UNIVERSITY OF SAN JOSE- RECOLETOS

COLLEGE OF NURSING

IN PARTIAL FULLFILMENT IN

SKILLS LABORATORY REQUIREMENTS

PAIN MANAGEMENT, NON PHARMACOLOGIC PAIN MANAGEMENT,

AND INFECTION CONTROL

TITLE PROCEDURE

PREPARED BY:

Simacon, Peps Iriel

Tabañag, Donnabelle

Tagadiad, Leah

Tan, Danielle Therese

Tangog, Charmy Fe

Turtoga, Jonessa

Ungod, Jean Rose

Taer,Godfrey Bryan

BSN-III BLOCK 4

PAIN MANAGEMENT
I. BASIC PRINCIPLES

 All patients have the right to have their pain relieved as much as
possible.

• The patient's age; gender; race or ethnic background; religious

beliefs; lifestyle choices; stage of illness; underlying diagnoses;
and/or history of substance abuse do not change this right.

• Some groups, including children, the elderly, the mentally or

physically disabled, and those with a history of addictions need
to have special care to be sure their pain is well-treated.

 Because pain is such a personal experience, the patient's report of

pain is the "gold standard", and all treatment is based on that report.

 The goal of treatment is to relieve as much of the patient's pain as is

possible.

• Sometimes, it may not be possible to relieve the entire patient's

pain. If this is the case, the goal should be to reduce the pain to
the level that the patient says is his/her goal.

• For the best pain relief, doctors, nurses, and other professionals
must watch out for side effects and their treatment; the goal is
to achieve the best pain relief with the least side effects.

 A complete review of the patient's pain should be done at the start of

treatment, and pain should be reviewed each time the patient is seen
by a health care professional after that.

• Pain should be considered the fifth vital sign, along with pulse,
breathing rate, blood pressure, and temperature.

• The review of the patient's pain should include a review of how

much pain the patient has; what the pain feels like; side effects
of the pain and medicines for it; mood; and how the pain affects
the patient in all areas of his/her life.

NURSING PRINCIPLES FOR ADMINISTERING ANALGESICS

1. Know the client’s previous response to analgesics.

 Determine whether relief was obtained.

 Ask whether a nonnarcotic was as effective as a narcotic.

 Identify previous doses and routes of administration to avoid

undertreatment.

 Determine whether the client has allergies.

2. Select proper medications when more than one is ordered.

 Use nonnarcotic analgesics or milder narcotics for mild to moderate

pain.

 Know that nonnarcotics can be alternated with narcotics.

 In older adults, avoid combinations of narcotics.

 Remember that morphine and hydromorphone are the narcotics of

choice for long-term management of sever pain.

 Know that injectable medications act quicker and can relieve severe,
acute pain within 1 hour and that oral medication may take as long as
2 hours to relieve pain.

 Use a narcotic with a nonnarcotic analgesic for severe pain because

such combinations treat pain peripherally and centrally.

3. Know the accurate dosage.

 Remember that doses at the upper end of normal are generally needed
for severe pain.

 Adjust doses, as appropriate, for children and older clients.

4. Assess the right time and interval for administration.

 Administer analgesics as soon as pain occurs and before it increases in

severity.

 Do not give analgesics only by ordered schedules. Remember that an

around-the-clock (ATC) administration schedule is usually best.

 Give analgesics before pain-producing procedures or activities.

 Know the average duration of action for a drug and the time of
administration so that the peak effect occurs when the pain is most
intense.

II. PAIN ASSESSMENT

 Although pain is referred to us the fifth vital sign, pain is a symptom.
Subjective in nature, pain is “whatever the person says it is whenever he or
she says it does” (McCaffery, 1999). Pain has also been defined as an
“unpleasant sensory and emotional experience associated with actual or
potential tissue damage” (International Association for the Study of Pain,
2006)

PURPOSE:

Accurate assessment of pain in the first step in developing and

effective treatment plan to deal with pain. The strategy of linking pain
assessment to routine vital sign assessment and documentation represents a
push to make pain assessment a routine aspect of care for all clients. Given
the highly subjective and individually unique nature of pain, a comprehensive
assessment of the pain experience (physiologic, psychologic, behavioral,
emotional, and sociocultural) provides the necessary foundation for optimal
pain control.

EQUIPMENTS/MATERIALS NEEDED:

Pain Assessment has various instruments. Consider the patient’s age

and developmental status along with his or her cultural background when
selecting a pain scale.

PROCEDURE/STEPS:

1. PQRST Tool

Precipitating / palliative / provocative

 What were you doing when the pain started?

