Pain in Pressure Ulcers

Janete Quirino, CETN, RN, BSN; Vera Lúcia Conceição de Gouveia Santos, CETN, RN, BSN, MSN, PhD; Tânia Josefina Petry Quednau, CETN, RN, BSN; Ana Paula Ferreira Martins, CETN, RN, BSN; Patrícia Lima, CETN, RN, BSN; Mercês Raimunda Maria Almeida, CETN, RN, BSN

Disclosures

Wounds. 2003;15(12) 

In This Article

Abstract and Introduction

Abstract

This study aims to describe the quantitative and qualitative characteristics of the pain related to pressure ulcers. A descriptive and cross-sectional study was carried out and data was obtained from hospitalized patients in three different Brazilian cities, after approval of the study by the Ethics Committees of the participating hospitals. First, the mental status of each patient was evaluated. Twenty patients were then submitted to physical and ulcer examination and interviewed about quantitative and qualitative pressure ulcer pain data using a 0-to-10 numerical pain rating scale and a short version of the McGill Pain Questionnaire, respectively. The data was analyzed by the Fisher test, Pearson's chi-square test, Kolmogorov-Smirnov Normality test, Student t-test, and ANOVA. All patients reported pressure ulcer pain, with 80 percent reporting constant pressure ulcer pain, not limited to a particular time of day (78.9%), and which did not affect daily activities besides movement in the bed and sitting up (80 and 75%, respectively). The mean pain intensity was 5.80±2.93, characterizing a moderate pain level. The McGill Questionnaire showed that sensitive descriptive elements and burning were most frequently used to describe pressure ulcer pain (56.57 and 35%, respectively). Significant associations were observed between painful condition and ethnic origin (p=0.034), ethnic origin and impaired appetite (p=0.014), age and impaired walking (p=0.002), and preferential time of day and number of ulcers (p=0.013). This study may contribute to breaking the myth of the absence of pain in pressure ulcers, permitting healthcare workers to understand this problem in order to improve pain management for patients with pressure ulcers.

Introduction

Pressure ulcers are the most frequent types of chronic lesions and continue to represent a great challenge to healthcare workers in Brazil in terms of their prevalence, incidence, prevention, and treatment. The prevalence and incidence of pressure ulcers vary according to the type of care unit, patients, and method of research involved, with rates from 5 to 66 percent observed in Brazil[1,2,3] compared to the United States (US) where the prevalence ranges from 0.4 to 38 percent.[4,5]

Pressure ulcers are caused mainly by the duration and intensity of pressure and by the degree of tissue tolerance, and they are defined as "localized areas of cell death that develop when soft tissue is compressed between a bone prominence and a hard surface for a prolonged period of time" by the National Pressure Ulcer Advisory Panel (NPUAP).[6,7,8,9] Pressure ulcers also have another fundamental but little investigated aspect, which is the pain that is associated with them. Although knowledge about pain—regarded as the fifth vital sign[10]—has been increasing, this symptom has been neglected in research on chronic wounds, especially pressure ulcers, with few investigations of this subject having been reported. Available studies are restricted to the assessment of pain as an indicator of the effectiveness[11] and/or performance of different dressings[12] or directly in specific situations, such as pain related to chronic lesions at rest and during dressing change.[8,13] Dallam, et al.,[14] attributed the scarcity of studies to the generally limited capacity of the affected individuals to report pain. In their study, Dallam, et al.,[14] reported that only one third of the 132 patients investigated were able to respond to questions about pain. Another relevant aspect concerns the influence of cultural factors on the manifestation and expression of the painful condition, impairing the investigation of pain and comparison of the results obtained.

According to the International Association for the Study of Pain (IASP), pain is a sensory and emotionally unpleasant experience associated with real or potential tissue damage or is described in terms of such damage. Each individual learns to use this term through previous experiences.[10,15,16,17] Within this definition, the following three characteristics should be emphasized: the lesion-tissue relationship in which the pain is not exclusive or direct; sensitive, emotional, and cognitive aspects that cannot be dissociated from the painful manifestation; and pain as a personal and subjective experience.[18]

In addition to these aspects, it is believed that, in the specific case of pain related to deeper and consequently more severe wounds, such as stage 3 and 4 pressure ulcers, the patients experience less intense pain due to the destruction of sensory nerve endings, a fact that has not yet been confirmed.[7,13]

Pain can be classified as acute or chronic.[19] In the area of wound care, Krasner[20] classified wound pain into the following categories: cyclic acute pain, which is periodic and corresponds to the pain experienced during repeated management, such as dressing changes or patient repositioning; noncyclic acute pain, which is incidental, including pain experienced during occasional procedures, such as debridement or drain removal; and chronic pain characterized as constant and persistent pain, which is present even in the absence of wound management and can be exacerbated during more invasive procedures.

Subjectively, the painful experience is intrinsically related to conceptions about pain and pain management (knowledge, beliefs, attitudes) acquired through social living and previous experience, which result in individual behaviors, meanings, and expectations about the pain itself and its evolution. Since cognitive aspects have a decisive influence on the appreciation and expression of and tolerance to pain, understanding them is important. In addition, evaluation of the damage caused by pain permits the assessment of its impact on daily life activities.[18] The identification of significant impairment, especially to movement and walking functions, as well as to other functions, such as sleep and the ability to establish social relationships, which are generally already compromised in patients with pressure ulcers, is important since this impairment might represent a risk factor for complications mainly related to psychological and social aspects.[21]

In view of the lack of descriptive and comparative studies regarding pressure ulcer-related pain, the authors carried out the present study with the following objectives: to describe the quantitative and qualitative characteristics of pressure ulcer pain in hospitalized patients; to identify measures of pain management and the level of patient satisfaction with these measures; and to correlate the pain characteristics with demographic data of the patients, ulcer characteristics, and analgesia.

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