A reflection on the successful

outcome of effective analgesia ina patient with a venous leg ulcerMaeve Coyle

Across cultures and across timeone of the most basic human

experiences is pain, which maybe acute or chronic (Madjar & Walton,1999). Addressing the control of pain,which is often the main concern in

patients with leg ulcers (Morrison etai, 1999) may lead to improvement inquality of life.

Pain in Venous Ulcers

There are two types of pain associated with

venous leg ulcers, neuropathic and nociceptive.

Neuropathic pain arises from damaged nerve

tissues (Mangwendeza, 2000). Nociceptive

pain, which is associated with trauma or injury

(Hall, 2003) results from actual or potential

tissue damage. Pain receptors may be excited

by mechanical, thermal or chemical stimuli and

they are especially common in the superficial

portions of the skin. Pricking or fast pain is

generally elicited by mechanical and thermal

type receptors whereas slow, aching pain can be

elicited by all three stimuli. Chemical substances

such as histamine, serotonin, prostaglandins and

cytokines are especially important in stimulating

the slow suffering type of pain that occurs from

epithelial and connective tissue injury (Martini &Bartholomew, 2000).

Tissue ischaemia is thought to cause pain because

of accumulation of large amounts of lactic acid in

the tissues. However, formation of bradykinin or

proteolytic enzymes from damaged cells may also

stimulate nerve endings (Guy ton, 1991).

Issues Related to Holistic Nursing Care

Provision of nursing care of patients with wounds

must begin with a comprehensive understanding

of the concept of pain. As well as physical

pain, those with chronic wounds also suffer

psychological, social and spiritual pain, and

their care must encompass all three dimensions

(Greenstreet, 2001). If true holistic care is to

be given physical aspects of pain cannot be

treated separately. However, observation and

measurement of physical pain are important

(Hawthorn and Redmond, 1998). Indeed

Moffatt(l999) identifies pain in chronic wounds

as a major issue in quality of life assessment.

Quality of life Issues

In this article I will focus on a patient in my

care and through reflection suggest that perhaps

there has not been enough consideration of

pain assessment and its documentation, with anassociated lack of evaluation of how effective

prescribed analgesia actually is. Research by

Charles (1995) identified pain as the worst aspect

of leg ulceration, a chronic condition which can

have a significant impact on the patients quality

of life (Cave, 1999).

Prevalence and Aetiology

A prevalence survey (O'Brien and Burke,

2002) in the Mid-Western Health Board region

of Ireland revealed a prevalence rate for leg

ulceration of 12/10,000. The prevalence increases

eightfold in the population over 70 years. The

average age of patients was found to be 72 years

and women were twice as likely to be affected as

men(O'Brien & Burke, 2002)

A recent study by Douglas (200 I) has shown

that 55% of patients with leg ulceration in the

United Kingdom are over 85 years of age. Itis also estimated that in the next two decades

the number of people aged over ninety is set to

double. This client group are often isolated due to

other medical conditions. Research into quality

of life in leg ulcer patients has found high levels

of social isolation, depression, anxiety (Keeling

et aI, 1996) and pain frequently compounds this

problem. Indeed a study by Moffatt (2001,a)

associated factors such as pain and depression

with delayed healing of leg ulcers. Low healing

rates together with high recurrence rates cause

untold suffering to the patient (Diamond, 1999).

Recurrence following healing is less common in

patients who comply with treatment programmes

(Tonge, 1995).

Maeve CoyleRGN,SCMStaff NurseOutpatients Department,Letterkenny General Hospital,Co. Donegal, Eire

LUF Journal Issue 17 - Autumn 2003 27

Reviewing the literature (Loveman & Gale, 2000;Greenstreet, 2001; Hawkins, 2001; Hollinworth,

2001) there were suggestions that wound pain

generally is poorly managed, indeed in leg ulcers

it may often be ignored (Mangwenwdeza, 2000).

Case StudyIneffective pain management was reflected

in practice with Mary, a seventy-two year old

married lady who presented to the hospital legulcer clinic for assessment. She had been treated

for the previous six months with four-layer

compression bandaging. The ulcer was on the

gaiter area of her left leg. A hydrogel to enable

autolytic debridement (Hollinworth, 2001) of

the wound bed was being used, together with a

secondary adhesive foam dressing. Granulation

tissue was beginning to fill the wound bed and

small islets of epithelium were visible. However

there were signs of tissue trauma around the edgeof the ulcer, which measured 3cms x 4.5cms.