 Does anything make it better, such as medication or a certain position?

 Does anything make it worst, such as movement or breathing?

Quality / quantity

 What does it feel like?

a. Superficial somatic pain is sharp, pricking, or burning

b. Deep somatic pain is dull or aching.

c. Visceral pain is dull, aching, or cramping

d. Neuropathic pain is burning, shocklike, jabbing, squeezing, or

aching.

 How often are you experiencing it?

 To what degree is the pain affecting your ability to perform your usual
daily activities?
Region / radiation / related symptoms

 Can you point to where it hurts?

 Does the pain occur or spread anywhere?

a. Localized pain confined to the sight of origin, such as cutaneous

pain.

b. Referred pain is referred to a distant structure, such as shoulder

pain with acute cholecyctitis or jaw pain associated with angina.

c. Projected pain is transmitted along a nerve, such as with herpes

zoster or trigeminal neuralgia.

d. Dermatomal pattern is as with peripheral neuropathic pain.

e. Nondermatomal pattern is as with central neurophatic pain.

Severity

 Use appropriate pain scale.

Timing

 When did the pain begin?

 How did it last?

a. Brief flash: Quick pain as with needle stick.

b. Rhythmic pulsation: pulsating as with migraine or toothache

c. Long duration rhythmic: as with intestinal colic

d. Plateau pain: pain that rises the plateaus such as angina

e. Paroxysmal pain: such as neuropathic pain

 How often does it occur?

a. Continuous fluctuating pain: as with musculoskeletal pain.

 Do you have times when you are pain free?

2. OLDCART

O – Onset: When did the pain begin?

L - Location: Where does it hurt? Can you point to where it hurts?

D - Duration: How long does it last?

C - Characteristics: What does it feels like?

A - Aggravating factors: Does anything make it worse?

R - Radiation: Does the pain go anywhere else?

T - Treatment: Did anything make it better? (Pain medication, ice,

heat?)

PAIN SCALE FOR ADULTS

1. Numeric Rating Scale

The Numeric Rating Scale rates pain on a scale of 0 (no pain) to either
5 or 10 (worst pain) by asking the patient to rate her or his current pain level.

2. Visual Analogue Scale

The Visual Analogue Scale utilizes a vertical or horizontal 10-cm line

with anchors. One end of the line is labeled “No Pain” and the opposite end of
the line is labeled “Worst Pain”. The patient marks his or her current pain
level on the line.

[______________________________________]

0 cm 10 cm

(no pain) (worst pain)

3. Categorical Scales

Categorical Scales use verbal or visual descriptors to identify pain

intensity. The patient selects the descriptor that she or he feels best
represents the current pain level. Verbal descriptors include:

• Mild, discomforting, distressing, horrible, excruciating.

• No pain, mild pain, moderate pain, severe pain, very severe pain,
worst possible pain.
 Visual descriptors include the Faces Pain Scale for Adults and Children

(FPS), which utilized illustrated faces with facial expressions ranging from
happy (no pain) to sad and crying (worst pain). The FPS has eight faces to
select current pain level. The patient is asked to select the face that best
represents his or her current pain level.

4. Multidimensional Pain Scales

These scales assess pain characteristics and its effects on patient’s

activities of daily living and include such scales as the Initial Pain Assessment
Inventory (IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ),
and the Neuropathic Pain Scale.

5. Initial Pain Assessment Inventory

The IPAI is used for initial assessment of pain. It assesses

characteristics of pain; effects of pain on the patient’s life, such as daily
activities, sleep, appetite, relationships, and emotions; and the patient’s
expression of pain. This assessment tool includes a diagram to not pain
location, a scale to rate pain intensity, and space to document additional
comments and the treatment plan.

6. Brief Pain Inventory

The BPI is used to quantify pain intensity and associated disability. It

assesses pain intensity, location, effects on life, type, and effectiveness of
treatment over the last 24 hours. Benefits of the BPI include that it is quick
and easy to use and available in multiple languages.

7. McGill Pain Questionnaire

The MPQ uses descriptive words to assess pain on three levels;

sensory, affective, and evaluative. It can be used with other tools and is
available in short and long forms.

8. Neuropathic Pain Scale

The Neuropathic Pain Scale assesses the type and degree of

sensations associated with neuropathic pain. The patient rates eight common
qualities of neuropathic pain (sharp, dull, hot, cold, sensitive, itchy, deep, or
surface pain) on a scale of 0 (no pain) to 10 (worst pain). This scale is still in
the developmental stages, but early testing holds diagnostic and therapeutic
promise.
PAIN SCALE FOR CHILDREN

1. Faces Pain Rating Scale

The FACES Pain Scale assesses pain for children ages 3 years and up.
The Wong-Baker has five faces from which the child can select her or his
current pain level.

