Pain in Fungating Wounds: Another Perspective
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
No significant surveys of wound pain have been conducted in this patient group. However, one small study (N =13) investigating the usefulness of a staging system for fungating wounds found that 38% of patients with fungating wounds experienced wound pain.24 It is estimated that 5% to 10% of patients with advanced cancer will develop a fungating wound.25 Several studies have indicated that 55% to 95% of cancer patients with advance disease experience severe pain26,27;hence it is likely that a significant number of patients suffer from pain related to a fungating wound.
The effective management of wound pain may fail for several reasons: inappropriate or nonexistent pain assessment; insufficient prescribing of analgesia; and confusion about the appropriate use of dressing products to reduce wound pain.27 In addition, healthcare professionals lack knowledge about pain and may hold inappropriate beliefs and attitudes, particularly relating to opioid drugs.4
These problems have been highlighted in a small study by Hollinworth,28 who found that nurses failed to assess wound pain either verbally or using an assessment tool; instead, they tended to rely on nonverbal indicators. Any pain assessment and subsequent management was not documented, and the nurses did not use pharmacological agents to control pain.
Non-pharmacological Pain Management
Regardless of whether pharmacological sources for pain management are introduced into the wound care regimen, non-pharmacological methods of wound pain management are a useful adjunct to pharmacological treatments and include wound-cleansing techniques, wound dressing products, and complementary therapies.
Wound cleansing. Hollinworth's method14 is currently recommended - gentle irrigation with warm 0.9% sodium chloride or water. However, the use of gauze or cotton balls may damage delicate new tissue and cause pain. In fact, unless a wound is contaminated or contains necrotic tissue, cleansing during dressing changes may not be necessary.29 The use of cold irrigation fluid or high pressure irrigation also can be painful or unpleasant for the patient, and using a sterile gloved hand rather than forceps can help reduce wound trauma.14
Using topical anesthetics such as hypochlorite solution, iodine, and acetic acid also may cause tissue damage and pain.10,30 Removal of necrotic tissue by sharp debridement can result in pain; however, this form of debridement is not recommended in the care of fungating wounds because of their tendency to bleed.31,32
Wound dressings. Traditional materials such as gauze and paraffin tulle should not be placed in direct contact with the surface of fungating wounds (as primary dressings) as they may dry out and adhere to the wound or become incorporated into tissues within the wound.33 When these dressings are removed, they can cause significant damage resulting in pain. Soaking these dressings to aid removal is rarely effective.14 Using modern wound care products that promote a moist environment can dramatically reduce pain experienced by patients during dressing changes.34
Occlusive dressings such as hydrocolloids and adhesive films maintain a pool of exudate or gel next to the wound surface, reducing dressing adhesion and preventing any exposed nerve endings from drying out.33 Alginate and hydrofiber dressings also produce gels in contact with wound fluid, helping to prevent pain and trauma on removal. Some clinicians are concerned that alginates cause discomfort on sensitive areas of the wound or dry out and adhere to the wound.28 Foam dressings are usually low- or non-adherent and can be used to manage high exudate wounds.
For superficial or low exudate wounds, hydrogel dressings can be applied and have the added benefit of being cooling and soothing.35 Care should be taken with dressings that have an "all-over adhesive," such as hydrocolloids, foams, and films, because they can cause pain on removal.15
The only dressings that have been specifically designed to be non-adherent and to provide "pain-free" removal are soft silicone products. The dressings are available in a number of netting forms that require an absorbent secondary dressing or come with a foam backing. One such dressing, Mepitel (Mölnlycke Health Care, Newtown, Pa.) has been shown to cause significantly less pain on removal from skin grafts, burns, surgical wounds, and traumatic wounds.36-38 This product also has been used successfully in the management of extensive mycosis fungoides (cutaneous T-cell lymphoma) of the face and scalp.39
Use of this dressing, along with appropriately prescribed analgesia, leads to a dramatic improvement in the patient's wound pain and emotional state. Unfortunately, many nurses are not aware that these "painless" dressings are available.15
When removing an adhesive dressing, the manufacturer's recommended method must be followed to prevent skin damage. For example, adhesive film dressings should be removed gently by lifting one edge and then stretching the dressing up and away from the wound rather than simply peeling the dressing back.40
In cases where the patient has delicate skin, adhesive dressing use is better avoided and retention bandages or tubular net used to secure dressings.10 Encouraging patients to participate in their wound care, especially dressing removal, can help lessen anxiety and subsequently reduce their response to pain.28
Complementary therapies. Any qualified nurse with appropriate knowledge and experience may undertake wound cleansing and dressing product selection. However, complementary therapies should only be administered by healthcare professionals with relevant training and qualifications.41 When used along with conventional pain management treatments, these therapies can be beneficial in reducing pain or the response to pain.
