13.1 Non-Pharmacologic Treatments & CAM
Key Takeaways
- Non-pharmacologic interventions are adjuncts to — not replacements for — analgesics; cold is preferred for acute injury (first 24-48 hours) and heat for chronic muscle and joint pain
- TENS works through the gate control theory, stimulating large A-beta fibers to close the pain gate in the dorsal horn of the spinal cord
- Complementary therapy is used together with conventional treatment; alternative therapy is used instead of it; integrative care coordinates both within conventional practice
- St. John's wort induces CYP3A4 and can reduce the effectiveness of warfarin, digoxin, oral contraceptives, and many other drugs; ginkgo, garlic, and ginseng increase bleeding risk with anticoagulants
- The nurse's role with CAM is nonjudgmental assessment, screening for interactions, documentation, and reporting red flags — especially when alternative therapy delays effective conventional treatment
Non-pharmacologic interventions are a core part of the medical-surgical nurse's toolkit and appear regularly on the MEDSURG-BC exam under Domain II (Planning, Implementation, and Evaluation). The unifying exam principle: these measures are adjuncts that work alongside pharmacologic therapy, not substitutes for it. Use them to reduce total analgesic dose, give the patient a sense of control, and treat symptoms that drugs handle poorly (anxiety, boredom, insomnia, muscle tension).
Physical and Cutaneous Modalities
Positioning
Body alignment is the cheapest and most underused intervention in the hospital. Key applications:
- Dyspnea: upright or high Fowler's position, or leaning forward on an overbed table (the tripod position), maximizes lung expansion and uses accessory muscles
- Pain: support painful limbs with pillows, maintain alignment after orthopedic surgery, and reposition at least every 2 hours in the immobile patient to prevent pressure injury
- Acute respiratory distress syndrome (ARDS): prone positioning for at least 12-16 consecutive hours per day improves oxygenation in moderate-to-severe ARDS
Heat and Cold
Choosing between heat and cold is a classic exam decision:
| Cold (cryotherapy) | Heat (thermotherapy) | |
|---|---|---|
| Best for | Acute injury, first 24-48 hours (sprains, strains, post-surgical swelling) | Chronic pain, muscle spasm, joint stiffness |
| Mechanism | Vasoconstriction — decreases blood flow, edema, inflammation, and nerve conduction | Vasodilation — increases blood flow, relaxes muscles, improves tissue elasticity |
| Application time | 15-20 minutes at a time, with a barrier between source and skin | 15-20 minutes at a time, with a barrier |
| Key caution | Never apply to ischemic tissue; watch for prolonged vasoconstriction | Never apply over acute bleeding, a new injury, or an active tumor site |
Both are contraindicated or used with extreme caution in peripheral vascular disease, diabetic neuropathy, and impaired sensation — the patient cannot report a burn or frostbite developing. Check the skin every 5-10 minutes during application.
Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous electrical nerve stimulation (TENS) delivers low-voltage electrical current through skin electrodes placed near the pain site. It is explained by the gate control theory of pain (Melzack and Wall): stimulation of large, fast A-beta sensory fibers closes the gating mechanism in the dorsal horn of the spinal cord, blocking transmission of slower pain signals from small C fibers. TENS is used for chronic low back pain, postoperative pain, and neuropathic pain. Do not place electrodes over the anterior neck (carotid sinus), over broken skin, over a pregnant uterus, or near a demand pacemaker.
Cognitive-Behavioral and Sensory Modalities
- Guided imagery: the patient uses all five senses to imagine a peaceful scene. Effective for procedural pain and anxiety; requires a patient able to concentrate, so it works poorly in acute severe pain or delirium.
- Distraction: redirects attention away from pain — conversation, video games during pediatric procedures, counting, or a task. Best for brief, mild-to-moderate pain; remember that a patient who can be distracted still has pain (distraction is not proof of faking).
- Relaxation breathing: slow, deep diaphragmatic breathing decreases sympathetic arousal and muscle tension. Teach a simple pattern such as inhaling through the nose for 4 counts and exhaling slowly through pursed lips for 6-8 counts.
- Music therapy: patient-selected music (not the nurse's preference) lowers anxiety, heart rate, and perceived pain; a common evidence-based choice during procedures and in palliative settings.
- Massage: reduces muscle tension and anxiety. Avoid massaging over areas of deep vein thrombosis, recent surgery, skin breakdown, infection, or a tumor site.
- Aromatherapy: inhaled essential oils — lavender for anxiety and sleep, ginger or peppermint for nausea. Evidence is modest; screen for allergies and asthma (scents can trigger bronchospasm), and never apply concentrated oils directly to skin.