2. Oucher

The Oucher scale assesses pain for children ages 3 to 13 years with
photos or a numeric scale. The photographic scale uses six photographs of
children ranging from a child with “no hurt” to a child with “a lot of hurt.” The
photographs are arranged vertically from 0 to 5, with 0 (no hurt) on the
bottom and 5 (lot of hurt) on the top. This scale also has photographs of black
and Hispanic children available.

Explain to the person that each face is for a person who feels happy
because he has no pain (hurt) or sad because he has some or a lot of pain.
Face 0 is very happy because he doesn’t hurt at all. Face 2 hurts a little
more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much
as you can imagine, although you do not have to be crying to feel this bad.
Ask the person to choose the face that best describes how he is feeling.
Rating scale is recommended for persons age 3 and older.

3. Numeric Scale
 The numeric scale ranges vertically from 0 to 100, with 0 being “no
hurt” and 100 being “biggest hurt”.

• 0 = no hurt
• 1-29 = little hurt
• 30-69 = middle hurt
• 70-99 = big hurt
• 100 = biggest hurt

4. Poker Chip Tool

The Poker Chip Tool assesses pain in children 4 years of age and up.
The nurse places red poker chips horizontally in front of the child, with the
poker chips denoting “pieces of hurt.” She then asks the child to select how
many pieces of hurt he or she has.

5. Word-Graphic Rating Scale

The Word-Graphic Rating Scale assesses pain in children ages 4 to 17

years. It uses words on a horizontal linear scale to assess pain. The child is
asked to identify her or his current pain level on the scale.

[__________________________________________________]

No Little Medium Large Worst

Pain Pain Pain Pain Pain

6. Numeric Scale

The Numeric Scale assesses pain for children ages 5 years and older. It
uses a horizontal linear scale with numbers from 0 to 5 or 10, with 0 being
“no pain” and 5 or 10 being “worst pain.” The child is asked to identify his or
her current pain level on the scale. Although similar to a scale used for
adults, this provides the child with a visual to help assess his or her pain.

No pain Worst pain

[_________________________________________________]

0 1 2 3 4 5

7. Visual Analogue Scale

 The Visual Analogue Scale, which assesses pain in children age 4 ½
and older, is similar to that used for adults. The child is asked to identify her
or his pain level by marking the line in the area that represents her or his
level of pain.

8. Color Tool

The Color Tool assesses pain for children as young as 4 years by

having the child create a body outline using colored markers or crayons. The
child selects four colors. The first color represents “most hurt,” the second
represents “little hurt,” the third represents “least hurt,” and the last
represents “no hurts.” Using all four colors, the child identifies areas and
degree of hurt on the body outline.

SOURCE: Dillon, Patricia M. Nursing Health Assessment. A Critical Thinking

Case Studies Approach. Edition 2. pp 97-100

Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2, pp

1311.

III. GENERAL PAIN MANAGEMENT STRATEGIES

1. Acknowledging and Accepting Client’s Pain.

According to the professional standards of conduct, nurses have a duty

to ask clients about their pain and to believe their reports of discomfort.
Challenging the client’s report of discomfort undermines the environment of
trust that is an essential component in the therapeutic relationship. Consider
these four ways of communicating this belief:

a.) Acknowledge the possibility of the.

Example: “Many people with your condition are bothered by leg pain.
Are you experiencing any leg discomfort? What does it feel like? How
concerned/upset are you about it?”

b.) Listen attentively to what the client says about the pain, restating
your understanding of the reported discomfort.

Example: Adding an empathetic statement like, “I’m sorry you are

hurting, it must be very upsetting. I want to help you feel better” lets the
client know you believe the pain is real and intend to help.

c.) Convey that you need to ask about the pain because, despite some
similarities, everybody’s experience is unique.
 Example: “Many people with you condition report having some
discomforts. Do you have any pain or other discomforts now?”

d.) Attend to the client’s needs promptly. It is unconscionable to

believe the client’s report of pain and then do nothing. After determining
the client has pain, discuss options and plan actions for providing relief.

Example: “Now that you have stated the site of pain and the intensity
of pain, we are now going to intervene you as much as we could.”

