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Ahmed El Geziry, Yasser Toble, Fathi Al Kadhi, Muhammad Pervaiz

and Mohammad Al Nobani (November 5th 2018). Non-Pharmacological Pain Management, Pain Management in Special Circumstances, Nabil A. Shallik, IntechOpen, DOI: 10.5772/intechopen.79689. Available from: https://www.intechopen.com/books/pain-management-in-special-circumstances/non-pharmacological-pain-management

Better Health (2017). Massage. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/massage

Bernatzky, G., Presch, M., Anderson, M., & Panksepp, J. (2011). Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neuroscience & Biobehavioral Reviews, 35(9), 1989-1999.

Goldhill, D., Badacsonyi, A., Goldhill, A., & Waldmann, C. (2008, April 11). A prospective observational study of ICU patient position and frequency of turning. Retrieved November 10, 2020, from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2007.05431.x

Hassett, A. L., & Williams, D. A. (2011). Non-pharmacological treatment of chronic widespread musculoskeletal pain. Best practice & research Clinical rheumatology, 25(2), 299-309.

Hsu WC, Guo SE, Chang CH (2020). Back massage intervention for improving health and sleep quality among intensive care unit patients. Nurs Crit Care. 2019.Sep;24(5):313–319

Martorella, G. (2019). Characteristics of Nonpharmacological Interventions for Pain Management in the ICU: A Scoping Review. AACN Advanced Critical Care, 30(4), 388–397. https://doi-org.ju.idm.oclc.org/10.4037/aacnacc2019281

Montefiore (2020). Creating a Healing Hospital Environment. https://www.montefiore.org/healingarts-healing-environment

Rousseaux, F., Faymonville, M.-E., Nyssen, A.-S., Dardenne, N., Ledoux, D., Massion, P. B., & Vanhaudenhuyse, A. (2020). Can hypnosis and virtual reality reduce anxiety, pain and fatigue among patients who undergo cardiac surgery: a randomised controlled trial. Trials, 21(1), 1–9. https://doi-org.ju.idm.oclc.org/10.1186/s13063-020-4222-6

Salamati, A., Mashouf, S., & Mojab, F. (2017). Effect of Inhalation of Lavender Essential Oil on Vital Signs in Open Heart Surgery ICU. Iranian Journal of Pharmaceutical Research, 16(1), 404–409.

Srouji, R., Ratnapalan, S., & Schneeweiss, S. (2010). Pain in children: assessment and nonpharmacological management. International journal of pediatrics, 2010, 474838. https://doi.org/10.1155/2010/474838

Stanford Healthcare (2017, September 12). Management of pain without medications. Retrieved November 10, 2020, from https://stanfordhealthcare.org/medical-conditions/pain/pain/treatments/non-pharmacological-pain-management.html

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-Pain for patients in an ICU is usually described as moderate to severe (Martorella, 2019)
-There are multiple examples of invasive procedures that occur in critical care patients such as chest tube removal, mechanical ventilation, and arterial line insertion that can contribute to more severe pain
-The main way to assess pain for patients is for the patient to verbally express their pain but that may not always be possible in an ICU, which is why is can be difficulty to assess and treat pain in these types of patients
-Because of the sedation levels of critical care patients, pain medication may be unsafe to use, which is why pain must be treated in other ways

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-Works by needles being placed in a specific region of body and stimulates the nerve
-Can have analgesic effect to reducing pain

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-Uses herbal extracts and oils
-Lavender is proven to be the most popular/most effective
-Helps reduce pain, anxiety, and enhance sleep quality
-Can assist in lowering blood pressure and heart rate when hypertensive and tachycardic

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"State of modified consciousness involving focused attention and reduced peripheral awareness, characterized by an enhanced capacity for response to suggestion" (Rousseaux et.al., 2020)
-Can help reduce acute and/or chronic pain in critical care patients
-Can also help to promote better and more restful sleep
-Has 3 main components:
1. Absorption- Become full involved in experience
2. Dissociation- Separate mentally from environment
3. Suggestibility- Responding to social cues. This is the stage when patient has tendency to follow instructions

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What is Non-Pharmacological Pain Management?

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What is Non-Pharmacological Pain Management?

