Understanding the origin of wound pain during dressing change.

n a recent multinational survey, practitioners reported dressing removal to be the most painful aspect of the dressing procedure. 1 This is particularly problematic where a dressing has stuck to the wound or removal of the dressing has torn the skin. Although practitioners are aware of issues surrounding wound pain, they often fail to manage pain effectively at dressing changes 4 due to lack of knowledge and understanding of the underlying physiology responsible for the perception of pain. Misconceptions with regard to pain relative to ulcer size and type frequently undermine appropriate treatment. In addition, nurses may use social defenses such as " distancing " and " denial " to protect them from feeling overwhelmed about inflicting pain on their patients 5 ; when used in excess, such strategies can result in poor practice. Practitioners need to understand that wound pain is multidimensional. Attempts to provide a structure for the complex experience of pain have generated various models. Krasner 6 presented one of the first models for chronic wound pain, which highlights the difference between background pain (associated with the underlying etiology of the wound) and the pain of treatment (iatrogenic pain), such as occurs at dressing changes. The model by Melzack and Casey, 7 proposed in 1968, presents three distinct dimensions of pain. Sensory dimension. This dimension focuses on how much the wound hurts and what it feels like (ie, the physical sensations of having a wound). Following initial tissue damage, the inflammatory response sensitizes the pain receptors in the skin, helping the person locate the extent and site of the wound so it can be protected. In an acute wound, this pain subsides with healing. In a chronic wound, the impact of the prolonged inflammatory response causes increased sensitivity in the wound and surrounding skin (primary and secondary hyperalgesia). If further painful or noxious stimuli are added as a result of repeated manipulation (eg, dressing changes), the patient may become locked into a cycle where any sensory stimulus will register as pain (allodynia). Additional complications may occur because wounds invariably involve damage to nerves, causing some patients to experience altered sensations as a result of how nerves respond (neuropathic pain). Even the lightest sensation (eg, temperature change or blowing on the wound) may produce an exaggerated response from the central nervous system, causing the patient to feel excruciating pain. Damaged nerves can also fire " ectopics " that …