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Chapter: Medical Surgical Nursing: Pain Management

Nonpharmacologic Interventions - Pain Management Strategies

Although pain medication is the most powerful pain relief tool available to nurses, it is not the only one.


Although pain medication is the most powerful pain relief tool available to nurses, it is not the only one. Nonpharmacologic nursing activities can assist in relieving pain with usually low risk to the patient. Although such measures are not a substitute for medication, they may be all that is necessary or appropriate to re-lieve episodes of pain lasting only seconds or minutes. In in-stances of severe pain that lasts for hours or days, combining nonpharmacologic interventions with medications may be the most effective way to relieve pain.

Cutaneous Stimulation and Massage

The gate control theory of pain proposes that the stimulation of fibers that transmit nonpainful sensations can block or decrease the transmission of pain impulses. Several nonpharmacologic pain relief strategies, including rubbing the skin and using heat and cold, are based on this theory.


Massage, which is generalized cutaneous stimulation of the body, often concentrates on the back and shoulders. A massage does not specifically stimulate the non-pain receptors in the same recep-tor field as the pain receptors, but it may have an impact through the descending control system (see earlier discussion). Massage also promotes comfort because it produces muscle relaxation.

Ice and Heat Therapies

Ice and heat therapies may be effective pain relief strategies in some circumstances; however, their effectiveness and mechanism of ac-tion need further study. Proponents believe that ice and heat stim-ulate the non-pain receptors in the same receptor field as the injury.


For greatest effect, ice should be placed on the injury site im-mediately after injury or surgery. Ice therapy after joint surgery can significantly reduce the amount of analgesic medication required subsequently. Ice therapy may also relieve pain if applied later. Care must be taken to assess the skin prior to treatment and to protect the skin from direct application of the ice. Ice should be applied to an area for no longer than 20 minutes at a time. This prevents the rebound phenomenon that occurs as the body attempts to warm up, rendering the treatment useless. Long applications of ice may result in frostbite or nerve injury. Both ice and heat therapy must be applied carefully and monitored closely to avoid injuring the skin. Neither therapy should be applied to areas with impaired cir-culation or used with patients with impaired sensation.


Application of heat increases blood flow to an area and con-tributes to pain reduction by speeding healing. Both dry and moist heat may provide some analgesia, but their mechanisms of action are not well understood. Application of heat to inflamed joints, for example, may provide temporary comfort, but increasing the intra-articular temperature may impair healing (Oosterveld & Rasker, 1994a, 1994b).

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain. It hasbeen used in both acute and chronic pain relief and is thought to decrease pain by stimulating the non-pain receptors in the same area as the fibers that transmit the pain. This mechanism is con-sistent with the gate control theory of pain and explains the effec-tiveness of cutaneous stimulation when applied in the same area as an injury. For example, when TENS is used in a postoperative patient, the electrodes are placed around the surgical wound.


Another possible explanation for the effectiveness of TENS is the placebo effect (the patient expects it to be effective). In a re-view of the literature, Carroll, Tramer, McQuay et al. (1996) found that in 15 of 17 studies with randomized control group de-signs, TENS was ineffective in relieving postoperative pain. In 17 of 19 studies that did not use this design, the authors of these studies concluded that TENS had a positive analgesic effect. The review of these studies suggests that a placebo effect may explain the effectiveness of TENS.


Distraction helps relieve both acute and chronic pain (Johnson & Petrie, 1997). Distraction, which involves focusing the patient’s at-tention on something other than the pain, may be the mechanism responsible for other effective cognitive techniques. Distraction is thought to reduce the perception of pain by stimulating the de-scending control system, resulting in fewer painful stimuli being transmitted to the brain. The effectiveness of distraction depends on the patient’s ability to receive and create sensory input other than pain. Distraction techniques may range from simple activities, such as watching TV or listening to music, to highly complex physical and mental exercises. Pain relief generally increases in direct pro-portion to the person’s active participation, the number of sensory modalities used, and the person’s interest in the stimuli. Therefore, the stimulation of sight, sound, and touch is likely to be more ef-fective in reducing pain than is the stimulation of a single sense.


Visits from family and friends are effective in relieving pain. Watching an action-packed movie on a large screen with “Surround-Sound” through headphones may be effective (provided the person finds it acceptable). Others may benefit from games and activities (eg, chess) that require concentration. Not all patients ob-tain pain relief with distraction, especially those in severe pain. With severe pain, the patient may be unable to concentrate well enough to participate in complex physical or mental activities.

Relaxation Techniques

Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to the pain. Considerable evidence supports relaxation as effective in relieving chronic low back pain (NIH Technology Assessment Panel, 1995). Few studies, however, support its effectiveness in reducing postoperative pain. This may be due to the relatively small role skeletal muscles play in postop-erative pain, or to the need for the patient to practice the relaxation technique for it to be effective. Practicing the technique may not be possible when it is taught only once, immediately before surgery. A patient who already knows a technique for relaxing may only need to be reminded to use it to reduce or prevent increased pain.


A simple relaxation technique consists of abdominal breath-ing at a slow, rhythmic rate. The patient may close both eyes and breathe slowly and comfortably. A constant rhythm can be main-tained by counting silently and slowly with each inhalation (“in, two, three”) and exhalation (“out, two, three”). When teaching this technique, the nurse may count out loud with the patient at first. Slow, rhythmic breathing may also be used as a distraction technique. Relaxation techniques, as well as other noninvasive pain relief measures, may require practice before the patient be-comes skilled in using them.


Almost all people with chronic pain can benefit from some method of relaxation. Regular relaxation periods may help to com-bat the fatigue and muscle tension that occur with and increase chronic pain.

Guided Imagery

Guided imagery is using one’s imagination in a special way to achieve a specific positive effect. Guided imagery for relaxation and pain relief may consist of combining slow, rhythmic breath-ing with a mental image of relaxation and comfort. The nurse in-structs the patient to close the eyes and breathe slowly in and out. With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain and tension and leaving behind a relaxed and comfortable body. With each inhaled breath, the patient imagines healing energy flowing to the area of discomfort.


If guided imagery is to be effective, it requires a considerable amount of time to explain the technique and time for the patient to practice it. Usually, the patient is asked to practice guided im-agery for about 5 minutes, three times a day. Several days of prac-tice may be needed before the intensity of pain is reduced. Many patients begin to experience the relaxing effects of guided imagery the first time they try it. Pain relief can continue for hours after the imagery is used. The patient needs to be informed that guided imagery may work only for some people. Guided imagery should be used only in combination with all other forms of treatment that have demonstrated effectiveness.


Hypnosis, which has been effective in relieving pain or decreas-ing the amount of analgesic agents required in patients with acute and chronic pain, may promote pain relief in particularly diffi-cult situations (eg, burns). The mechanism by which hypnosis acts is unclear. Its effectiveness depends on the hypnotic suscep-tibility of the individual (Farthing, Venturino, Brown et al., 1997). In some cases, hypnosis may be effective in the first ses-sion, with effectiveness increasing in additional sessions. In other cases, hypnosis does not work at all. Usually, hypnosis must be induced by a specially skilled person (a psychologist or a nurse with specialized training in hypnosis). Sometimes patients learn to perform self-hypnosis.


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