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Apr.29.2021

Comfort Promotion: Distraction (Ambulatory) - CE

OVERVIEW

The pain experience is a product of a person’s pain experiences, values, cultural expectations, and emotions. Pain is a subjective measurement and varies among patients. Nonpharmacologic pain-control measures include massage, meditation, acupuncture, relaxation breathing, guided imagery, and heat and cold application.undefined#ref3">3,4 Such measures should be used in conjunction with pharmacologic interventions and can reduce the amount of analgesic medication required. Nonpharmacologic techniques help diminish the physical effects of pain, alter a patient’s perception of pain, and provide the patient with a greater sense of control. Nonpharmacologic interventions are appropriate for patients who find them appealing or who have incomplete pain relief with drug therapy alone.3,5

Certain diagnostic and therapeutic procedures commonly cause pain. Evidence suggests that fewer than half of surgical patients report adequate postoperative pain relief.2 Many times, multimodal regimens for postoperative pain relief are required. The administration of an analgesic before implementing a nonpharmacologic strategy, such as guided imagery, may help the patient gain a level of comfort. Adding nonpharmacologic interventions may enhance the effects consistent with the biopsychosocial model of pain.2 The patient, setting, and surgical procedure affect the exact components of effective pain relief.2 Because patients respond differently to nonpharmacologic techniques, finding the most effective methods can take time. In most cases, a combination of techniques is beneficial.

By introducing meaningful stimuli that can help refocus attention, the health care team member distracts the patient’s attention from the sensation of pain. Distraction strategies include changing activities, listening to music, reading, focusing on another person, walking, napping, writing, concentrating on a mental and physical activity simultaneously (playing a musical instrument), learning something new (completing a crossword puzzle), and listening to or watching a comedy program. Therapeutic communication with the health care team member is another example of distraction. When the distraction is removed, the patient may experience a heightened awareness of pain.4

Distraction appears to be most effective for acute episodes of mild to moderate pain lasting from minutes to an hour, such as during bone marrow biopsy, lumbar puncture, burn debridement, venipuncture, and discomfort experienced during childbirth. The use of music has been shown to optimize pain control and promote healing after surgery by reducing anxiety and stress.3

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain distraction therapy, including its purpose and rationale to the patient.
  • Explain what is expected of the patient during the procedure.
  • Explain how the patient can maximize the benefits of therapy.
  • Explain that some techniques require practice before a patient achieves results.
  • Explain that analgesic medication may be required to further reduce pain and to augment comfort-promotion measures.
  • Teach the patient to rest between periods of activity because fatigue increases the perception of pain.
  • Discuss distraction techniques and have the patient practice them to use at home.
  • Provide written instructions before patient leaves.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
  6. Determine the patient’s pain status using an organization-approved pain scale.
  7. Observe the patient for physiologic, behavioral, and emotional signs and symptoms of pain.
  8. Evaluate the characteristics of pain and the underlying probable cause.
  9. Evaluate the patient’s understanding of pain and willingness to use nonpharmacologic pain-control measures.
  10. Identify the patient’s home activities that promote relaxation (e.g., jigsaw puzzles, crocheting or knitting, board games, music, imagery, relaxation recordings).
  11. Plan to perform the technique when the patient is able to concentrate (e.g., after voiding).
  12. Prepare the environment.
    1. Control lighting in the room.
    2. Minimize distractions by health care team members.
    3. Maintain a comfortable room temperature (a sheet or light blanket prevents chilling).
    4. Provide privacy.
  13. Assist the patient to a comfortable position for the technique, such as the semi-Fowler or Sims position.
  14. Examine the site of the patient’s pain or discomfort.
    1. Inspection (discoloration, swelling, drainage)
    2. Palpation (change in temperature, area of altered sensation, painful area, areas that trigger pain, and areas that reduce pain)
    3. Range of motion of involved joints (if applicable)
  15. Review the practitioner’s orders for pain relief.
  16. Administer an analgesic, if needed.
  17. Reassess the patient’s pain status, allowing for sufficient onset of action per medication, route, and the patient’s condition.
  18. Direct the patient’s attention away from the pain with distraction techniques.
    Rationale: Redirection of attention alters emotional or cognitive aspects of pain.
  19. Ask the patient to close his or her eyes or to focus on a single object in the room.
    Rationale: These actions direct attention inward and protect the patient from external distraction.
  20. Instruct the patient to concentrate on slow, rhythmic breathing. Guide breathing or instruct the patient to control and concentrate on breathing by thinking “in, one, two; out, one, two.”
    Rationale: Rhythmic breathing promotes relaxation by concentrating on kinesthetic action, thus reducing the patient’s ability to concentrate on pain.
  21. Continue distraction using the chosen activity.
    1. Use music of the patient’s choosing. Emphasize listening to the rhythm and adjust the volume as pain increases or decreases.
      Rationale: Focusing on an activity diverts attention from painful sensation.
    2. Direct the patient to give a detailed account of an event or a story.
      Rationale: Stressing details of an event enhances distraction from the pain stimulus.
    3. Engage the patient in conversation.
  22. Evaluate the patient’s respirations, body position, facial expression, tone of voice, mood, mannerisms, and expressions of discomfort.
    Rationale: This evaluation determines the effectiveness of the procedure, the level of relaxation, and the degree of pain relief. It also indicates which procedures were the most effective.
  23. Observe the patient performing the pain-control measures.
  24. Assess, treat, and reassess pain.
  25. Remove PPE and perform hand hygiene.
  26. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient demonstrates and describes pain-control measures.
  • Patient is relaxed and comfortable after the procedure as evidenced by slow, deep respirations; calm facial expressions and vocal tone; and relaxed muscles and posture.
  • Patient states that pain is reduced.
  • Patient requires less pain medication.

