Pain at first dressing change after toenail avulsion: the experience of nurses, patients and an observer: 1

Ingrowing toenails are often treated surgically by nail avulsion, with paraffin tulle gauze applied to the toenail bed afterwards. In one large city's primary care trusts, community nurses reported that patients felt pain when the gauze was removed postoperatively. This study looked at patients' general pain experience, and their pain during the first dressing change after toenail avulsion. Patients' perceptions of their pain were investigated, along with nurses' experience of redressing toenail beds, their technique and their interaction with patients, especially in relation to pain prevention.

First an extensive literature review was conducted. Then a collective instrumental case study design was used. This allowed triangulation of data sources using patient and nurse interviews, and non-participant observation, from six cases recruited from the city's primary care trusts. Data were subjected to thematic content analysis, with two main categories identified. These were 'setting up of expectations' and 'a painful experience: but for whom?'

This study provides a unique description of the type of pain patients experience. It raises serious issues about the adequacy of nurses' management of pain, including assessment, documentation and advice on pain-relief strategies. It supports discontinuing the use of paraffin tulle gauze as the postoperative dressing, and raises ethical issues about changing treatments and lack of communication with secondary care. Finally, it identifies a gap in knowledge of the most suitable dressing product to apply immediately after surgery. A randomised controlled trial is needed to clarify these preliminary findings.