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Pain management techniques that don't involve the use of medications to treat and manage pain are non-pharmacological techniques. There are many reason why a patient would choose this method for example, pain medications may interact with another treatment they are receiving, allergies, side effects tp medications, and some people may struggle with addiction and fear becoming addicted to pain medications. (Stanford Healthcare, 2017, September 12)

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Benefits of Non-Pharmacologic Pain Management Techniques

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Benefits of Non-Pharmacologic Pain Management Techniques

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-Minimal to no side effects.
-Development of good habits.
-Easy combine treatments.
-Fewer reactions with medications.

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Utilization and benefits of the management technique with critical care patients.

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•Define psychological intervention.
•Give importance of psychological intervention
.•Give examples of psychological interventions.
•Music therapy.

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• This  refers to management of pain without using medicine.
• Makes use of altering thoughts and focus concentration to ease and

manage pain.

• Non –pharmacological therapies are categorized into either sensory intervention and psychological interventions.

• Sensory interventions are characteristically patient specific and impede pain acuity and nociceptive contribution.

• Non –pharmacological pain management technique can contribute to the uncertain postoperative management of pain to assist nurses carry their routine chores and reduce the necessity of medications.

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• Includes the measures that that can ease discomfort intensity and improve one’s quality of life.

• Include practices like massage , cold and hot treatments , positioning , transcutaneous electrical nerve stimulation (TENS), progressive muscle relaxation and acupuncture.

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Massage As Non-Pharmacological pain Management Technique.

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Massage As Non-Pharmacological pain Management Technique.

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• What constitutes massage

• Importance distress cycle
• Importance of massage in improving blood floor
• How it is beneficial to cancer patients.
• Roles in reducing anxiety and depression.

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Guided Imagery As Non-pharmacological Pain Management technique.

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Guided Imagery As Non-pharmacological Pain Management technique.

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• In this management technique, experienced nurses helps a patient provoke a mindset or mental images especially in the absence of such stimuli.

• Range of management techniques from simple cognitive therapy and direct imagery -based recommendations through story telling and metaphor.

• Guided imagery progressively explored in various medical settings for example managing low back pain, post –operative pain , fibromyalgia and musculoskeletal-related pain.

• Images if vivid enough may provoke a psychosomatic response, via inflections at the level of the autonomic nervous system. Imagery effects may result into variations of the respiratory , nervous cardiovascular , immune and endocrine system.

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Music Therapy As a Non-pharmacological Pain Management Technique.

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Music Therapy As a Non-pharmacological Pain Management Technique.

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• Since primeval times, music has been used to reduce suffering and pain and enhance comfort.

• Playing music for patients after or during surgery can prove vital in reducing pain.

• people who listen to music register significantly lower pain scores, less tranquility and shorter examination times.

• Music during labor can reduce women perception of pain and their response to that pain. This is the same in premature infants and also group of individuals who suffer from chronic pain.

• Labor women who enjoy listening to slow soft type of music experience low distress ascribed to pain. Music acts as effective and helpful tool.

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•Decrease the feeling of weakness.

• Lowers stress and anxiety.

• Increase patient’s ability to control how they feel.

• Boost the functional capability and activity level.

• Reduce the dosage of pain-relieving drugs thereby reducing the evident harmful effects of those drugs.

• Lower focused pain levels and the pain behavior.

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-Helps with Pain Management.
-Decreases the risk of further complications.
-Helps to maintain range of motion.
-Improve blood circulation.
-Elevating extremities can help with preventing edema.
(Ahmed El Geziry, Yasser Toble, Fathi Al Kadhi, Muhammad Pervaiz
and Mohammad Al Nobani November 5th 2018)

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When position patients, sometimes we forget how the act of position can have an affect on their pain. There is also little education on proper ways to turn patients to ensure the least discomfort possible. While most of these tips seemed like common sense, a lot of them seem to be over looked or not thought of.
-Never Pull a patient by their arms to aid them in rolling on their side. Slide sheets should always be utilized if a patient struggles to turn on their own.
-Ensure you have all the supplies needed prior to laying the patient flat and starting to have them turn. Also when changing linens for a bed bound patient, ensure everything is set up before having them turn over to lessen the amount of times they will need to turn.
When assessing patient positions its important to ensure they look natural. If their head is elevated does it appear that they are crunching? Or properly elevated from the lower back up. Are their hips crooked or aligned. Simple adjustments in posture in bed can help to elevate pain especially in patient's back and neck.
Lastly its important to ensure that sheets or chucks aren't crumpled underneath patients. This can lead to pressure on certain areas of the skin which can become uncomfortable as well as lead to skin breakdown. Patients who aren't able to turn themselves should be turned properly every 2 hours. If patients stated they don't want to be turned that much their position should still be assess to ensure they are in a natural position and they aren't sliding down in the bed or off to one side.

