Comfort Promotion: Guided Imagery - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

OVERVIEW

The pain experience is a product of a person’s values, cultural expectations, emotions, and prior pain experiences. Pain is a subjective measure and varies among patients. Nondrug pain-control measures include massage, meditation, acupuncture, relaxation breathing, distraction, 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 pain medication required. Nondrug techniques help diminish the physical effects of pain, alter a patient’s awareness of pain, and give the patient a greater sense of control. Nondrug interventions are appropriate for patients who find them appealing or who 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 patients having an operative or invasive procedure report enough postoperative pain relief.⁵ In many situations, a combination of different pain relief techniques is needed to effectively relieve pain after a procedure. Giving a pain medicine before starting a nondrug strategy, such as guided imagery, may help the patient with comfort. Adding nondrug techniques may improve the outcomes when addressing the biopsychosocial model of pain, which considers biological, psychological, and social factors.⁵ The patient, setting, and procedure affect the exact components of effective pain relief.⁵ Because patients respond differently to nondrug techniques, finding the most effective method can take time. A combination of techniques is often beneficial.

Guided imagery is a creative sensory experience that reduces pain awareness 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

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Describe guided imagery therapy, including its purpose and rationale, to the patient and family.
• Describe what is expected of the patient during the procedure.
• Describe how the patient can maximize the benefits of therapy.
• Explain that some techniques require practice before a patient achieves results.
• Explain that pain 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.
• Give written teachings at the time of discharge.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Review the patient’s previous experience and knowledge of guided imagery for comfort promotion and understanding of the care to be provided.
3. Find out the patient’s pain level using a validated pain scale.
4. Watch the patient for the physiologic, behavioral, and emotional signs and symptoms of pain.
5. Look for the characteristics of pain and the underlying probable cause.
6. Review the patient’s understanding of pain and willingness to use nondrug pain-control measures.
7. 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 do the technique when the patient can concentrate (e.g., after voiding or waking from a nap).
3. Give a pain medication, if needed.
4. Rate the patient’s pain again after allowing enough time for the medication to work based on the 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. Give privacy.
6. Help the patient into a comfortable position for the technique, such as the semi-Fowler or Sims position.

PROCEDURE

1. Check the site of the patient’s pain or discomfort.
   1. Look for discoloration, swelling, and drainage.
   2. Feel for a change in temperature, altered sensation, painful area, areas that trigger pain, and areas that reduce pain.
   3. Check the range of motion of involved joints (if applicable).
2. Direct the patient through a guided imagery exercise.
   1. Teach 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. Teach the patient to imagine inhaled air traveling to the area of pain.

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

3. 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. Ask the patient to practice deep, slow, rhythmic breathing.

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

   4. Ask the patient to count to three, inhale, and open the eyes. Suggest moving about slowly at first.
4. Give the patient time to practice the exercise without interruption.

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

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 finds out 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. Watch the patient doing the pain-control measures.
3. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• 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.

UNEXPECTED OUTCOMES

• Patient is not able to concentrate on the guided imagery technique because of intense pain.

DOCUMENTATION

• Guided imagery pain-control technique(s) used
• Patient’s response to the guided imagery technique
• Changes in patient’s condition (e.g., blood pressure, pulse, respiration, skin condition; reports of dizziness)
• Patient’s unusual responses to techniques (e.g., uncontrolled or aggravated pain), if any
• Education
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• Because children have active imaginations, guided imagery is often a powerful pain-control adjuvant.
• Family members can help give pain relief. Family members give comfort by their presence and their conversation, as well as by holding and cuddling their child.

OLDER ADULT CONSIDERATIONS

• In many older adult patients, visual, hearing, cognitive, and motor difficulties may make the use of comfort promotion techniques, such as guided imagery, difficult and impair understanding of and participation in procedures. Making sure that a patient is wearing necessary assistive devices (e.g., glasses, hearing aids) may help make sure that a comfort promotion procedure is effective.

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
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
5. Small, C., Laycock, H. (2020). Acute postoperative pain management. The British Journal of Surgery, 107(2), e70-e80. doi:10.1002/bjs.11477

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

National Center for Complementary and Integrative Health. (2021). Relaxation techniques: What you need to know. Retrieved April 23, 2025, 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.

Clinical Review: Kerrie L. Chambers, MSN, RN, CNOR, CNS-CP(E)

Published: June 2025