2. Assisting support persons.

Support persons often need assistance to respond in a helpful manner

to the person experiencing pain. Nurses can help by giving them accurate
information about the pain and providing opportunities for them to discuss
their emotional reactions, which may include anger, fear, frustration, and
feelings of inadequacy. Support persons also may need the nurse’s
understanding, reassurance, and perhaps access to resources that will help
them cope as they add the caregiver role to an already stressful life
circumstance.

3. Reducing Misconceptions about pain.

Reducing a client’s misconceptions about the pain and its treatment

will remove one of the barriers to optimal pain relief. The nurse should
explain to the client that pain is a highly individual experience and that it is
only the client who really experiences the pain, although others can
understand and empathize.

4. Reducing fear and anxiety.

It is important to help relieve strong emotions capable of amplifying

pain (e.g., anxiety, anger, and fear). When clients have no opportunity to talk
about their pain and associated fears, their perceptions and reactions to the
pain can be intensified. Often, these emotions are related to uncertainty
about the future, feeling mistreated in the past, or having unmet
expectations.

5. Preventing pain.

A preventive approach to pain management involves the provision of

measures to treat the pain before it occurs or before it becomes severe. This
strategy prevents the windup and sensitization described earlier that
spreads, intensifies, and prolongs pain.

SOURCE: Kozier and Erb’s Fundamentals of Nursing. Eight Edition. Vol. 2.

pp.1206-1208.
1V. POST OPERATIVE PAIN

Pain Management in patient post operatively

Although pain is a sensory and emotional experience that serves to

alert us to harm and initiate responses to avoid or minimize harm, pain in the
surgical client has little protective value.

Pain is usually greatest 12 to 36 hours after surgery, decreasing after

the second or third postoperative day. During the initial postoperative period,
patient-controlled analgesia (PCA) or continuous analgesic administration
through an intravenous or epidural catheter is often prescribed. The nurse
monitors the infusion or amount of analgesic administered by PCA, assesses
the client’s pain relief, and notifies the primary care provider if the client is
experiencing unacceptable side effects or inadequate pain relief.

An anti-inflammatroy agent such as ibuprofen or ketorolac (Toradol) is

often administered in conjunction with a narcotic analgesic to enhance pain
relief. Clients need to be reminded that analgesics are most effective when
taken on a regular basis or before pain becomes severe. Because muscle
tension increases pain perception and responses, nurses need to use
nonpharmacologic measures in addition to prescribed analgesia. These
include ensuring that the client is warm and providing back rubs, position
changes, diversional activities, and adjunctive measures such as imagery.

Types of Pain-Control Treatments:

1. Patient-Controlled Analgesia (PCA)

It is an interactive method of pain management that permits clients to

treat their pain by self-administering doses of analgesics. The oral route for
PCA is most common, but the subQ, IV, and epidural routes are increasingly
being used. PCA pumps are designed with built-in safety mechanisms to
prevent client overdosage, abusive use, and narcotic theft.

Patient-controlled analgesia (PCA) is a computerized pump that safely

permits you to push a button and deliver small amounts of pain medicine into
your intravenous (IV) line, usually in your arm. There is no injection of
needles into your muscle. PCA provides stable pain relief in most situations.
Many patients like the sense of control they have over their pain
management.
2. Patient-Controlled Epidural Analgesia

In epidural analgesia, pain medications are injected through a long,

thin tube (catheter) inserted into the epidural space within your spinal canal
but outside your spinal fluid. An epidural catheter is often used for labor and
delivery, and sometimes before a major operation such as joint replacement
or lung surgery. The epidural catheter can be left in place for several days if
needed to control postoperative pain. A continuous infusion of pain relievers
— including numbing medications (local anesthetics) and opioid medications,
such as morphine or fentanyl — can be delivered through the catheter to
control pain.

3. Spinal anesthesia

Some surgeries can be done with spinal anesthesia. Unlike epidural

analgesia, this form of pain relief involves medications injected directly into
the spinal fluid. Spinal anesthesia is easier and faster than epidural analgesia,
but it doesn't last as long because there is no catheter to allow the
administration of additional medication. Your doctor can add a long-acting
opioid to the spinal medication that can relieve post-surgical pain for up to 24
hours.

4. Nerve block

A nerve block provides targeted pain relief to an area of your body

such as an arm or leg. It prevents pain messages from traveling up the nerve
pathway to your brain. If you need only a few hours of pain relief, your
anesthesiologist may use a single injection of local anesthetic around the
appropriate nerves related to your surgery. For longer pain relief, your
anesthesiologist may place a catheter into that area to deliver a continuous
infusion of pain medications.

