The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [346]
Figure 9.13 TENS machine.
To date, there is limited scientific evidence for the effectiveness of TENS. Despite this, many healthcare professionals use TENS for a variety of chronic pain conditions and support the view that this is a useful form of analgesia (Walsh 1997). In contrast, TENS has not been found to improve the control of acute pain following surgery (McQuay et al. 1997).
Acupuncture
This involves placing fine solid needles into the skin at acupoints or trigger points (Figure 9.14). Although the exact mechanism of action is unknown, acupuncture is believed to work in part by stimulating release of the body’s own natural opioids. Although there is also limited scientific evidence for the pain-relieving effects of acupuncture, largely due to the poorly controlled studies (Ezzo et al. 2000), it is used widely and has an important role in pain management.
Figure 9.14 An increasing number of hospital pain clinics now offer acupuncture as a treatment for chronic pain.
© istockphoto.com/Håvard Sæbø.
Heat therapies
For decades superficial heat therapy has been used to relieve a variety of muscular and joint pains, including arthritis, back pain and period pain. There is much anecdotal and some scientific evidence to support the usefulness of heat as an adjunct to other pain treatments (Akin et al. 2001, Nadler et al. 2002).
Heat works by:
stimulating thermoreceptors in the skin and deeper tissues, thereby reducing the sensitivity to pain by closing the gating system in the spinal cord
reducing muscle spasm
reducing the viscosity of synovial fluid which alleviates painful stiffness during movement and increases joint range (Carr and Mann 2000).
In the home environment people use a variety of different methods for applying heat therapies, such as warm baths, hot water bottles, wheat-based heat packs and electrical heating pads. In the hospital setting, caution is required with this equipment as it does not reach health and safety standards (no even and regular temperature distribution) and there have been incidences of serious burns (Barillo et al. 2000). Carr and Mann (2000) note that heat therapy should not be used immediately following tissue damage as it will increase swelling. The Medicines and Healthcare Products Regulatory Agency (MHRA 2005) has documented evidence of burns caused by using heat patches or packs and therefore urges caution in their use and also recommends regular checking of skin throughout therapy.
Cold therapies
Cold therapies can also be used to stimulate nerves and modulate pain (Carr and Mann 2000). Cold may be particularly valuable following an acute bruising injury where it can help to reduce inflammation and limit further damage. Cold can be applied in the form of crushed ice or gel-filled cold packs which should be wrapped in a towel to protect the skin from an ice burn.
Postprocedural considerations
Education of patient
Opioids and driving
In 2004, an article in the journal Palliative Medicine offered guidance for professionals on the advice they should offer to patients who were taking opioids and driving. One of the contributors to the guidance was the medical advisor to the Driver and Vehicle Licensing Agency (DVLA) (Pease et al. 2004).
(a) A patient should not drive:
for 5 days after starting or changing the dose of the recommended opioid
if they feel sleepy
after drinking alcohol or taking strong opioids which have not been recommended by the doctor or non-medical prescriber, for example cannabis
on days when additional breakthrough medication of an opioid has been taken.
(b) Patients can restart driving:
after 5 days starting or changing the dose of the recommended opioid and if the patient does not feel sleepy. But the patient:
—should make the first trip short
—should drive on roads that the patient is familiar with
—should drive at a time when the traffic is not too busy