Comfort Promotion: Guided Imagery - CE/NCPD

OVERVIEW

The pain experience is a product of a person’s past 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#ref2">2,3} 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 have incomplete pain relief with drug therapy alone.^2,4

Certain diagnostic and therapeutic procedures commonly cause pain. Evidence suggests that fewer than half of surgical patients report adequate postoperative pain relief.⁵ 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.⁵ The patient, setting, and surgical procedure affect the exact components of effective pain relief.⁵ Because everyone responds differently to nonpharmacologic techniques, finding the methods that are most effective for a patient takes time. A combination of techniques is often beneficial.

Guided imagery is a creative sensory experience that reduces pain perception and minimizes the reaction to pain. It draws on internal experiences of memories, dreams, fantasies, and visions, and it explores the inner world of experience, protects the patient’s privacy, and fosters the imagination. The goal of imagery is to have the patient use one or more of the senses to create an image of a desired result. This image creates a positive psychophysiologic response. Focusing the imagination helps patients change their perceptions about their disease, treatment, and healing ability, which helps relieve pain, tension, and stress. Choosing images that the patient finds pleasant requires careful assessment by the health care team member. Otherwise, the health care team member could mistakenly describe images of objects or things that a patient fears or dislikes. For example, a scene of rolling waves at the seashore may be restful to one patient but desolate or frightening to another.³ To be most effective, guided imagery requires individual coaching of the patient. A major barrier to this therapy is that individual coaching is not always feasible. However, when the patient understands how to use guided imagery, the technique can produce positive results.¹

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain guided imagery therapy, including its purpose and rationale, to the patient and family.
• 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 guided imagery techniques and have the patient practice the techniques to use at home.
• Provide written instructions at time of discharge.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. 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. Assess the patient’s pain status using an organization-approved pain scale.
5. Assess the physiologic, behavioral, and emotional signs and symptoms of pain.
6. Assess the characteristics of pain and the underlying probable cause.
7. Assess the patient’s understanding of pain and willingness to use nonpharmacologic pain-control measures.
8. Identify the patient’s home activities that promote relaxation (e.g., jigsaw puzzles, crocheting, knitting, board games, music, imagery, relaxation recordings).

Preparation

1. Review the practitioner’s orders for pain-relief techniques.
2. Plan to perform the technique when the patient is able to concentrate (e.g., after voiding or waking from a nap).
3. Administer an analgesic, if needed.
4. Reassess the patient’s pain status, allowing for sufficient onset of action per medication, route, and the patient’s condition.
5. Prepare the environment.
   1. Control lighting in the room.
   2. Minimize distractions by visitors and health care team members.
   3. Maintain a comfortable room temperature (a sheet or light blanket prevents chilling).
   4. Provide privacy.
6. Assist the patient to a comfortable position for the technique, such as the semi-Fowler or Sims position.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. 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, areas that reduce pain)
   3. Range of motion of involved joints (if applicable)
5. Remove gloves and perform hand hygiene.
6. Direct the patient through a guided imagery exercise.
   1. Instruct the patient to imagine that inhaled air is a ball of healing energy.

      Rationale: Development of specific images helps remove the perception of pain.

   2. Instruct the patient to imagine inhaled air traveling to the area of pain.

      Rationale: The patient’s ability to concentrate decreases the perception of pain.

7. Alternatively, direct a guided imagery process.
   1. Ask the patient to imagine a pleasant place, such as the beach or mountains.
   2. Direct the patient to experience all sensory aspects of a restful place (e.g., for the beach, a warm breeze, warm sand between toes, warmth of sunshine, rhythmic sound of waves, smell of salt air, gulls gliding and swooping in air).
   3. Direct the patient to practice deep, slow, rhythmic breathing.

      Rationale: This method of breathing promotes muscle relaxation and overall relaxation.³

   4. Direct the patient to count to three, inhale, and open the eyes. Suggest moving about slowly at first.
8. Provide the patient with time to practice the exercise without interruption.

   Rationale: Guided imagery requires an intense level of concentration that takes time to achieve.

9. Remove PPE and perform hand hygiene.
10. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Assess the patient’s respirations, body position, facial expression, tone of voice, mood, mannerisms, and expressions of discomfort.

   Rationale: This assessment 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.

2. Observe the patient performing the pain-control measures.
3. Assess, treat, and reassess pain.

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

• Assessment findings before and after the procedure
• Procedure performed, and pain-control technique used
• Patient preparation
• Patient’s response to the procedure
• Further comfort needs provided, if any
• Alterations in patient’s 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

PEDIATRIC CONSIDERATIONS

• Because children have active imaginations, guided imagery is often a powerful pain-control adjuvant.
• Family members 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, vision, hearing, cognitive, and motor difficulties may make the effective use of procedures such as guided imagery difficult, but it should not be assumed that the procedure will not work.
• In many older adults, vision, hearing, cognitive, and motor difficulties may impair understanding of and participation in procedures. Making certain that a patient is wearing assistive devices, such as glasses and hearing aids, may facilitate the learning and understanding processes.

HOME CARE CONSIDERATIONS

• Encourage family members to collaborate to reduce noise and other stimuli in the home to promote the patient’s relaxation.
• Instruct the patient to practice guided imagery techniques at home.
• Discuss nonpharmacologic pain-management interventions with the patient’s family and friends.

REFERENCES

1. Felix, M.M.D. and others (2019). Relaxation therapy with guided imagery for postoperative pain management: An integrative review. Pain Management Nursing, 20(1), 3-9. doi:10.1016/j.pmn.2017.10.014 (Level I)
2. 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.
3. 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.
4. Rudnick, C., Sulaiman, E., Orden, J. (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)
5. Small, C., Laycock, H. (2020). Acute postoperative pain management. The British Journal of Surgery, 107(2), e70-e80. doi:10.1002/bjs.11477 (Level I)

ADDITIONAL READINGS

Álvarez-García, C., Yaban, Z.Ş. (2020). The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis. Complementary Therapies in Clinical Practice, 38, 101077. doi:10.1016/j.ctcp.2019.101077

American Nurses Association (ANA). (2018). Position statement: The ethical responsibility to manage pain and the suffering it causes. Retrieved March 9, 2023, from https://www.nursingworld.org/~495e9b/globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf

National Center for Complementary and Integrative Health. (2021). Relaxation techniques: What you need to know. Retrieved March 9, 2023, from https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills & techniques (10th ed.). St. Louis: Elsevier.

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