Patient demographics. The 12 patient participants (mean age 65.91 ± 6.21) included 6 women. All patients had at least a primary school education. The patients had been receiving NPWT for a mean of 10.07 ± 3.75 (range 5–15) days and had 2 to 3 NPWT dressing changes per week. The average number of dressing changes for all participants was 2.25 ± 0.62. Key patient characteristics are shown in Table 1. The length of voice recordings was 33 to 41 minutes, with a mean duration of 37 minutes. Mean current pain level was 4.83 ± 2.72. Four (4) patients used analgesics to cope with pain, and 6 of the patients were debrided and had their dressings changed under sedation.
Themes. From the data analysis, 4 overarching themes were identified: 1) patients’ pain experiences during therapy, 2) patients’ pain coping skills, 3) patients’ pain prevention experiences, and 4) effects of pain on patients’ daily life activities. These main themes, together with the subthemes, are summarized in Table 2A and Table 2B.
Theme 1: Patients’ pain experiences during therapy. The first theme dealt with 2 subthemes. For the first subtheme, pain during treatment, patients gave information on the severity of their pain, initiating/enhancing factors, and the region, duration, and characteristics of their pain experience. For the second subtheme, pain during dressing changes, patients gave information on wound debridement, foam changes, and adhesive wrap changes.
For pain during treatment, patients quantified their pain using numbers. Patients were asked to give a number between 0 (no pain) and 10 (extreme pain) to define the severity of their pain. Patients also combined quantitative and qualitative words in several different ways, and they characterized the factors that increased or decreased their pain. In the patients’ descriptions, lying down, coughing, standing up, sitting for a long time for meals, feeling cold, and the first NPWT application period increased their pain. When patients were asked about the location of their pain, they described it as being situated in different parts of the NPWT as well as spreading from the wound. They described that the pain was felt in different NPWT locations such as under the foam or around the foam area. The patients expressed different time periods for how long their pain lasted; these periods ranged from 2 seconds to 10 minutes. When speaking about pain characteristics, they described the pain as a “pulling-out” and “stabbing in and out” feeling (a shooting pain). Some of the patients associated the pain characteristics with the sounds caused by the negative pressure and movements inside the wound during NPWT (see Table 2A and Table 2B).
Patients also reported pain during the dressing change (ie, when the foam dressing was being applied or changed, during wound debridement, and when the adhesive wraps were removed from the skin). The patients said that while watching the wound debridement, it was very painful when the surgeon put his or her hands inside the wound or touched the wound. Patients who were provided anesthesia before debridement and dressing changes reported they did not feel any pain. Patients who had not undergone anesthesia during foam changes described the experience of pain severity as including yelling and crying. The main causes of dressing change pain were swift wrap removal and the resulting traumatized skin (see Table 2A and Table 2B).
Theme 2: Patients’ pain-coping skills. Patient coping mechanisms with regard to pain included using self-management, positioning, and medicine (the only option for some patients); others did nothing (see Table 2A and Table 2B).
To self-manage pain, patients said they pressed on the painful area, covered the painful area because they thought the pain was due to cold, walked, tried to forget it, tried not to cough, and lay down on the bed. They suggested wetting the adhesive wraps before pulling them off the skin during dressing changes to cope with the pain. For positioning, the patients dealt with pain by lying on their side. Four (4) patients who needed medical treatment to cope with pain stated intramuscular injection (eg, meperidine), oral analgesics, and intravenous treatment (eg, nonsteroidal anti-inflammatory drugs) were effective. Patients were unsure about whether the medical treatment was working; 3 of the patients who experienced pain said they did not do anything to cope with the pain, tried to endure, waited for it to pass, and did not inform nurses (see Table 2A and Table 2B).
Theme 3: Patients’ pain prevention experiences. Patients’ pain prevention experiences were categorized into 3 subthemes: staying in the same position, changing position, and doing nothing. To prevent pain, some of the patients preferred to turn slowly, stay in bed constantly except to use the toilet, and avoid coughing, while others preferred to change position by walking (moving). Some stated that they did nothing because they believed they could not do anything to prevent pain (see Table 2A and Table 2B), but 2 patients preferred to change position by walking (moving).
