Hollinsworth4 examined the methods used by nurses to assess, manage and document pain at wound dressing changes. She concluded that teaching strategies should be developed so that nurses have a more sensitive approach, which should include patient involvement in pain assessment before dressing changes, documented pain assessments and wider availability of nitrous oxide (Entonox) for inhaled analgesia.
For many years now, it has been known that ribbon gauze used to dress cavity wounds can be uncomfortable in situ, excruciatingly painful to remove5 and also damage healthy granulation and epithelial tissue. Many health care professionals still choose to use these conventional dressings despite the availability of, for example, alginate dressings, which are known to be almost painless to remove, comfortable in situ and which do not cause any damage to healthy tissue on removaL METHODOLOGY This small study had a very specific objective: to 1mt1ate a change of practice and to encourage general surgeons to change from packing surgical cavity wounds with ribbon gauze soaked in Proflavine cream to using a calcium alginate dressing. Previous attempts had failed and it was decided to adopt a multidisciplinary team approach. The Clinical Nurse Specialist from the Acute Pain Service was involved alongside the Clinical Nurse Specialist in Tissue Viability, surgical ward nurses, theatre nurses and surgeons. Table I. Pain assessment tool
LOW SEVERE 1 2 4 3 5 6 7 8 9 10 It was thought that to highlight the pain suffered by patients during and after dressing changes and for the surgeons to talk to the patients involved, may be a way to change their practice. In this situation we would be utilising the cognitive dissonance theory of change described by Walsh and Ford6 - 'seeing is believing'. A data collection tool was developed and a pain assessment tool was utilised (Table 1) on the advice of the pain control nurse specialist.
A random sample of patients with surgical cavity wounds was used, the wound types mainly being from excision of pilonidal sinus, breast abscesses and abdominal surgical wounds. The calcium alginate used was Sorbsan because of its particularly easy removal. Sorbsan dissolves when irrigated with saline, which also makes the dressing change less time consuming and cost effective as no auxiliary dressing packs are required. RESULTS The results from 24 patients, 10 in the ribbon gauze group and 14 in the calcium alginate group are outlined in Table 2. Patients in the calcium alginate group reported little or no pain and required no analgesia during dressing changes. Patients in the ribbon gauze group reported severe pain during the dressing change and immediately afterwards and all were reporting at least some pain two hours later. Most of the ribbon gauze group required analgesia. Dressing changes took, on average, three times longer in the ribbon gauze group than in the calcium alginate group. DISCUSSION The results of this small study support the views of others7•8, that those patients returning from theatre with ribbon gauze packs suffer discomfort from the dressing and extreme pain on removal which can last a considerable length of time.
For the process of change to be successful, a deeper understanding of the nature of change and its effect on the people involved should be encouraged9 • The management of change was considered carefully before the start of this study. Because of this, a change in practice was achieved. Two years after the study an audit revealed that in 85% of cases, calcium alginate was used in preference to a ribbon gauze pack. ACKNOWLEDGEMENTS I would like to thank Lucy Jones, Clinical Nurse Specialist Pain Control, and Beryl Griffiths, Surgical Staff Nurse, both at Wrexham Maelor Hospital NHS Trust for their help in undertaking this study and their continued support. Address for correspondence Clare Williams,Clinical Nurse Specialist Tissue Viability, Wrexham Maelor Hospital NHS Trust,Clwydd LL13 7TD. REFERENCES 1. Rice ASC. Pain, inflammation and wound healing. Journal of Wound Care1994; 3(5):246-248. 2. Pediani R. Recent developments in the control of surgical wound pain. Journal of Wound Care 1994; 3(8): 394-396. 3. Thomas S. Pain and wound management. Community Outlook 1989; July: 11-15.
