practice review

Keywords Stress | Pain | Wound healing Managing stress and pain to prevent patient discomfort, distress and delayed wound healing Evidence suggests stress slows the healing of wounds but pain may also play a part. Regular assessment could improve patients’ quality of life and recovery time

AUTHORS Kazia Solowiej, BSc psychology, personal experience, for example, while a practice pointS is research assistant; Dominic Upton, PhD, dressing change may be excruciatingly FBPsS, CPsychol, is professor of health painful for some patients, it may be only The following techniques can help reduce pain psychology; both at the University of mildly painful for others. and stress during wound treatments: Worcester. Wound pain can result from the wound Interacting with, and listening to, patients; ABSTRACT Solowiej K, Upton D (2010) itself but can also be caused by treatments Encouraging them to articulate their pain Managing stress and pain to prevent patient that are administered for the underlying experience; discomfort, distress and delayed wound condition (Solowiej et al, 2009). It is well Implementing coping strategies (focus or healing. Nursing Times; 106: 16, 21-23. established that psychological factors, distraction techniques); This article explores the relationship including stress and anxiety, can play a role Using warm cleansing solutions; between stress and delayed wound healing, in the perception of pain – for example, Encouraging patients to participate in their together with the role of pain as a stressor. under conditions of increased stress, the own dressing removal; It offers practical advice on regular anticipation of pain at dressing change can Ensuring correct selection and application assessment and management of stress and lead to an increase in pain severity (Melzack of dressings; pain during wound care. and Wall, 1996). Regularly reviewing the frequency and Kammerlander and Eberlein (2002) necessity of dressing changes. Acute and chronic wounds can cause conducted a survey of nurses’ views about considerable pain and discomfort for wound pain and trauma. The majority Source: adapted from Hollinworth (2005) patients. They can also cause significant perceived dressing removal and wound stress which is often associated with an cleansing as the most painful wound individual’s response to physical and treatment procedures. In addition, a myopathy, weakness, fatigue and a emotional threats (Ice and James, 2007). multinational survey of the assessment of suppressed immune function (Melzack and Prolonged stress can have a detrimental pain at dressing change from patients’ Wall, 1996). effect on health and cause a number of perspectives revealed similar findings (White, It is known that stressors such as pain can psychological and physiological symptoms, 2008). A consistent trend emerged to suggest cause a set of physiological responses, for for example, poor coping and reduced that pain levels (measured using the visual example elevated cortisol levels, heart rate, immune function. analogue scale) increased considerably blood pressure and respiration rate, which A recent review of stress and wound during dressing removal compared with can impact on skin physiology (Altemus et healing studies found that stress is associated pain scores taken just before the treatment al, 2001). As a physical and psychological with impaired wound healing and that this is began. Likewise, results obtained from an stressor itself, pain may put patients at a consistent across a variety of clinical and international survey of dressing related pain greater risk of delayed healing (Christian et experimental studies, and acute and chronic revealed that more than 62% of patients al, 2007). Research evidence has shown an wound types (Walburn et al, 2009). Both reported their pain took up to two hours to association between stress and reduced pain and stress can impact on wound subside after a dressing change (Price et al, immune function, which can be detrimental healing and psychological wellbeing 2008). In this study 40% of patients also to wound healing. For example, punch (Solowiej et al, 2009); this can also negatively indicated that the pain at dressing change biopsy wounds took almost 1.25 times affect patients’ quality of life (QoL). was the worst part of living with a wound. longer to heal in a sample of women caring Although there is considerable evidence for a relative with Alzheimer’s disease, than suggesting a link between stress and delayed Stress and wound healing in a matched pair control group (Kiecolt- wound healing, little is known about how The physiological processes involved in Glaser et al, 1995). Similarly, Ebrecht et al pain may influence this relationship. This is wound healing (Ebrecht et al, 2004; (2004) found that high stress scores were important because if nurses can reduce pain Broadbent et al, 2003; Altemus et al, 2001) negatively correlated with the speed of (and/or stress), patients’ QoL and rate of have also been studied and the impact that wound healing. In addition to this, results of healing could improve. stress can have on healing clearly cortisol samples taken from participants demonstrated. For example, stress can revealed that as cortisol levels increased, the Experience of pain increase the production of the hormone speed of wound healing decreased. These Experience of pain is highly subjective and cortisol and, if this increase is maintained, findings suggest that stress can impact on can be influenced by psychological, wound healing can be impaired (Sivamani et wound healing, and that increased cortisol emotional and social factors. Pain is a al, 2009). Raised levels of cortisol can lead to levels play a role in this.