Unfortunately, these therapies are often underused or inappropriately administered and may have poor scientific evidence to back up claims of their effectiveness. From personal experience, the patient is usually the one to initiate a complementary therapy rather than the healthcare professional; often the therapy is not provided by the treating hospital, although this is changing with increased demand and acceptance of these therapies. Useful therapies for pain management include relaxation, massage, visualization, imagery, and distraction.7,42
Relaxation and massage help reduce tension and anxiety; in doing so, the patient's pain tolerance in improved by breaking the anxiety-pain cycle. Visualization and imagery focus the patient's attention away from the painful stimulus by creating images that are either consciously selected (visualization) or spontaneously occurring from the unconscious (imagery).43 Distraction also draws attention away from the pain but uses a specific physical stimulus to do so, such as television, music, or conversation.44 These focusing methods may be particularly helpful for acute pain and may be combined with relaxation or massage to give added benefit. For example, a combination of breathing techniques, relaxation, and music may be useful during dressing changes.
Other complementary therapies that may be useful in managing wound pain include acupuncture, acupressure, autogenic therapy, biofeedback, and hypnosis.44,45 Aromatherapy may help disguise wound odor or promote a relaxing atmosphere.
While not exactly complementary therapy, transcutaneous electrical nerve stimulation (TENS) and low-level laser therapy (LLLT) can be used to manage wound pain. The transmission of low-voltage current to the body via electrodes placed on the skin, TENS is believed to work on the gate control mechanism and produces its effect by stimulating large diameter nerve fibers that carry signals to the spinal cord and inhibit the transmission of pain signals.46,47 Grocott48 found TENS to be effective in relieving the itching associated with a fungating wound. The application of non-thermal, multi-wavelength laser to the wound surface, LLLT has been shown to reduce pain when used as a palliative treatment for fungating wounds.49
Wound pain is often viewed as an unavoidable consequence of living with a chronic wound, but this myth needs to be dispelled. It is no longer permissible to accept wound pain as inevitable, and nurses must take the lead in changing how pain is managed as their close relationship with the patient puts them in the perfect position to assess and treat wound pain.
Pain from fungating wounds may be controlled through the use of palliative anti-cancer therapies but the mainstay of treatment is based on pharmacological and non-pharmacological methods of pain management. The perception of pain may be altered by manipulating the patient's cognitive and motivational states and this is the basis for many complementary therapies that reduce anxiety, fear, and tension or focus attention away from the painful stimulus.
In addition, the use of appropriate wound cleansing techniques and dressing products will help reduce pain associated with wound care procedures. Gentle irrigation followed by the application of modern, non-adherent dressings will reduce the possibility of causing trauma and pain at dressing changes. Good communication and an appreciation for the psychological, social, and spiritual aspects of pain can improve the patient's response to pain by addressing fears, anxiety, and information needs.
More overall research is needed to underpin the management of wound pain, especially the pain associated with fungating wounds. Much of the information in this article was derived from the management of other sources of pain which, while providing useful and relevant information, may not directly reflect the wound pain experience. Further research is needed into the use of dressings to reduce wound pain, and because nurses have shown concern with this area of care, they should be leading these studies.
Finally, while no concrete evidence is available to go on, it would seem that an holistic approach that uses a combination of medication, complementary therapies, and appropriate wound care will control pain in the majority of patients with fungating wounds - OWM