Diversional Activity and Sleep Promotion
Hospitalized patients lose the structure of normal life, and diversional activity deficit is a real nursing diagnosis. Match the activity to the patient's interests, energy level, and physical ability: reading, crafts, visits from family or therapy animals, time out of the room, or simply scheduling the day around a meaningful event (a favorite show, a grandchild's video call). For long-stay patients, maintain day-night orientation with calendars, clocks, windows, and conversation about current events.
Sleep promotion matters because sleep deprivation slows healing, worsens pain perception, and contributes to delirium. Nursing actions:
- Cluster care to allow uninterrupted 90-minute sleep cycles; avoid waking the patient for nonessential tasks
- Dim lights, reduce monitor and hallway noise, and close the door at night
- Keep the patient's usual bedtime routine when possible (warm non-caffeinated drink, hygiene, preferred position)
- Limit daytime napping, caffeine, and late-evening fluids; promote daytime light exposure and activity
Sleep disruption is a major driver of intensive care unit (ICU) delirium, so quiet-time protocols are now standard quality measures.
A patient with chronic low back pain is using a TENS unit at home and asks the nurse how it works. Which explanation is most accurate?
Complementary, Alternative, and Integrative — Know the Difference
The exam tests this terminology precisely:
| Term | Definition | Example |
|---|---|---|
| Complementary therapy | Non-mainstream practice used together with conventional treatment | Guided imagery plus opioids for postoperative pain |
| Alternative therapy | Non-mainstream practice used instead of conventional treatment | Using herbal remedies alone instead of chemotherapy |
| Integrative (integrated) care | Coordinated combination of conventional and complementary approaches within the treatment plan | A cancer center offering acupuncture alongside chemotherapy |
Commonly Used CAM Modalities
- Acupuncture: insertion of fine needles at specific points along meridians; best evidence is for chronic pain, osteoarthritis, and chemotherapy-induced nausea. Caution with anticoagulated patients and those with severe neutropenia (infection risk).
- Chiropractic: spinal manipulation for musculoskeletal pain. Avoid manipulation with osteoporosis, spinal cord compression, bone metastases, or coagulopathy.
- Herbal/botanical therapy: the highest-risk category because products are pharmacologically active, loosely regulated, and often undisclosed. Details below.
- Mind-body practices: meditation, yoga, tai chi, biofeedback, hypnotherapy, and prayer/spiritual practices. Generally low risk and useful for stress, hypertension, and chronic pain.
The Nurse's Role When Patients Use CAM
- Assess nonjudgmentally. Ask directly and neutrally — 'Many people use herbs, vitamins, or other practices. What do you use?' Patients hide CAM use when they expect disapproval, and roughly half never volunteer it.
- Screen for interactions. Cross-check every supplement against the medication list, especially anticoagulants, antiplatelets, sedatives, and narrow-therapeutic-index drugs.
- Document and report. Record specific products, doses, and frequency in the medical record and communicate them to the provider and pharmacist.
- Educate without lecturing. Provide accurate risk information, encourage disclosure, and support safe complementary choices within the plan of care.
Safety Red Flags
- St. John's wort: a potent CYP3A4 inducer — lowers levels and effectiveness of warfarin, digoxin, oral contraceptives, cyclosporine, and many antidepressants. Combined with selective serotonin reuptake inhibitors (SSRIs), it can precipitate serotonin syndrome.
- Ginkgo, garlic, ginseng, ginger, feverfew: increase bleeding risk, especially with warfarin, heparin, aspirin, or clopidogrel; most should be stopped 1-2 weeks before surgery.
- Kava and comfrey: hepatotoxicity.
- Ephedra (ma huang): hypertension, arrhythmias, stroke — banned from U.S. supplements but still encountered.
- Licorice: hypokalemia and hypertension, dangerous with digoxin.
- The most dangerous red flag of all: a patient using alternative therapy to delay or refuse effective conventional treatment (curable cancer, insulin for type 1 diabetes, antibiotics for sepsis). Respond by exploring the patient's concerns and providing accurate information — never by endorsing the delay or by abandoning the patient.
During medication reconciliation, a patient taking warfarin after a mechanical heart valve replacement reports recently starting ginkgo biloba and garlic supplements for memory and heart health. What is the nurse's priority action?
A patient newly diagnosed with an early-stage, potentially curable breast cancer tells the nurse she plans to postpone surgery for six months to try an herbal regimen she found online. Which response by the nurse is most appropriate?