PAIN MEDICATIONS TAKEN BY MOUTH

1. Opioids (Narcotics) after surgery (medications such as morphine,

fentanyl, hydromorphone):

Indication: Strong pain relievers. Many options are available if one is

causing significant side effects.

Contraindication: May cause nausea, vomiting, itching, drowsiness,

and constipation. The risk of becoming addicted is extremely rare.

2. Opioids (Narcotics) at home (Percocet®, Vicodin®, Darvocet®, Tylenol

®)

Indication: Effective for moderate to severe pain. Many options

available.

Contraindication: Nausea, vomiting, itching, drowsiness,

constipation. Stomach upset can be lessened if the drug is taken with
food. Should not drive or operate machinery while taking these
medications. Note: These medications often contain acetaminophen
(Tylenol®). Make sure that other medications that you are taking do not
contain acetaminophen, as too much of it may damage your liver.

Be sure to tell your doctor about all medications (prescribed and over-
the- counter), vitamins and herbal supplements you are taking. This may
affect which drugs are prescribed for your pain control.

3. Non-Opioid (Non-narcotic) Analgesics (Tylenol®, Feverall®)

Indication: Effective for mild to moderate pain. They have very few
side effects and are safe for most patients. They often decrease the
requirement for stronger medications, which may reduce the incidence
of side effects.

Contraindication: Liver damage may result if more than the

recommended daily dose is used. Patients with pre-existing liver
disease or those who drink significant quantities of alcohol may be at
increased risk.

4. Nonsteroidal Anti-inflammatory Drugs (NSAIDS) ibuprofen (Advil®),

naproxen sodium (Aleve®), celecoxib (Celebrex®)

Indication: These drugs reduce swelling and inflammation and relieve

mild to moderate pain. Ibuprofen and naproxen sodium are available
without a prescription, but you should ask your doctor about taking
them. They may reduce the amount of opioid analgesic you need, possibly
reducing side effects such as nausea, vomiting, and drowsiness. If taken
alone, there are no restrictions on driving or operating machinery.

Contraindication: The most common side effects of nonsteroidal anti-

inflammatory medication (NSAIDS) are stomach upset and
dizziness. You should not take these drugs without your doctor's
approval if you have kidney problems, a history of stomach ulcers, heart
failure or are on "blood thinner" medications such as Coumadin®
(warfarin), Lovenox® injections, or Plavix®.

SOURCE:

Kozier & Erb’s Fundamentals of Nursing. Concepts, Process, and

Practice. Eight Edition. Volume 2. pp. 962,1216
 http://www.riversideonline.com/health_reference/Nervous-
System/PN00060.cfm
V. PAIN MANAGEMENT FOR ELDERLY
MISCONCEPTIONS
1. Pain is a natural outcome of
growing old.
2. Pain perception, or sensitivity,
decreases with age.
3. If the older client does not report Older clients commonly underreport
pain, he or she does not have pain.
4. If an older client appears to be
occupied, asleep, or otherwise
distracted from pain he or she does
not have pain.
CORRECTIONS
It is true that older adults are at
greater risk (as much as twofold)
than younger adults for many painful
conditions; however, pain is not an
inevitable result of aging.
This assumption is unsafe. Although
there is evidence that emotional
suffering specifically related to pain
may be less in older than in younger
clients, no scientific basis exists for
the assertion that a decrease in
perception of pain occurs with age or
that age dulls sensitivity to pain.
Assessment and intervention for pain
in older adults should begin with the
assumption that all
neurophysiological processes
involved in nociception are unaltered
by age.
pain. Reasons include expecting to
have pain with increasing age; not
wanting to alarm loved ones; being
fearful of losing their independence;
not wanting to distract, anger, or
bother caregivers; and believing
caregivers know they have pain and
are doing all that can be done to
relieve it. The absence of a report of
pain does not mean the absence of
pain.
Older clients often believe it is
unacceptable to show pain and have
learned to use a variety of ways to
cope with it. Sleeping may be a
coping strategy or indicate
 exhaustion, not pain relief.

5. The potential side effects of Opioids may be used safely older

opioids make them too dangerous to adults. Although the opioid-naïve
use to relieve pain in older adults. older adult may be more sensitive to
opioids, this does not justify
withholding the use of them in the
management of pain in this
population. The key to use of opioids
in older adults is to “start low and go
slow.” Potentially dangerous opioid-
induced side effects can be
prevented with slow titration; regular,
frequent monitoring and assessment
of the client’s response; and
adjustment of dose and interval
between doses when side effects are
detected. If necessary, clinically
significant respiratory depression can
be reversed by an opioid antagonist
drug.