Theme 4: Effects of pain on patients’ daily life activities. The study found eating, breathing, sleeping, physical activities, and communication are affected by pain; therefore, these were selected as subthemes. The patients stated eating was not affected all that much by pain, but breathing was affected (ie, feeling “not able to inhale”). The patients who experienced pain said they could not sleep easily and needed analgesics and sleeping pills to fall asleep. The patients also reported on the effects of pain during physical activities; although walking decreased pain, the patients experienced pain when sitting and getting out of bed, so they did not even want to go to toilet because of that pain. When the patients experienced pain, they did not want to see anyone or talk with anybody. Because they could not tolerate listening to others talk, they believed the pain was affecting their communication activities (see Table 2A and Table 2B).
Theme 1: Patients’ pain experiences during therapy.
During treatment. In the present study, some patients quantified their pain in numbers while others expressed the level as little or no pain. These results are similar to the literature. A qualitative study by Andrews and Upton23 explored the views of 50 patients undergoing NPWT and found 81% had minimal pain (0–3 points) during NPWT. In an observational study, 24 10 patients who underwent thoracic surgery with NPWT reported no pain associated with the NPWT system and dressing change. In a descriptive and follow-up study by Egemen et al,25 patients who had chronic venous ulcers and were treated with NPWT for at least 6 weeks stated they did not feel enough pain to interrupt their NPWT. On the other hand, in clinical reviews of pain and wound healing, pain during wound care and dressing changes made patients feel anxious and stressed.26,27 In the current study, some patients cried or yelled because of their pain. These vocal expressions are a response to pain that can cause more stress. On the positive side, in this study, pain did not affect the continuity of treatment.
Patients described pain when lying down, standing up, and sitting for a long time when eating meals, and they claimed their pain disappeared occasionally when they got up and walked around. Andrews and Upton23 found similar results; in their study, pain was caused by turning in bed, walking, and going to the toilet. Monsen et al10 investigated the experiences of patients with NPWT provided to the groin area after vascular surgery; patients stated bending over and sitting in the same position for a long time increased pain, but changing positions helped diminish the pain. Staying in the same position for a long time and changing positions also were the pain-enhancing factors mentioned by patients undergoing NPWT after abdominal surgery in the retrospective study by Nobaek et al.28
Patients in the present study also reported the first NPWT application procedure was very painful. According to the experimental and prospective clinical studies, patients feel pain especially during the first application of NPWT in both acute and chronic wounds.29,30 Apostoli and Caula15 reported 5/25 patients undergoing NPWT in the hospital took a break from treatment because of pain. According to patient reports, pain was less before therapy started and increased significantly after therapy had begun. In the study by Andrews and Upton,23 18% of patients who had undergone NPWT said the first dressing change was the most painful period of this treatment. These findings suggest patients should be supported psychologically or with analgesics during the first application of NPWT.
In the current study, some patients experienced instantaneous pain upon NPWT application that lasted between 2 seconds and 10 minutes. In a pilot randomized study,31 10 patients provided NPWT for diabetic foot wound care stated they had pain for <30 seconds when the foam collapsed and during the foam dressing removal, even though they may have had neuropathy that could have blunted pain sensation. In a RCT by Gonzalez et al32 involving 126 patients with a total 144 lower limbs ulcers, pain relief was better after 3 days of treatment and was associated with the limited systemic inflammatory response by the third day; the systemic inflammatory response was limited and edema was decreased among patients treated with a suction system at the bedside, which does not occur as part of ambulatory wound management.
Because pain is an individual experience, pain perception may vary from person to person. For some patients, pain was described as a pulling-out, stabbing, or tingling feeling, and others described their pain characteristics with sounds like “vıykk vıykk” and “gorrk.” Similarly, Andrews and Upton23 stated patients who had undergone NPWT interpreted the vacuum sound of the device as a pain feature and as a strange and tingling feeling. In addition, the sounds coming from the device were described as characteristic of the pain they felt when the vacuum was turned on.