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This article has been double-blind peer-reviewed

In studies of patients with acute surgical wounds there is also evidence about the fig 1. pain rating scales relationship between stress and wound Simple Descriptive Pain Intensity healing. Broadbent et al (2003) found high levels of preoperative stress in patients undergoing inguinal hernia surgery were No Mild Moderate Severe Very severe Worst associated with lower levels of pain pain pain pain pain possible pain proinflammatory cytokines in the wound fluid. It is known that wound inflammation is needed to clear debris and infection but, if 0-10 Numeric Pain Intensity Scale levels of proinflammatory cytokines are reduced, this process may cause damage that 1 2 3 4 5 6 7 8 9 10 delays healing (Bosch et al, 2007). On the No Worst other hand, Holden-Lund (1988) pain possible pain demonstrated that surgical patients who had undergone a relaxation intervention Visual Analog Scale (VAS) experienced significantly less anxiety and lower cortisol levels one day after their surgery No Pain as bad as it compared with a control group. This pain could possibily be indicates that implementing an intervention to reduce stress could be associated with faster wound healing. Physiological symptoms of stress, such as measure specific causes of anxiety such as A study investigating the impact of stress increased heart rate, blood pressure and dressing change, as well as items that on chronic wound healing demonstrated respiration rate, can be measured fairly easily measure more general long term anxiety that delayed healing was associated with using methods that may already be part of traits. Similarly, HADS allows for the higher anxiety and depression scores routine wound care. These assessments assessment of specific anxiety. (Cole-King and Harding, 2001). Patients who should be accompanied by other stress If pain, as a stressor, has the potential to were categorised in the top 50% of scores measures, however, to eliminate alternative contribute to delays in wound healing, then were found to be four times more likely to causes (increased heart rate or blood accurate and frequent assessment of pain experience delayed healing than those in the pressure could be due to many factors). should be incorporated into routine wound bottom 50%. Similarly, a study exploring the Alongside these physiological indicators, care. A review of pain and wound care prevalence of anxiety and depression in psychological measures of stress can be used, studies identified that nurses consistently people with chronic leg ulceration which are designed to obtain emotional rated patients’ experiences of pain lower categorised 27% of participants as being responses from patients self reporting their than patients did themselves (King, 2003). depressed and 26% as suffering from anxiety personal experience of stress. There are This suggests that more attention should be (Jones et al, 2006). many different types of psychological tools paid to patient feedback during the wound The findings of these studies suggest stress for measuring stress, for example the care process. can contribute to delays in healing. Moreover, Perceived Stress Scale (Cohen, 1983), which It is apparent from the literature that both stress can affect healing in both psychological is a self report questionnaire that measures patients and nurses regard dressing change and physiological ways. However, evidence the extent to which situations in patients’ and cleansing as the most painful wound to suggest pain can influence the relationship lives, such as dressing change, are perceived treatments. Pain can be measured using a between stress and wound healing is limited. as stressful. This measure has been widely variety of self report methods, such as rating used in experimental settings and is scales. These include verbal, numerical, Assessing stress and pain recommended for use in clinical practice. An and visual analogue scales (Fig 1), all of The literature provides evidence supporting advantage is that it focuses on patients’ which require patients to rate their level of the relationship between stress and wound appraisal of stressful situations as opposed to pain using either numbers or describing healing. Although less is known about the the number of stressful situations words, or placing a cross on a line to indicate influence of pain in this relationship, it is experienced by an individual. However, its severity. important for nurses to acknowledge both patients are instructed to complete the items Pain can also be assessed using pain and stress in clinical practice. If pain with reference to how they have been feeling multidimensional measures, for example the and stress are assessed and managed over the past month, which may not McGill Pain Questionnaire (MPQ) effectively during wound care, this could measure stress specifically associated with (Melzack, 1995). As well as measuring pain contribute to faster wound healing. wound treatments. intensity, the items in this questionnaire are A number of methods are widely used in Other examples of psychological measures designed to assess different components of experimental settings to measure and assess of stress include the Hospital Anxiety and reported pain, how pain changes over time, pain and stress; these could be used by nurses Depression Scale (HADS) (Zigmond and and the factors that relieve or increase it. As a as part of routine wound care. It is beneficial Snaith, 1983) and the State Trait Anxiety result of this, the MPQ is sensitive to to measure pain and stress in patients before, Inventory (STAI) (Speilberger, 1968). Both treatment related changes and can produce during and after wound treatments such are suitable for nurses to use to measure information on the specific effects of a as dressing changes, to determine any anxiety (a reaction to stress) in clinical treatment on the sensory, affective and differences in symptom severity. practice. The STAI consists of items that evaluative dimensions of pain.