6. Clients with Alzheimer’s disease No evidence exists that cognitively

and others with cognitive impairment
do not feel pain, and their reports of
pain are most likely invalid.
impaired older adults experience less
pain or that their reports of pain are
less valid than those of individuals
with intact cognitive function. It is
probable that clients with dementia,
progressive deficits of cognition,
apraxias, and agnosia, particularly
those in long-term care facilities,
suffer significant unrelieved pain and
discomfort. Assessment of pain in
these clients is challenging but
possible. The best approach is to
accept the client’s report of pain.

7. Older clients report more pain as
they age.
Even though older clients experience
a higher incidence of painful
conditions, such as arthritis,
osteoporosis, peripheral vascular
disease, and cancer, than younger
clients, studies have shown that they
underreport pain. Many elderly clients
grew up valuing the ability to “grin
and bear it,” and, unfortunately, have
been heavily influenced by the “Just
Say No” to drugs campaign.
SOURCE: Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2,
pp. 1292.

2.) NON-PHARMACOLOGIC PAIN MANAGEMENT

Definition:

Non-pharmacological or natural therapies are things you can do or

think about that help decrease your pain. These therapies do not involve
taking medicines, but work along with your medicines. People have used
"natural" ways to help with pain and healing from the very beginning of time.

Indication:

A long time ago, the Chinese learned that putting special needles in
areas of the body could decrease pain. Music has also a very important part
of healing the sick over time. Scientists are learning that common things like
music, laughter, exercise and good smells cause our brains to make special
chemicals. These special chemicals may help us to feel less pain.

Contraindication:

Being tense and upset causes pain to become worse. When you are
tense, your muscles get tight which decreases blood flow in your body. Your
heart beats faster and your blood pressure goes higher. Your breathing also
gets faster and shallower. Your brain begins to make chemicals, including
ones that may cause pain. This stress and upset cycle causes you more pain.
Certain ways to relax help loosen muscles. This breaks the whole cycle and
may decrease your pain.

The following are the common non pharmacologic managements:

1. PHYSICAL INTERNVENTIONS

The goals of physical intervention include providing comfort, altering

physiologic responses to reduce pain perception, and optimizing functioning.

a.) Breathing exercises- are another physical way to help your body relax.
Teaching your body to relax, helps make the pain less. Breathing in and out
very slowly is all you do. Women have used breathing exercise for many
years to decrease the pain of childbirth.

2. CUTANEOUS STIMULATION – this can be applied directly to the painful

area, proximal to the pain or distal to the pain (along the nerve path or
dermatome), and contralateral (exact location, opposite side of the body), to
the pain.

Indication:

 It can provide effective temporary pain relief.

  It distracts the client and focuses attention on the tactile stimuli, away
from the painful sensations, thus reducing pain perception.

 It interferes with the transmission and perception of pain by stimulating

the large-diameter A-beta sensory nerve fibers that activate the
descending mechanisms that can reduce the intensity of pain, activate
the endorphin system of pain control, and thus diminish conscious
awareness of pain.

Contraindication:

 In the areas of skin breakdown or impaired neurological functioning.

a.) Massage – a nonpharmacologic management technique that uses

ointments or liniments that provide localized pain relief with joint or muscle
pain. Massage can involve the back and neck, hands and arms, or feet.

Indication:

 It aids relaxation.

 It decreases muscle tension.

 It eases anxiety because the physical contact communicates caring.

 It decreases pain intensity by increasing superficial circulation to the

area.

Contraindication:

 In the areas of skin breakdown, suspected clots, or infections.

Equipments:

 Ointments, liniments, extra towel, etc.

b.) Heat and Cold Application – a warm bath, heating pads, ice bags, ice
massage, hot or cold compresses, and warm or cold sitz baths in general
relive pain and promote healing of injured tissues.

c.) Accupressure – It was developed for the ancient Chinese healing system
of acupuncture. The therapist applies finger pressure to points that
correspond tomany of the points used in acupuncture.

d.) Contralateral Stimulation – it can be accomplished by stimulating the

skin in an area opposite to the painful area (e.g., stimulating the left knee if
the pain is in the right knee). The contralateral area may be scratched for
itching, massaged for cramps, or treated with cold packs or analgesic
ointments. This method is particularly useful when the painful area cannot be
touched because it is hypersensitive, when it is inaccessible by a cast or
bandages, or when the pain is felt in a missing part.