Mary said she now dreaded the weekly dressing

changes as pain caused by removal of theadhesive foam was unbearable. Modern dressing

products such as adhesive foams, hydrocolloids

and films often cause pain and tissue trauma at

dressing changes due to their adhesive properties

(lones and Milton, 2000 a; Hollinworth, 2000).

Alginates may adhere to the wound when the

level of exudate decreases (lones and Milton,

2000b) causing further suffering and trauma.

Mofatt (200Ib) found that ritualistic procedures

involving dressing techniques often isolates the

wound from the patient. She found that among

nurses the evidence based care agenda supporting

wound care was still dominated by the biomedical

model. Also professionals felt ill-equipped to

face emotional and psychosocial issues raised by

patients. Mary had been prescribed paracetamol

I gramme four times daily, for the ulcer pain

which she described as a constant gnawing. She

reasoned that daily dressing changes without four

layer bandaging would help, she felt there wouldbe less adherence of the foam after 24 hours. She

also complained that she found the four layer

bandages hot, malodorous and bulky, she was

unwilling to tolerate them any longer. Hayward

(2002) found that there are many reasons for non­

compliance with compression bandaging such as

pain, discomfort, immobility, social isolation due

to malodour or simply because the patient wants

to shower every day. Mary felt socially isolated

due to the malodour from the bandages, which

28 LUF Journal Issue 17 - Autumn 2003

was evident on the second day following dressing

changes. Due to the bulk of the bandages shecould not wear her normal shoes, instead she had

to resort to slippers, which were also moist andmalodorous due to excessive exudate.

Effects of pain on mobility, sleep andinfection

Walshe (1995) found that pain limits mobility

and interrupts sleep. Due to constant pain, Marywas too debilitated and tired to mobilise. Also

the constant ache in her leg prevented her from

having a good nights sleep. Poor management of

wound pain often leads to increased frequency

of infection, delayed healing and suppressed

inflammatory response (Flanagan, 1997) issues

which all complicate leg ulcer management.

Infection had been excluded in Mary's case as a

swab had been taken the previous week. Mary felt

that her district nurse, who was constantly rushingdue to her excessive caseload, had underestimated

the significance of her pain. Hollinworth (1999)

found that those inflicting wound pain often

dismiss its significance.

Perhaps there has not been enough consideration

given to pain assessment and its documentation,with an associated lack of evaluation of how

effective prescribed analgesia actually is.

Clearly more communication with the patient

when planning treatment is necessary, a finding

supported by Scherwitz et al (1997) who found

that more than anything the patient wants to

be acknowledged, seen and heard. Due to staff

shortages in the workplace nurses may not have

time to sit and talk to the patients or ask them

how they feel about their ulcer. Often talking

to the patients and comforting them contributes

to pain relief (Pediani, 1998). Bernason et al

(1998) concluded that although pain control

was a priority in nursing care, pain managementwas ineffective and inconsistent. Often the

nurses perception of how much pain the patient

is experiencing differs greatly from what the

patients are actually suffering (Carr, 1997).

Language and ethnic differences can impedeeffective communication; however, nurses are

becoming increasingly aware of these differences

(O'Keefe, 2001). It was explained to Mary that

compression of the oedematous leg, plus elevation

to aid venous return and reduce swelling (Moffatt

& Harper, 1997) would in turn reduce pain. The

explanations were made using diagrams showing

lymphatic drainage plus venous return to the

heart. Use of the diagram aided her understanding

of the importance of leg elevation. Bradley (200 I)

acknowledges that sharing knowledge at the

patients level of understanding may help them

to grasp the importance of interventions such as

compression bandaging.

