Personal pain relief strategies used by venous ulcer patients^*

ABSTRACT

BACKGROUND AND OBJECTIVES:

Pain is a common symptom in venous ulcer patients and should be controlled. Knowing the strategies used by patients and offering new pain control possibilities may be effective means to improve assistance. This study aimed at identifying personal pain relief strategies used by venous ulcer patients.

METHODS:

This is a qualitative research including 14 venous ulcer patients treated in the angiology ambulatory of a teaching hospital in the central region of Rio Grande do Sul. Data were collected in the months of January and February 2013 by means of semi-structured interviews and data were evaluated by content analysis.

RESULTS:

Strategies used by participants were: self-treatment, search for health service and religious support for pain relief. Reports suggest that patients have not received guidance with regard to venous ulcers pain management and tried to reach pain relief by their own methods.

CONCLUSION:

Participants of the study have reported using simple, however limited, strategies for pain relief, indicating a gap in the assistance offered to such patients.

Keywords:
Chronic pain; Nursing; Venous ulcer

RESUMO

JUSTIFICATIVA E OBJETIVOS:

A dor é um sintoma frequente em pacientes com úlceras venosas, e deve ser controlada. Conhecer as estratégias utilizadas pelos pacientes e oferecer novas possibilidades de controle da dor podem ser meios eficazes de melhorar a assistência. O objetivo deste estudo foi identificar as estratégias pessoais de alívio da dor utilizadas por pacientes com úlcera venosa.

MÉTODOS:

Pesquisa qualitativa, que incluiu 14 pessoas com úlcera venosa acompanhadas no ambulatório de angiologia de um hospital universitário, da região central do Rio Grande do Sul. A coleta de dados foi realizada nos meses de janeiro e fevereiro de 2013. Utilizou-se a entrevista semiestruturada e os dados foram avaliados por meio da análise de conteúdo.

RESULTADOS:

As estratégias usadas pelos participantes foram: autotratamento, busca ao serviço de saúde e busca religiosa para o alívio da dor. Os relatos sugerem que os pacientes não receberam orientações relacionadas ao manejo da dor em úlceras venosas e buscaram encontrar alívio da dor por seus próprios meios.

CONCLUSÃO:

Os participantes do estudo relataram usar estratégias simples, mas limitadas, para alívio da dor, indicando uma lacuna na assistência oferecida a esses pacientes.

Descritores:
Dor crônica; Enfermagem; Úlcera venosa

INTRODUCTION

Venous ulcer (VU) is a chronic wound affecting 1to 3% of the world population, including active or healed ulcers¹. In Brazil, data on the prevalence of VU are scarce, but there are studies on the socio-demographic and clinical characterization of affected population in different country regions, indicating that this type of injury affects the adult population with higher incidence among the elderly and people with low socio-economic conditions^2-5. Comparative studies evaluating VU patients in Brazil and in Portugal have shown better quality of life (QL) in the pain domain among patients seen in health services of Evora, Portugal^6,7.

Lower limbs VU negatively affects QL of people living with this injury^8,9. Pain is frequent in VU patients and significantly impacts QL perception, because it tends to limit mobility, to impair labor activities, in addition to causing changes in daily life activities and sleep pattern^8,9. Continuous pain may lead to social isolation, increased expenses with treatment and decreased yield^10-12.

Studies indicate that the prevalence of pain in VU patients vary from 70 to 90% and this symptom is influenced by socio-demographic factors related to the assistance and to the injury^9,10,13. Pain impairs the healing process¹⁴ and is one of the primary reasons for VU patients to look for professional aid¹⁴. In Brazil, however, many patients use personal pain-relief methods, even before looking for the assistance of health professionals^15,16.

In light of such considerations, it is critical to investigate personal pain relief strategies used by VU patients. Knowing this reality will enable the identification of failures and the review of assistance, aiming at developing a tailored care plan not focused only on the injury. It is worth stressing that effective pain control may improve treatment adherence rates, in addition to improving QL of such patients¹⁷. So, this study aimed at identifying personal pain relief strategies used by VU patients.

METHODS

This is a descriptive and qualitative study carried out in the angiology outpatient setting of a Teaching Hospital in the central region of Rio Grande do Sul, Brazil.

