Pain in Fungating Wounds: Another Perspective
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A sk any nurse about pain and he/she will most likely tell you "pain is what the patient says it is." This is the belief promoted by McCaffery1 and a key starting point to effective pain management.2 But how many nurses actually believe this statement? How many take the time to thoroughly assess pain from the patient's perspective? All too often nurses do not believe patients' self-ratings of symptoms and tend to underestimate the amount of pain a patient is experiencing.3,4
Nekolaichuk et al5 found that both nurses and doctors recorded significantly lower scores for pain than patients did when using the Edmonton Symptom Assessment System. However, Seers3 believes that nurses are in the perfect position to perform pain assessment and then intervene with and evaluate pain control. Furthermore, patients believe that pain relief is one of the most important aspects of nursing care.4
Pain is a complex phenomenon and has been described as an undesirable sensation resulting from illness, injury, or emotional distress.6,7 Perhaps a more precise definition comes from the International Association for the Study of Pain (IASP), which describes pain as "an unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage or both."8 The physiological function of pain is to provide information about noxious stimuli causing actual or potential tissue injury, thus enabling the body to protect itself from greater damage.9
Pain is a particular problem in wound management, where it is often regarded as an inevitable aspect of wound care.10 Several studies have found that patients deem wound pain to be one of the most difficult symptoms to cope with in relation to chronic wounds.11-13 The distress caused by wound pain can reduce compliance with wound management regimens.14
On a more positive note, a recent survey in the UK found that nurses considered preventing wound pain at dressing changes a main priority.15 However, this concern needs to be extended to include all aspects of the wound management process because patients may experience pain while the dressing is in place and not just during wound care procedures.
Fungating Malignant Wounds
One group of patients that presents a challenge in wound pain management are those with fungating malignant wounds. Fungating wounds arise as a result of infiltration of the structures of the skin by malignant cells. These cells may originate from a primary skin cancer, an underlying malignant tumor, or through metastatic spread from a distant malignant tumor.16 As the malignant cells multiply in the skin, they form a tumor that enlarges, causing a disruption of skin capillaries and lymph vessels, eventually leading to tissue hypoxia and subsequent skin necrosis.17-19
The term fungating refers to a process of both ulcerating and proliferative growth.20,21 Lesions that have a predominantly proliferative growth pattern may develop into a nodular "fungus" or cauliflower-shaped lesion; whereas, a lesion that is ulcerating will produce a wound with a crater-like appearance.17,22 It is possible for a lesion to present with a mixed appearance of both proliferating and ulcerating areas.18,23
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