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Benefits of Position Changes in Critical Care Units

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Benefits of Position Changes in Critical Care Units

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Periods of immobility can cause complications in many organ systems. Skin break down is one of the most common thought of complication. Prolonged pressure on skin can lead to break down and deep tissue wounds. Muscles break down which lead to weakness and lose of movement when patients become alert again. The saying goes you don't use it you lose it. This plays especially true for muscles. Bones also can become weak and brittle. Other organs that can be affected are lungs, cardiovascular and GI complications. Positioning Therapy has been used in preventing many of these complications. Patients should be turned from their backs to their sides regularly and turning patients every 2 hours has been added as a standard to routine care across most aspects of healthcare for total care patients. In a healthcare setting position changes can be used to elevate pain, prevent further complications are recovery, and treat complications the patient is diagnosed with. (Goldhill, D., Badacsonyi, A., Goldhill, A., & Waldmann, C. 2008, April 11).

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Positions for Improving Respiratory Function

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Positions for Improving Respiratory Function

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4 ways of improving respiration with positioning

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From the above illustrations, it is evident that research on non- pharmacological pain management techniques is important to ensure patients are offered with information that guarantee them the most effective alternatives for their pain treatment.

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Therapeutic- Most popular form of massage that promotes relaxation and improves blood circulation

Myotherapy- Treatment of soft tissue pain, injury, and dysfunction affecting movement and mobility

Reflexology- Concentration of pressure on reflex points such as the hands, feet, face, and ears that heal the body as a whole

Lymphatic- Relaxes the nervous system and assists the body's immune system

Sports- A variety of methods used to enhance performance and help overworked muscles to recover

Shiatsu- An oriental massage technique that improves the energy flow by working on certain points of the body

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- Improved circulation
- Reduced muscle tension
- Relaxation
- Increased mental alertness
- Reduced anxiety and depression
- Stimulation of the lymphatic  system
- Reduction of stress hormones
-Increased mobility and flexibility

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In 2019 a study was done on the effects of back massage on critical care patients in ICU. In the study, 30 patients received a 10-minute back massage for three consecutive days, and another 30 patients received the usual care. Results showed that the patients that received massage showed improved breathing and respiratory status, improved sleep quality, and a reduction in anxiety (Hsu, Guo, & Chang, 2019).

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Distraction techniques for pain management can be used with patients of all ages, but it is most commonly used with children in the hospital setting.

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Thank you

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Neonates/Infants: Sucking on a pacifier, skin to skin contact, rocking/holding, swaddling

Toddlers: Blowing bubbles, toys that light up and make noise, asking them questions (How old are you?, Do you have any brothers or sisters?), read them a book, sing songs

School-Age: Relaxation breathing, singing songs, squeezing balls, listening to music, watching videos, tell them a story, color a picture

Adolescents: Striking up conversations, watching videos, breathing techniques,  listening to music, play a game

Adults: Breathing techniques, watching TV, listening to music, puzzles, knitting, reading books, TENS therapy, play a game, having friends/family visit

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These are simple and easy pain management techniques that allow for a more comfortable environment for the critical care patient. It's the little things that count!

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-A room with soothing colors, visual stimuli such as artwork, and cleanliness
- Soothing/pleasant background sounds
-Exposure to nature, such as being able to look out a window, access to outdoor areas or gardens, and aquariums
- Adequate seating for visiting friends and family
-Reduction of environmental stressors such as noise, glare from lights, and poor air quality
-A quiet environment and limiting interventions at night to promote sleep
- Encouraging patients to bring personal items for their room, such as their favorite blanket, picture frames, sentimental items, etc.