Inclusion criteria were: having VU, being above 18 years of age and being treated in the outpatient setting during the data collection period, which went from January to February 2013. Exclusion criteria were patients with other types of skin injuries and with understanding or communication difficulties.

A semistructured interview, made up of questions regarding socio-demographic characteristics and practices/care adopted as from the onset of the injury was used for data collection, stressing pain-related strategies.

For data analysis, interviews were fully transcribed and then submitted to the content analysis process¹⁸, by means of three stages: pre-analysis, exploration of material and treatment of results, inference and interpretation.

Analysis of gross data obtained from interviews transcription started with a broad reading and subsequently several detailed readings, through which it was possible to cut record units, until then called by a generic title. Chosen record unit was of the theme-type, organized and included in categories and sub-categories, which has allowed the investigation of common and diverging points. Then, inference was carried out, that is, the discussion of obtained data with existing scientific publications.

This study complied with ethical principles of Resolution 466/2012, of the National Health Council, which defines the principles of Bioethics for studies involving human beings.

The study was approved by the Research Ethics Committee of the University to which it was linked, under protocol 23081.000145/2008-19.

RESULTS

Sample was made up of 14 VU patients, being nine females and five males, aged between 47 and 79 years, most of them above 60 years of age.

Pain was a frequent symptom in our sample. Many patients followed up by the angiology outpatient setting have referred worsening of pain at night and that it would induce sleep changes and mobility limitations, factors which affect QL.

Pain relief strategies referred by participants are presented below, in the following categories: self-treatment and search for the health system and religious search for pain relief.

Reports show the practice of self-treatment, including home practices, self-medication and search for the health service as pain relief strategies.

Patients have reported using home practices, including the application of physical methods (heat/cold and positioning) for pain relief.

Codes E1 to E14 were used, where the letter E meant "respondent" and the number referred to the order of participation in the study.

It was very uncomfortable, lot of pain, this is horrible, it hurts. At home I could not stand it and I put my feet in the water, it smokes, so high is the fever, so hot were my legs (E4).

When it is inflamed it hurts a lot, I use an ice pack and this relieves. No one said, I use it, I don't use it on the wound but up here and the fever is gone. Life teaches [laughs] us to do things (E9).

I started using alcohol and then this pain was relieved (E6).

When I am laying down I almost do not feel pain. Because I felt severe pain and difficulty to sleep, this was day and night (E6).

As from personal experiences, care practices with regard to pain were developed by respondents, such as the use of heat or cold, alcohol and rest.

Still at home, patients have referred the practice of self-medication, practice present even when VU patients had access to different health services, such as the Basic Health Unit, outpatient setting, first aid unit or hospital.

Today it is not hurting, I had a medicine before leaving home. The other days the wound hurts as if it was being cut with a serrated knife. Doctor said it is poor circulation and that I have to buy medicines [to improve blood circulation]. And the health center does not have this medicine (E5).

For pain, they [outpatient setting physicians] just tell you to have paracetamol, but sometimes I have other, because pain is not relieved. I buy it myself, sometimes I go to the big center [Basic Health Unit], if the pain is very severe. My pain is when I walk, I take the medicine and it relieves, I solve it by myself, I am used to it. What shall I do? I go to the first aid unit, they give me an injection and that's it (E12).

There are some days that pain ... for God's sake! I have to take a medicine and another one, even yesterday I had to go to the hospital and they gave me morphine (E14).

We have observed that pain, which so much interferes with QL of such patients, was not adequately treated by health professionals seeing them. Although punctual pharmacological actions were identified, most reports show lack of pain evaluation and monitoring which may negatively influence the therapeutic scheme. In this sense, the lack of pain control leads VU patients to look for other strategies as from their own knowledge and judgment, built by social and spiritual living.

Religious search for pain relief

Patients have also mentioned faith and search for religious practices as pain relief strategies.

Praying, still today I am praying, I notice that it relieves when you pray, you ask for the one up there to help and you have to have faith, because if you don't have faith, it is useless to pray (E6).