UNEXPECTED OUTCOMES

  • Patient is not able to concentrate on technique because of intense pain.
  • Patient states that pain intensity is unchanged or escalating.
  • Patient demonstrates nonverbal behavior indicating pain.

DOCUMENTATION

  • Evaluation findings before and after the procedure
  • Procedure performed, and pain-control technique used
  • Patient preparation
  • Patient response to the procedure
  • Further comfort needs provided, if any
  • Alterations in patient condition (e.g., changes in blood pressure, pulse, respiration, skin condition; reports of dizziness)
  • Unusual responses to techniques (e.g., uncontrolled or aggravated pain)
  • Education
  • Unexpected outcomes and related interventions
  • Evaluation findings communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

  • Using music or an electronic device as a distraction for pediatric patients has proven to alleviate stress and pain.5
  • Distraction strategies should be targeted to the pediatric patient’s developmental level (e.g., using a pacifier for an infant or toddler, listening to a recording of a favorite story for a preschooler, listening to music on headphones for an adolescent). Play therapists are good resources for appropriate distraction techniques.
  • The use of a distraction technique during pediatric immunizations can be highly effective in reducing the pain associated with injections.1
  • Family members can help provide pain relief. Family members provide comfort by their presence and their conversation, as well as by holding and cuddling their child.

OLDER ADULT CONSIDERATIONS

  • In many older adults, visual, hearing, cognitive, and motor difficulties may make the use of procedures such as distraction difficult, but not necessarily ineffective.
  • In many older adults, visual, hearing, cognitive, and motor difficulties may impair understanding of and participation in procedures. Ensuring that a patient is wearing his or her assistive devices, such as glasses and hearing aids, increases the likelihood that relaxation therapy will be successful.
  • Music can be highly effective in reducing pain, promoting healing, and decreasing agitation in dementia patients.

REFERENCES

  1. Birnie, K.A. and others. (2018). Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database of Systematic Reviews, 10. Art. No.: CD005179. doi:10.1002/14651858.CD005179.pub4 (Level I)
  2. Chou, R. and others. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain, 17(2), 131-157. doi:10.1016/j.jpain.2015.12.008 (Level VII)
  3. Miller-Saultz, D. (2020). Chapter 8: Pain. In M.M. Harding and others (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems (11th ed., pp. 102-126). St. Louis: Elsevier.
  4. Rateau, M. (2020). Chapter 6: Stress management. In M.M. Harding and others (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems (11th ed., pp. 76-87). St. Louis: Elsevier.
  5. Rudnick, C., Emaan, S., Jillian, O. (2018). Effect of virtual reality headset for pediatric fear and pain distraction during immunization. Pain Management, 8(3), 175-179. doi:10.2217/pmt-2017-0040 (Level VI)

ADDITIONAL READINGS

American Nurses Association (ANA). (2018). Position statement: The ethical responsibility to manage pain and the suffering it causes. Retrieved February 26, 2021, from https://www.nursingworld.org/~495e9b/globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf

Joint Commission, The. (2018). R3 report issue 14: Pain assessment and management standards for ambulatory care. Retrieved February 26, 2021, from https://www.jointcommission.org/standards/r3-report/r3-report-issue-14-pain-assessment-and-management-standards-for-ambulatory-care/

National Center for Complementary and Integrative Health. (2016). Relaxation techniques. Retrieved February 26, 2021, from https://nccih.nih.gov/sites/nccam.nih.gov/files/Relaxation_Techniques_05-31-2016.pdf

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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