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Implications for nursing practice Table 1. Behavioural signs of pain and stress (Feldt, 2000) The effect of stress on wound healing has Pain been demonstrated in many studies and this Vocal expressions: moans, grunts, cries, sighs, gasps needs to be taken into account when caring Facial expressions: winces, grimaces, furrowed brow, tightened lips, jaw drop, for patients with wounds in clinical practice. clenched teeth Despite the limited evidence for the role of Bracing: clutching/holding bedrails, tray or table, or affected area of pain pain in this relationship, both stress and pain Restlessness: shifting position, hand movements, unable to keep still should be assessed and managed during the Rubbing: touching, holding, rubbing or massaging affected area wound care process to prevent patient Stress Increased breathing rate discomfort, distress and delayed healing. A thorough person centred assessment is Faster eye blink rate essential to provide sensitive and effective Accelerated heart rate management of wound pain (Hollinworth, Muscle tension 2005). Nurses need to observe patients’ Squirming behaviour (both verbal and non-verbal) as Sweating palms well as implementing standard assessments Dry mouth, tense voice as this can help to identify signs of pain and Pale skin, cold sweat stress. Such signs are outlined in Table 1. Both psychological and physiological Avoidance behaviour measures, as well as patient feedback on their perception of stress and pain, can be used to In particular, they valued being listened to, Conclusion monitor changes associated with stress and consulted with and distracted from wound Nursing care is vital to safe pain relief and to pain. Such routine assessments at the start care procedures. optimal wound healing. There is increasing of, and during, treatments should be carried The correct selection of dressings can also evidence supporting a relationship between out, to ascertain patients’ individual needs, contribute to improving pain, stress and stress and the delayed healing of wounds, such as effective pain relief (White, 2008). QoL. The World Union of Wound Healing suggesting that successful stress assessment In order to maintain patient comfort and Societies (WUWHS) (2007) identified that and management during wound care will trust in nursing care, patients should be soft silicone adhesive dressings are prevent delays in healing. encouraged to participate in their wound advantageous compared with other dressing Minimising pain could reduce its effect as care. In an international dressing related types because they produce minimal pain a stressor; however, research is needed to pain survey (Price et al, 2008), more than and trauma at dressing changes, provide demonstrate the role of pain in the 80% of patients reported that they liked to good adherence to the skin without strong relationship between stress and wound be actively involved in dressing changes. bonding, stick instantly to the skin, healing. Despite this, assessment and They felt it was beneficial to receive effective and are easy to remove to check the wound management of pain and stress as part of analgesics, and for nurses to be careful and and then reapply (WUWHS, 2007). routine wound care could provide the basis gentle with their wound. In addition to this, White (2008) also found that such for faster wound healing and improved many patients noted the importance of dressings could significantly reduce pain QoL for patients who have acute and communication during wound treatment. at dressing change. chronic wounds. l

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