3. IMMOBILIZATION/BRACING – immobilizing or restricting the movement

of a painful body part (e.g., arthritic joint, traumatized limb). Splints or
supportive devices should hold joints in the positions of optimal function and
should be removed regularly in accordance with agency protocol to provide
ROM exercises. Therefore, clients should be encouraged to participate in self-
care activities and remain as active as possible, with frequent ROM exercises.

Indication:

 To help manage episodes of acute pain.

Contraindication:

 Prolonged immobilization can result in joint contracture, muscle

atrophy, and cardiovascular problems.

Equipments:

 Splints, brace, tractor, etc.

4. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) – is a

method of applying low-voltage electrical stimulation directly over identified
pain areas, at an acupressure point, along peripheral nerve areas that
innervate the pain area, or along the spinal column. The TENS unit consists of
a portable, battery operated device with lead wire and electrode pads that
are applied to the chosen area of skin.

Indication:

 To activate large-diameter fibers that modulate the transmission of

the nociceptive impulse n the peripheral and CNS (closing the pain
“gate”), resulting in pain relief.

 It causes a release of endorphins from the CNS center.

Contraindication:

 Contraindicated for clients with pacemakers or arrhythmias

 In areas of skin breakdown.

 It is generally not used on the head or over the chest.

5. COGNITIVE-BEHAVIORAL INTERVENTIONS

Indication:

 It provides comfort.

 It alters psychologic responses to reduce pain perception.

  To optimize functioning.

a.) Distraction – this draws the person’s attention away for the pain and
lessens the perception of pain. In some instances, distraction can make a
client completely unaware of pain. Distraction makes the person unaware of
the pian only for the amount of time and to the extent that the distracting
activity holds his or her “undivided” attention.

b.) Biofeedback - teaches your body to respond in a different way to the

stress of being in pain. Teaching your body to relax, helps make the pain less.
Caregivers may use a biofeedback machine so that you know right away
when your body is relaxed. But, often you may not need any machines. Learn
to take your pulse. Then take it while making your mind think about "slowing
down" your pulse. This can work with breathing, temperature, and blood
pressure too.

c.) Guided imagery - teaches you to put pictures in your mind that will
make the pain less intense. With guided imagery, you learn how to change
the way your body senses and responds to pain. Imagine floating in the
clouds or remembering favorite place. Guided imagery seems to help people
with chronic lower back pain.

d.) Self-hypnosis - is a way to change your level of awareness. This means

that by focusing your attention you can move away from your pain. You make
yourself open to suggestions like ignoring the pain or seeing the pain in a
positive way. It is not known exactly how hypnosis helps pain. But, hypnosis
can give long-lasting relief of pain without affecting your normal activities.
Self-hypnosis gives you better control of your body. You may feel less
hopeless and helpless because you are doing something to decrease the
pain.

e.) Laughter - It has been said that "10 minutes of belly laughter gives 2
hours of pain-free sleep! Laughter helps you breathe deeper and your
stomach digest (break down) food. It lowers blood pressure and may cause
your brain to make endorphins. Laughter can also help change your moods. It
helps you relax and let go of stress, anger, fear, depression, and
hopelessness. These are all parts of chronic pain.

f.) Music - it does not matter whether you listen to it, sing, hum or play an
instrument. Music increases blood flow to the brain and helps you take in
more air. Scientists are learning that it increases energy and helps change
your mood. Music also may cause your brain to make special chemicals like
endorphins. Endorphins are a natural body chemical like morphine that
decrease pain. People who use music often say it decreases their need of
medicines for pain and anxiety.
SOURCE: Kozier & Erb’s Fundamentals of Nursing. Concepts, Process, and
Practice. Eight Edition. Vol. 2pp. 1217-1221

3.) INFECTION CONTROL

- An infection is the entry and multiplication of an infection agent in the
tissues of a host. If the infectious agent (pathogens) fails to cause
injury to cells or tissues, the infection is asymptomatic.
- If the pathogens multiply and cause clinical signs and symptoms, the
infection is symptomatic. If the infectious disease can be transmitted
directly from one person to another, it is a communicable, or
contagious, disease
- Infection control refers to policies and procedures used to minimize the
risk of spreading infections, especially in hospitals and health care
facilities.

Purpose:

- To reduce the occurrence of infectious diseases. These diseases are

usually caused by bacteria or viruses and can be spread by human-to-
human contact, animal-to-human contact, human contact with an
infected surface, airborne transmission through tiny droplets of
infectious agents suspended in the air, and, finally, by a common
vehicle such as food or water.