70
Journal of Tissue Viability 1996 Vol6 No 3 Table 2. Results Patient no
Wound type dressing change
Analgesia during before dressing
Pain during
immediately after
5 mins after
Length of
30 mins after
120 mins after
dressing (mins)
Sorbsan group 1
PS
-
1
4
1
0
0
0
20
2
PS
-
0
2
0
0
0
0
15
3
ACW
-
0
1
0
0
0
0
MID
4
BA
-
2
2
0
0
0
0
15
5
PS
-
1
1
0
0
0
0
25
6
PS
-
0
2
0
0
0
0
10
7
BA
-
0
1
0
0
0
0
MID
8
PS
-
1
2
0
0
0
0
15
9
ACW
-
1
2
0
0
0
0
MID
10
ACW
-
0
2
1
1
1
0
10
11
PS
-
0
2
1
0
0
0
20
12
PS
-
0
1
0
0
0
0
15
13
AA
-
1
1
0
0
0
0
10
14
PS
-
0
1
1
1
0
0
10
Ribbon dressing group 15
PS
Nitrous Oxide
1
10
10
9
5
3
60
16
PS
Nitrous Oxide
2
9
8
5
5
2
50
17
BA
Pethidine
2
9
9
7
5
4
30
18
PS
Nitrous Oxide
3
10
6
4
4
1
60
19
ACW
Nitrous Oxide
2
8
6
5
1
1
80
20
PS
-
2
7
5
5
4
2
35
21
PS
Pethidine
1
7
6
4
1
1
45
22
BA
-
1
7
4
3
1
1
65
23
BA
Nitrous Oxide
2
9
6
5
3
1
MID
24
PS
Nitrous Oxide
1
8
7
6
3
1
40
KEY: PS -Pilonidal Sinus, BA -Breast Abscess, AA- Axilla Abscess, ACW- Abdominal Cavity Wound, MID - Missing Data 4. Hollinsworth H. Nurses assessment and management of pain at wound dressing changes. Journal of Wound Care 1995; 4 (2): 77-83. 5. Gibson C. Cavity dressings ancient and modem: a little research. British Journal of Theatre Nursing 1993;3(1): 8-10. 6. Walsh M, Ford P. Nursing rituals, research and rational actions. Oxford: Heineman Nursing, 1989: 112-114. 7. Miller L, Jones V, BaleS. The use of alginate packing in
the management of deep sinuses. Journal of Wound Care 1993; 2(5): 262-263. 8. Gupta R, Foster ME, Miller E. Calcium alginates in the management of acute surgical wunds and abscesses. Journal ofTissue Viability 1991; 1(4): 115-116. 9. Williams C. Putting theory into practice: the management of change in a hospital ward. Journal of Wound Care 1994: 3 (7): 344-345.
69
PAINFUL DRESSINGS Clare Williams Tissue Viability Nurse, Maelor Hospital NHS Trust (A paper presented at the Society's 26th Conference) INTRODUCTION Pain and ·wound healing are closely linked through the process of inflammation and hyperalgesia1• The stress response which is increased by unrelieved pain promotes platelet aggregation. At a cellular level, stress hormones such as cortisol interfere with wound healing and hypoxia, (the result oflimited painful breathing and peripheral vasoconstriction), reduces oxygen at the wound site 2 • Despite this, the control of pain has been very much under-estimated within wound managemene. It is unacceptable nowadays, with modem dressings and available information, for patients to suffer pain other than minimal discomfort from dressings and the wound dressing procedure. Hollinsworth4 examined the methods used by nurses to assess, manage and document pain at wound dressing changes. She concluded that teaching strategies should be developed so that nurses have a more sensitive approach, which should include patient involvement in pain assessment before dressing changes, documented pain assessments and wider availability of nitrous oxide (Entonox) for inhaled analgesia.
For many years now, it has been known that ribbon gauze used to dress cavity wounds can be uncomfortable in situ, excruciatingly painful to remove5 and also damage healthy granulation and epithelial tissue. Many health care professionals still choose to use these conventional dressings despite the availability of, for example, alginate dressings, which are known to be almost painless to remove, comfortable in situ and which do not cause any damage to healthy tissue on removaL METHODOLOGY This small study had a very specific objective: to 1mt1ate a change of practice and to encourage general surgeons to change from packing surgical cavity wounds with ribbon gauze soaked in Proflavine cream to using a calcium alginate dressing. Previous attempts had failed and it was decided to adopt a multidisciplinary team approach. The Clinical Nurse Specialist from the Acute Pain Service was involved alongside the Clinical Nurse Specialist in Tissue Viability, surgical ward nurses, theatre nurses and surgeons. Table I. Pain assessment tool
LOW SEVERE 1 2 4 3 5 6 7 8 9 10 It was thought that to highlight the pain suffered by patients during and after dressing changes and for the surgeons to talk to the patients involved, may be a way to change their practice. In this situation we would be utilising the cognitive dissonance theory of change described by Walsh and Ford6 - 'seeing is believing'. A data collection tool was developed and a pain assessment tool was utilised (Table 1) on the advice of the pain control nurse specialist.