The vascular consultant prescribed Co-proxamol,

two tablets, three times daily plus Zimovane

7.5mg nocte to induce sleep, as inappropriately

managed pain is often associated with sleep

disturbance (Hofman, 1997). A home help was

arranged to help with the housework and cooking

so that Mary could rest and relax more with her

legs elevated. The occupational therapist was

asked to assess her home for grant aid for the

addition of a shower and toilet on the ground

floor of the house, a traditional two-storey. The

leg ulcer nurse specialist, in consultation with

the vascular surgeon suggested the use of short

stretch cohesive bandages, the weave of these

bandages allowing for minimal stretch and recoil,

resulting in a low resting pressure (Hayward,

2002). Mary agreed to try them for four weeks.Instead of the adhesive foam a soft silicone

dressing (Mepitel) was applied over the ulcer, a

dressing which has been shown to reduce wound

pain in children with partial -thickness scalds(Gotschall, 1998). When Mary returned to the

clinic four weeks later she felt that her quality

of life had improved. Her physical pain haddecreased as well as the size of the ulcer, and the

swelling in her leg had also reduced. She was

happy to be able to wear her normal shoes.

Pain Assessment Tools

A phenomenological study by Thomas (2000) on

the lives of individuals suffering non malignant

chronic pain found that most participants

described the pain as unremitting torment, which

affected the way they viewed their bodies.

Participants did not perceive nurses as supportive

of their pain experience even though they were

actively involved and ethically bound to deliver

quality care. Pain in venous ulcers may be

excruciating (Hollinworth, 2001) or 'bursting',

'heavy' or 'dull' (Moffatt, 1998). Many patients

may experience nocturnal pain which affects their

sleep (Liew et. aI., 2000). Pain management is an

important aspect of leg ulcer care (Mangwendeza,

2000). However physical pain is subjective

in nature, therefore difficult to measure. Pain

assessment tools can provide a quantitative

assessment of the degree of the patients suffering

Effective analgesia in a patient witha venous leg ulcer (continued)

(Harlos and Dudgeon, 1998). The Chronic

Limb Venous Insufficiency Questionnaire

(CLVIQ) (Franks and Moffatt, 1998) may beused as a means of addressing and evaluating

pain management. However the McGill Pain

Questionnaire (MPQ) is the one favoured in my

workplace as it is thought to be more useful than

the CLVIQ for assessing pain in wounds generally

(Gaglese and Melzack, 1997). Incorporation of a

valid pain assessment tool into wound care plans

has been suggested to the wound care committee.

Wound pain isdistressing and

debilitating but itcan be minimised by

appropriate assessmentand management

techniques

Conclusion

The wide-ranging consequences of pain in

wounds, a complex phenomenon, is perhaps

often ignored by caregivers (Flurrie, 2001).

Wound pain is distressing and debilitating but it

can be minimised by appropriate assessment and

management techniques (Hollinworth, 200 I).

Management of pain in leg ulcers by nurses is

often inadequate and research has shown that

continuing education raises awareness and

enhances standards (Mangwendeza, 2000). Flurrie

(200 I) suggests that quality of life measurementtools are vital. Franks and Moffatt (1999) suggestthat these studies should illustrate a holistic view

of the patient rather than focussing on the woundalone. There is a need to channel resources into

the setting-up of dedicated pain clinics for leg

LUF Journollssue 17 - Autumn 2003 29

ulcer patients, where health education aimed at

primary prevention (Ewles and Simnett, 1999)

and promoting healthier lifestyle choices would

make better use of scare resources. Briggs

and Torra i Bou (1999) suggest that adequate

analgesia may benefit wound healing rates.

Early audits in the North Western Health Board

area show high healing rates, with cost effectiveevidence based care and a reduction in recurrence

rates for patients who have access to established

leg ulcer clinics (Diamond, 1999). This case study

has implications for future wound care planning

in the authors workplace so that nurses can

continue to promote clinically effective outcomes,

utilising evidence based, cost effective, trueholistic care. MC

Acknowledgements

The author acknowledges the clinical guidance

provided by Mrs. P. Diamond, North Western

Health Board, Wound Management Facilitator.Also the invaluable assistance of Ms. Lilian

Bradley, Tissue Viability Nurse, Ulster

Community and Hospitals, HSS Trust/Lecturer,

School of Nurs.ing and Midwifery, Queens

University, Belfast, where the author is currently

studying for a Diploma in Health Studies (Wound

Management and Tissue Viability pathway).

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