Equipments:

 Antimicrobial or regular soap

 Clean orangewood sticks or toothpick (optional)

 Paper towel or hand towel

 Easy to reach sink with warm running water

Procedure: HANDWASHING
 PROCEDURES RATIONALE

1.
1. Inspect surface of hands for breaks Open cuts or wounds can harbor high
or cuts in skin or cuticles. concentration of microorganism

2. Open cuts or wounds can harbor Nails should be short and filled
high concentration of microorganism because most microbes of hands
came from beneath the fingernails

3. Remove wristwatch and avoid Provide complete access to fingers,

wearing rings hands, and wrist. Wearing of rings
can increase numbers of
microorganism and the hands

4. Stand in front of the sink, keeping Provides complete access to fingers,

hands and uniform away from the hands, wrists. Wearing of rings
sink surface. (If hands touch sink increases number of microorganisms
during hand washing repeat.) on hands.

5. Turn on water. Turn faucet on or To let the water flow over the hands
push knee pedals laterally or press and facilitate in washing.
pedals with foot to regulate flow and
temperature.

6. Avoid splashing water against Microorganisms travel and grow in

uniform. moisture.
7. Regulate flow of water so that
temperature is warm.
8. Wet hands and wrists thoroughly
under running water. Keep hands
and forearms lower than elbows
during washing.
2. 9. Apply a small amount of
soap or antiseptic, lathering
thoroughly. Soap granules and
leaflet preparations may be used.
10. Wash hands using plenty of
lather and friction for at least 10 to
15 seconds. Interlace fingers and
rub palms and back of hands with
circular motion at least 5 times
each. Keep fingertips down to
facilitate removal of
microorganisms.
11. Areas underlying fingernails are
often soiled. Clean them with
fingernails of other hand and
additional soap or clean
orangewood stick.
12. Rinse hands and wrists
thoroughly, keeping hands down
and elbows up.
13. Dry hands thoroughly from
fingers to wrists and forearms with
paper towel, single-se cloth, or warm
air dryer
14. If used, discard paper towel in
proper receptacle.
Warm water removes less of the
protective oils than hot water.
Hands are the most contaminated
parts to be washed. Water flows
from least to most contaminated
area, rinsing microorganisms into
the sink.
Use of antiseptic exclusively can be
drying to hands and can cause skin
irritations. The decision whether to
use an antiseptic should depend on
the procedure to be performed and
the client’s immune status.
Soap cleanses by emulsifying fat
and oil and lowering surface
tension. Friction and rubbing
mechanically loosen and remove
dirt and transient bacteria.
Interlacing fingers and thumbs
ensures that all surfaces are
cleansed.
Area under nails can be highly
contaminated, which will increase
the risk of infection for the nurse or
the client.
Rinsing mechanically washes away
dirt and microorganisms.
Drying from cleanest (fingertips) to
least clean (forearm) area avoids
contamination. Drying hands
prevents chapping and roughened
skin.
Prevents transfer of
microorganisms.
 15. Turn off water with foot or knee Wet towel and hands allow transfer
pedals. To turn off hand faucet, use of pathogens by capillary action.
clean, dry paper towel; avoid
touching handles with hands.

16. If hands are dry or chapped, a Use small, individual-use container

small amount of lotion or barrier of lotion because large, refillable
cream can be applied. containers have been associated
with nosocomial infections.

17. Inspects surfaces of hands for Determines if hand washing is

obvious signs of soil or other adequate.
contaminants.

18. Inspects hands for dermatitis or Indicates complications from

cracked skin. excessive hand washing.

Nursing Responsibility:

- Encourage hand washing before and after eating and going to the
comfort room

- Instruct clients about cleaning equipments using soap and water and
disinfecting with an appropriate disinfectants

- Demonstrate proper hand washing, explaining that it should be done

before and after all treatments and when infected body fluids are
contacted.

- Instruct client about signs and symptoms of wound infection

- Instruct clients to place contaminated dressing and their disposable

items containing infectious body fluids in impervious plastic bags.

- Place needles in metal containers such as soda cans and tape the
opening shuts.

- Clean noticeably solid linen separate from other laundry. Wash in

water that is as hot as the fabric will tolerate

Evaluation:

- As client or family member to describe techniques used to reduce

transmission of infection.

- Have client demonstrate select techniques

- Ask client to explain risk for infection based on the condition.

Source:

- Fundamentals of Nursing, Potter and Perry, 5th Edition, Vol. 2, pp 835-

864