A random sample of patients with surgical cavity wounds was used, the wound types mainly being from excision of pilonidal sinus, breast abscesses and abdominal surgical wounds. The calcium alginate used was Sorbsan because of its particularly easy removal. Sorbsan dissolves when irrigated with saline, which also makes the dressing change less time consuming and cost effective as no auxiliary dressing packs are required. RESULTS The results from 24 patients, 10 in the ribbon gauze group and 14 in the calcium alginate group are outlined in Table 2. Patients in the calcium alginate group reported little or no pain and required no analgesia during dressing changes. Patients in the ribbon gauze group reported severe pain during the dressing change and immediately afterwards and all were reporting at least some pain two hours later. Most of the ribbon gauze group required analgesia. Dressing changes took, on average, three times longer in the ribbon gauze group than in the calcium alginate group. DISCUSSION The results of this small study support the views of others7•8, that those patients returning from theatre with ribbon gauze packs suffer discomfort from the dressing and extreme pain on removal which can last a considerable length of time.
For the process of change to be successful, a deeper understanding of the nature of change and its effect on the people involved should be encouraged9 • The management of change was considered carefully before the start of this study. Because of this, a change in practice was achieved. Two years after the study an audit revealed that in 85% of cases, calcium alginate was used in preference to a ribbon gauze pack. ACKNOWLEDGEMENTS I would like to thank Lucy Jones, Clinical Nurse Specialist Pain Control, and Beryl Griffiths, Surgical Staff Nurse, both at Wrexham Maelor Hospital NHS Trust for their help in undertaking this study and their continued support. Address for correspondence Clare Williams,Clinical Nurse Specialist Tissue Viability, Wrexham Maelor Hospital NHS Trust,Clwydd LL13 7TD. REFERENCES 1. Rice ASC. Pain, inflammation and wound healing. Journal of Wound Care1994; 3(5):246-248. 2. Pediani R. Recent developments in the control of surgical wound pain. Journal of Wound Care 1994; 3(8): 394-396. 3. Thomas S. Pain and wound management. Community Outlook 1989; July: 11-15.
70
Journal of Tissue Viability 1996 Vol6 No 3 Table 2. Results Patient no
Wound type dressing change
Analgesia during before dressing
Pain during
immediately after
5 mins after
Length of
30 mins after
120 mins after
dressing (mins)
Sorbsan group 1
PS
-
1
4
1
0
0
0
20
2
PS
-
0
2
0
0
0
0
15
3
ACW
-
0
1
0
0
0
0
MID
4
BA
-
2
2
0
0
0
0
15
5
PS
-
1
1
0
0
0
0
25
6
PS
-
0
2
0
0
0
0
10
7
BA
-
0
1
0
0
0
0
MID
8
PS
-
1
2
0
0
0
0
15
9
ACW
-
1
2
0
0
0
0
MID
10
ACW
-
0
2
1
1
1
0
10
11
PS
-
0
2
1
0
0
0
20
12
PS
-
0
1
0
0
0
0
15
13
AA
-
1
1
0
0
0
0
10
14
PS
-
0
1
1
1
0
0
10
Ribbon dressing group 15
PS
Nitrous Oxide
1
10
10
9
5
3
60
16
PS
Nitrous Oxide
2
9
8
5
5
2
50
17
BA
Pethidine
2
9
9
7
5
4
30
18
PS
Nitrous Oxide
3
10
6
4
4
1
60
19
ACW
Nitrous Oxide
2
8
6
5
1
1
80
20
PS
-
2
7
5
5
4
2
35
21
PS
Pethidine
1
7
6
4
1
1
45
22
BA
-
1
7
4
3
1
1
65
23
BA
Nitrous Oxide
2
9
6
5
3
1
MID
24
PS
Nitrous Oxide
1
8
7
6
3
1
40
KEY: PS -Pilonidal Sinus, BA -Breast Abscess, AA- Axilla Abscess, ACW- Abdominal Cavity Wound, MID - Missing Data 4. Hollinsworth H. Nurses assessment and management of pain at wound dressing changes. Journal of Wound Care 1995; 4 (2): 77-83. 5. Gibson C. Cavity dressings ancient and modem: a little research. British Journal of Theatre Nursing 1993;3(1): 8-10. 6. Walsh M, Ford P. Nursing rituals, research and rational actions. Oxford: Heineman Nursing, 1989: 112-114. 7. Miller L, Jones V, BaleS. The use of alginate packing in
the management of deep sinuses. Journal of Wound Care 1993; 2(5): 262-263. 8. Gupta R, Foster ME, Miller E. Calcium alginates in the management of acute surgical wunds and abscesses. Journal ofTissue Viability 1991; 1(4): 115-116. 9. Williams C. Putting theory into practice: the management of change in a hospital ward. Journal of Wound Care 1994: 3 (7): 344-345.