Notes on burn nursing : aspects of pain management

Abstract

Adequate management of burn pain may influence pain resistance, analgesic requirements, sensitivity to pain over time, wound healing and the development of delirium and posttraumatic stress symptoms. Efforts should be made to optimize pain management. An important step is effect evaluation of interventions by pain measurement. Another step is to disclose the latest insights from the literature, especially on non-pharmacological interventions during wound care. In these two steps, burn care nurses, confronted with pain on a daily basis, play a central role.

Tools with good clinimetric properties to evaluate pain in burned children aged 0-4 years, unable to provide self-reports, are necessary. Therefore, reliability and validity of the pain observation scale for young children (POCIS), the COMFORT behaviour scale (COMFORT-B), and the nurse observational visual analogue scale (VAS obs) have been tested. The POCIS and COMFORT-B provide ratings obtained by structured observation, the VAS obs provides a global impression of pain. When burn care nurses used the VAS obs simultaneously, their ratings corresponded less well when compared to POCIS and COMFORT-B ratings, suggesting better reliability for structured observation. The POCIS and COMFORT-B were also able to differentiate background from procedural pain and seemed to measure one unidimensional construct, indicating validity. Nurses preferred the COMFORT-B. Ranges at which adapted treatment needs consideration appeared 6-13 (mild), 14-20 (moderate) and 21-30 (severe).

The visual analogue thermometer (VAT) is an instrument with good clinimetric properties for self-reports of pain in adults with burns. The graphic numeric rating scale (GNRS) is another brief, simple and easy to use tool for pain assessment. To legitimate their interchangeable use, scores and cutpoints were compared, and their ability to differentiate background from procedural pain. Mean VAT self-reports turned out to be lower than GNRS scores, suggesting that they cannot be used interchangeably without taking their differences into account. However, both scales were able to differentiate background from procedural pain. They also seemed to share a similar cutpoint: patients indicated that a pain level of more than 2 on the 0-10 scales was unacceptable.

The state of art is that adequate management of burn pain consists of an individualized approach, using drugs with different mechanisms of action, combined with non-pharmacological interventions. Considerations when selecting non-pharmacological interventions are: simplicity, immediate usability and minimal expenditure of time and effort during use. The effectiveness of simple relaxation on procedural pain in adults was examined by a literature review. Previous research did not examine our patient group, but simple relaxation is a low risk intervention which shows promise in enhancing pain management. The best available evidence was found for active hypnosis, rapid induction analgesia and distraction relaxation.

Pain remains a challenging problem in the burn field. Managing this problem requires adequate pain measurement to improve individualized outcomes. The reliable and valid pain measurement instrument arsenal is enlarged, implying that pain measurement is currently feasible for a larger group of patients and that cutpoints can be used for treatment protocols including non-pharmacological interventions.