Pain during dressing change. In the current study, patients stated they experienced pain during several stages — namely, the application of suction and during the removal of dressings and adhesive wraps. A black, foam-based NPWT dressing was used on all patients in the present study; 2 experienced pain when the foam dressing was being changed. Procedural pain during dressing changes is described in the literature and appears to be related to the type of NPWT dressing.7 According to the literature, including consensus reports about wound-related pain, patients experience pain during dressing changes because new granulation tissue that grows into the dressing foam is torn during dressing removal, causing pain.33,34 Several studies have addressed dressing type and pain. In a pilot study involving 20 patients, Panicker35 compared gauze dressing with the foam used in topical NPWT and reported minimal pain at dressing removal with the gauze dressing compared to the medical sponge. Fraccalvieri et al6 researched pain feedback among 31 NPWT patients by comparing gauze and foam; less pain was reported in persons who received gauze dressing. In the prospective, multi-centered study by Hurd et al36 (N = 152), 20% of participants experienced pain with gauze-based NPWT.
A case series3 and a pilot37 study on NPWT (N = 7) recommend that white foam should be used in order to reduce pain. According to the prospective study by Mendez-Eastman38 in which the guidelines for using NPWT are described, it is postulated white foam has smaller pores than black foam, thus restricting the growth of granulation tissue into the foam and reducing pain upon removal. These findings highlight that dressing type is an important factor for reducing pain.
In the current study, patients had 2 to 3 dressing changes per week, with between 50 mm Hg and 125 mm Hg of negative pressure applied. This is similar to previously published studies. According to the results of a prospective study,39 dressings should be changed every 2 to 5 days, and based on international consensus,40 a therapeutic range of -40 mm Hg to -150 mm Hg is recommended.
Similarly, previous studies conducted on patients undergoing NPWT report dressing changes every 3 to 5 days and using a pressure application of between -50 mm Hg and -125 mm Hg.36,41 In a pilot observational study by Stansby et al,42 3 NPWT dressing changes were performed per week; 22% of the patients described pain when the treatment started and 31% reported pain during dressing changes. Low-pressure NPWT (75 mm Hg) was explored in a case study with 3 patients by Nease,43 in which low pain levels were reported. In an experimental study by Borgquist et al44 that explored the influence of pressure levels during NPWT, a pressure of -125 mm Hg was required to remove exudate from peripheral wound tissue in 16 wounds, but this NPWT level can cause ischemia and pain. These results indicate negative pressure levels and dressing changes should be taken into account during treatment to control pain. If possible, the pressure level may be decreased as needed for patient comfort.
Some patients in the current study stated they were anesthetized during the debridement and dressing change procedures and did not feel any pain. Furthermore, patients who received anesthesia did not need to take any analgesics. Schimp et al11 noted that during the NPWT procedure on patients with massive wounds or extensive debridement, dressing changes were performed in the operating room under anesthesia or pain medications were used at the time of dressing change. In a consecutive case series study by Saadi et al45 that reviewed the medical records of 27 patients who had undergone intrathoracic NPWT, NPWT dressing changes were performed under general anesthesia, thus none of the patients felt pain; Begum and Papagiannopoulos24 performed NPWT dressing changes on 11 patients under general anesthesia and found similar results. In the cited studies, opioid analgesics (eg, morphine or fentanyl) and topical lidocaine also were used for pain management during wound care therapy.19,46 A retrospective study by Wolvos47 conducted among 5 patients receiving NPWT found using topical anesthetics on the wound reduced pain during NPWT. In summary, appropriate analgesia or anesthesia modalities can be used to increase patient comfort and decrease pain levels during treatment or dressing changes in a variety of wound types.
In the current study, some patients described feeling pain when the adhesive wraps were removed from the skin because the skin was traumatized skin and hair pulled off. In their RCT reporting 16 patients’ experiences with NPWT, Monsen et al48 also found removing the adhesive wrap was associated with pain and caused skin damage. In the pilot study by Ousey et al,4 a patient said, “It was like being waxed… it pulled the hair off,” similar to current findings. This patient recommended shaving the wound area. In their pilot RCT, Gillespie et al49 noted 69% of the 70 patients undergoing NPWT had skin complications such as bruising. The descriptive study by Kim et al50 explored 399 nurses’ perceptions of patient pain during dressing changes and found that although nurses were aware dressing changes caused wound-related pain, no pain reduction measures were employed. To prevent skin trauma and pulling out hair, patients can be shaven if needed and water can be applied to ease removal of adhesive wraps.