Praying in the Evangelist church. I do it when I have lots of pain, there are days when I have lots of pain, even with the treatment of not lowering the leg, of having to remain with the leg raised, laying down, sitting down and then I pray and it relieves. It is the faith we have, if we don't have faith [...] (E1).

I just thank God for the way I am and I don't complaint, for me it is as if I had nothing, unless when it hurts (E12).

A miracle of God! If you have that faith that you are going to win and if you trust God, you have to dedicate with faith. Because God left the doctors and both operate together, doctors with medication and God with His help (E1).

I pray asking God for health and peace, because I go after remaining things. Help, we have lots of spiritual strength. In general, those who study a lot, in this case you doctors, nurses, then you don't have that spiritual strength, I believe. But we who have not studied a lot, we cling to spiritual strength, because everything that is spiritual is easy and helps us (E2).

Religious practices, such as praying, were frequently reported in the attempt to control or minimize pain, evidencing that there are failures in the assistance they receive.

DISCUSSION

Pain was a common symptom among participants in this study, in line with systematic review carried out by United Kingdom nurses, which has concluded that pain was the most common symptom among VU patients⁸.

Studies in France, United Kingdom and Canada have analyzed experiences of VU patients and have observed that pain was constant, with variable intensity along the day and was described as anguishing, changing daily life activities and increasing the sensation of isolation¹⁹. Similarly, participants of this study have reported that pain impairs sleep and mobility, in addition to making difficult labor performance.

Pain control is critical in the assistance of VU patients and should be a concern of health professionals treating this population²⁰. It was observed, however, that VU patients very often stand pain and suffering in silence, due to lack of knowledge or ineffective treatment²¹.

Pain may be associated to edema, ischemia, hypoxia, inflammation, infection or adherence of dressings on wound beds, question which was identified in the evaluation of VU patients, being referred in the injury and with moderate intensity²². Decreased pain improves the healing process and favors QL of VU patients²².

Pain control is essential part of effective wound management and health professionals must know major interventions to handle VU-related pain, supplying resolute and tailored care²³.

Participants in this study have reported using simple, however limited strategies for pain relief. Reports included self-treatment by means of application of physical methods, self-medication and search for health services, as well as spiritual/ religious practices. Reports indicate that patients are not oriented about pain relief methods and try to find relief by their own, showing a gap in their assistance.

Self-medication may pose risks, because in a situation of severe pain, drugs may be indiscriminately used and in high doses, or even people may wait longer before looking for health professionals help¹⁶.

Looking for health services is the most indicated attitude in the situation of VU-related pain. Team following up the injury should evaluate pain and offer effective analgesic methods for pain relief. Guidance about pain handling is critical for patients to have subsidies to minimize pain-related distress. Spiritual/religious methods, which comfort during anguish and affliction times, were strategies used by patients of this study, similarly to a study evaluating elderly with cancer²⁴. Similarly, the manifestation of spirituality, the belief in a Superior Being, is looked for to strengthen hope in treatment and wound healing¹⁵.

Physical methods are a strategy producing pain relief and are recommended, be it by applying bags or pads of heat or cold, massage or by practicing physical activities¹⁶.

A study developed in Australia has tested the intervention based on social interaction, counseling, support and guidance about preventive care, by means of weekly meetings with VU patients²⁵. Results have shown that the intervention group has significantly decreased pain and the level at which it has affected mood, sleep and work, in addition to significantly decreasing VU size²⁵, indicating that multimodal therapies may be effective to control pain and heal ulcers.

CONCLUSION

Participants of this study have reported using simple, however limited strategies for pain relief, indicating a lack in the assistance offered to such patients. So, it is important to call the attention to the fact that pain is a frequent VU symptom and should be controlled. Knowing strategies used by patients and offering new pain control possibilities could be effective means to improve the assistance offered to such patients. This study has shown the difficulty to handle pain reported by VU patients treated in a Teaching Hospital. Further studies should be developed to confirm such results and to indicate effective strategies for VU-related pain relief.

• Sponsoring sources: CAPES scholarship for Post-Doctorate.
• *
  Received from Federal University of Rio Grande do Norte, Natal, RN, Brazil.

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Publication Dates

• Publication in this collection
  Jan-Mar 2015

History

• Received
  25 Aug 2014
• Accepted
  15 Apr 2015