BURNS ARE AMONG the most intensely painful type of injury, because a series of local and systemic processes continue to damage tissue for at least 24 hours after the burn occurs. Irritating substances released from damaged cells, combined with local inflammatory and immune responses, amplify your patient's pain, making it worse before it gets better.
This heightened pain perception, called primary hyperalgesia, usually occurs at the center of superficial burns and closer to the edges of the deepest burns. Primary hyperalgesia develops at the site of tissue injury and is associated with an increased sensitivity of the peripheral nerve fibers that transmit pain impulses. The sensitivity then spreads to adjacent body parts. This phenomenon, called secondary hyperalgesia, develops in uninjured tissue surrounding the burn and is caused by enhanced neural responsiveness in the central nervous system.1
Assessing burn pain
For example, suppose you're caring for a 25-year-old man who has second-degree burns on his torso and third-degree burns on his right forearm from a gas grill accident 2 days ago. Each day he demands more analgesics, but any more than 5 mg morphine per hour I.V. results in severe pruritus and sedation. He has severe pain, especially during dressing changes, and I.V. ketorolac doesn't seem to help.
When you assess your patient, determine if light touch or exposure to cool air triggers pain. If so, the patient is experiencing allodynia (pain from stimuli that aren't normally painful), which denotes damage to pain-signaling nerves. Allodynia or paresthesias increase the risk that your patient will be among the 30% of burn patients who continue to have pain for months and years after the burn wounds have healed.2
You may have noticed that your patient's pain has two distinct components—background or constant pain during rest, and pain induced by activity or treatments. Background pain is typically constant, with periodic flares called breakthrough pain that can be spontaneous or provoked. Even when background pain is relatively stable and adequately controlled by the analgesic regimen, you should anticipate and plan interventions for these transitory exacerbations.
A patient with deep burns will experience the most intense pain during dressing changes. Activity-induced pain typically is twice as intense as background (or at-rest) pain, but pain during dressing changes may be five times as intense as background pain.3 Wound care is especially painful because it triggers hyperalgesia or allodynia mechanisms by physical stimulation and exposure of the burned area to air. Other nursing interventions likely to trigger pain include repositioning, range-of-motion exercises, and splint application.4
Your patient also may be anxious, frightened, angry, or depressed—emotions that can worsen pain and intensify his distress. The patient may feel helpless and be worried about how disfigurement will affect current or future relationships. Assess for intrusive thoughts and bad dreams that could signal posttraumatic stress disorder, which often follows burn trauma. Refer the patient to a mental health professional as needed; early recognition of psychosocial needs and appropriate interventions are key in the patient's long-term adjustment to the injury.5
The right analgesics
A patient with moderate or severe burns needs a continuous opioid infusion with additional doses available for breakthrough pain. Nonsteroidal anti-inflammatory drugs such as ibuprofen can be used cautiously, but can add to the risk of complications involving the skin, gastrointestinal tract, and kidneys that often occur after a burn.6 The patient should also receive additional analgesia just before painful procedures such as a dressing change.
Fentanyl may be a better choice of analgesic than morphine, because it may be more effective and cause less pruritus after a burn injury.7 Also, your patient will likely need higher doses at more frequent intervals than you might expect, because his kidneys and liver are working extra hard to eliminate all impurities (including medications) from the body. Breakdown products from hemoglobin and myoglobin can obstruct the renal tubules. This, combined with fluid and electrolyte imbalances that are common with severe burns, puts the patient at risk for multisystem organ failure.
Assess the patient's pain intensity level using an appropriate pain rating scale to determine the effectiveness of treatment. The patient's healthcare provider should adjust the continuous opioid infusion rate once daily based on the previous day's total amount used, until pain has stabilized and meets realistic goals for patient comfort and function.
If dose-limiting adverse reactions occur, the healthcare provider will prescribe a different opioid or add an adjuvant drug rather than increasing the dose. If this is ineffective, the healthcare provider should consider moderate sedation and analgesia or general anesthesia during dressing changes.
Other interventions that may help include proper body positioning, relaxation techniques, and distraction therapy with music, television, and games. Virtual reality technologies are increasingly available; in one, the patient can use simple eye and finger movements to throw snowballs in a serene mountain setting.8
Keep physical and mental stress at a minimum by limiting strenuous activities and alternating periods of activity with rest. Organize nursing interventions to minimize their disruptive effect on sleep patterns so your patient can get the rest needed for optimal healing.
1. Meyer RA, Ringkamp M, Campbell JN, Raja SN. Neural mechanisms of hyperalgesia after tissue injury. Johns Hopkins APL Technical Digest
2. Schneider JC, Harris NL, Shami AE, et al. A descriptive review of neuropathic-like pain after burn injury. J Burn Care
3. Connor-Ballard PA. Understanding and managing burn pain: part 1. Am J Nurs.
4. Connor-Ballard PA. Understanding and managing burn pain, part 2. Am J Nurs.
5. Klinge K, Chamberlain DJ, Redden M, King L. Psychosocial adjustments made by postburn injury patients: an integrative literature review. J Adv Nurs
6. Dore J, Salisbury RE. Morbidity and mortality of mucocutaneous diseases in the pediatric population at a tertiary care center. J Burn Care Res
7. Li H, Shi H, Sun G. Fentanyl for pain relief in burn patients. Cochrane DatabaseSyst Rev
. 2009(1):CD007534. DOI: 10.1002/14651858.CD007534.
8. van Twillert B, Bremer M, Faber AW. Computer-generated virtual reality to control pain and anxiety in pediatric and adult burn patients during wound dressing changes. J Burn Care Res