Theme 2: Patient pain-coping skills. Patients in this study suggested wetting the adhesive wraps before pulling them off the skin during dressing changes as a way to cope with the pain. Other patients dealt with pain by lying on their side. A study that investigated the perspectives of patients undergoing NPWT found patients did not change positions to prevent pain23 and another study that examined the experiences of patients undergoing NPWT found pain disappeared with changing positions.10 According to these results, some patients may avoid movement so patient mobility levels should be considered by health professionals.
In the present study, patients used analgesics to cope with pain; these patients’ dressing changes were not performed under anesthesia. In the retrospective study by Nobaek et al,28 patient-reported outcomes and long-term results of NPWT showed 6/8 patients used drugs to cope with pain. In the study by Price and Harding,17 64% of 135 patients undergoing NPWT for chronic wounds used analgesics in order to cope with pain; in another qualitative study23 exploring the experiences of patients undergoing NPWT, 36% of 50 patients stated analgesics should be used for pain relief. The authors recommend nurses give patients information about pain-coping strategies and use analgesics as needed to decrease pain levels and reduce stressful conditions.
Theme 3: Patient pain prevention experiences. In the current study, while some patients preferred to move slowly, stay in bed except to use the toilet, and avoid coughing to prevent pain, others preferred to change position by walking. In their critical analysis, Eriksson et al51 examined patients’ pain experiences after surgery and found some patients performed self-care by using distraction to avoid pain; some stated they did not want to disturb health care professionals while they were working. Similarly, 1 patient in the current study stated, “I don’t do many things to relieve the pain. I don’t tell the nurse about it.” (S, 67). Some patients tried to cope using self-care methods such as pressing on the wound, trying to forget the pain, not coughing, and lying down in bed in order to prevent pain. However, some of these pain prevention methods may cause unwanted effects. If patients try to not cough, this may retain secretions; if they try to maintain their position, immobilization may cause harmful results, all underscoring that patients should be encouraged to tell nurses about their discomfort and obtain professional help with pain management.
Theme 4: Effects of pain on patient daily life activities. The patients in this study experienced pain when sitting and getting out of bed; 1 patient did not want to go to the toilet because of that pain. In a multicenter RCT,52 132 patients reported NPWT negatively affected their normal activities and mobility. According to descriptive and prospective studies53,54 related to pain-relieving strategies, patients were not satisfied with their nurses’ pain-relieving strategies, and patients whose pain was not adequately controlled were not able to perform activities such as moving, breathing effectively, and coughing. The current study similarly showed patients had difficulty breathing, coughing, sleeping, moving, and communicating due to pain. According to a meta-analysis by Smetana et al,55 the general rate of pulmonary complications is between 7.7% and 19.7% after abdominal surgeries. In the current study, 1 patient reported, “I can’t cough because I don’t want to have or cause pain, so I can’t expel my mucus and my breath is diminished” (B, 49). Therefore, nurses should teach patients (especially those undergoing abdominal NPWT) about deep-breathing exercises and, if appropriate, coughing exercises to prevent pulmonary complications.
Patients in the current study who experienced pain said they could sleep only if they were provided analgesics and sleeping pills. In the questionnaire survey study by Upton and Andrews,56 33% of patients had sleep disturbances during NPWT because of pain, worrying about the treatment process, and sleeping in an uncomfortable position because of the device. In the RCT by Armstrong et al52 on the effectiveness of NPWT devices conducted among patients with noninfected and nonischemic diabetic and venous wounds treated in various settings, 25% patients reported interrupted sleeping periods because of NPWT, so nursing activities should focus on patients’ quality of sleep and provision of interventions if needed.
The present study also found that some patients did not want to communicate because of their pain. A qualitative study by Yılmaz and Gürler53 that investigated the pain control expectations of postoperative patients found patients recommended visitor restriction and that nurses should be more considerate; for example, because communication with a patient in pain requires specific skills, short sentences can be used during communication and support can be gathered from patient caregivers. In a review by Kösgeroglu and Ünver57 about patient education on NPWT, emotional support was underlined as an important nursing care intervention.