7.1 Nonpharmacologic Pain Interventions

Why this topic is on the CHPN

The Hospice and Palliative Credentialing Center (HPCC) Certified Hospice and Palliative Nurse (CHPN) examination is a 150-item, 3-hour computer-based test (135 scored plus 15 unscored pretest items). Domain 2, Patient Care — Pain Management, contributes 26 scored items. Task G on the detailed content outline names ice, positioning, palliative surgery, palliative radiation, and psychological therapy. Complementary modalities such as Reiki, hypnosis, and pet therapy are Task H and belong in the next section. This section stays on nurse-owned comfort measures, conceptual transcutaneous electrical nerve stimulation (TENS), and the interdisciplinary procedures that change the mechanical or oncologic generator of pain.

If a stem mentions scoring, the passing standard is a scaled score of 500 on a 200–800 range, not a raw 75 percent. Items use generic drug names.

Nonpharmacologic care is not a moral substitute for opioids. Severe cancer pain still needs an opioid. The classic CHPN trap is delaying morphine while you try ice on a patient with a lytic femoral metastasis. The opposite trap is stacking gadgets and appointments while the patient remains in crisis. Use these tools with opioids, not instead of them, unless the pain is mild, incident, or clearly positional.

Positioning as a first-line nursing intervention

Positioning is the highest-yield bedside intervention because it is immediate, inexpensive, and nurse-owned. Bone metastases, pleural disease, sacral pressure, abdominal distention, and plexopathy often have a positional component. Offload the painful site with pillows. Do not park the patient directly on a painful iliac wing, greater trochanter, or posterior rib lesion. Support a painful arm after brachial plexopathy so the weight of the limb is not hanging on the plexus. Keep the spine aligned and log-roll if instability or cord compression is in the differential.

Incident pain with transfers is expected around vertebral and hip lesions. Raise the bed, bring the commode to the patient, and give a breakthrough opioid 15–30 minutes before movement. High Fowler or a wedge can ease orthopnea-associated chest-wall pain. Elevate a lymphedematous limb; a dependent arm aches and throbs.

Do not force range-of-motion through an unstable joint or a bone with an impending pathologic fracture. Immobilize, notify the provider, and discuss orthopedic evaluation. Keep-them-moving-at-all-costs is restorative-care rhetoric, not a hospice pain strategy when the femur is about to fail.

Ice, heat, and nursing massage

Ice (cryotherapy) helps localized inflammation, some procedure sites, and selected musculoskeletal flares. Use a cloth barrier, limit applications to about 15–20 minutes, and reassess skin. Do not ice an ischemic limb, insensate skin (risk of unnoticed tissue injury), or moist desquamation from radiation.

Heat helps muscle spasm, stiffness, and some cramping. Cover the pack and check temperature. Avoid heat over insensate skin, active bleeding, acute trauma, and poor perfusion. Heat over a bulky tumor is a comfort measure if the patient wants it and skin is intact — it is not antineoplastic therapy.

Nursing massage in this chapter means light comfort touch: a back rub, hand or foot massage, lotion on dry limbs, and presence. It is not deep-tissue work over bone metastases, not aggressive abdominal massage in bowel obstruction, and not a licensed massage-therapy visit (that is Task H). Light touch can reduce guarding and anxiety. Deep pressure over a lytic lesion can fracture bone or cause hematoma, especially with thrombocytopenia or anticoagulation.

TENS, conceptually

TENS uses cutaneous electrodes and a gate-control idea: non-painful afferent input can inhibit nociceptive traffic in the dorsal horn. It is most plausible for localized neuropathic or musculoskeletal pain (post-herpetic neuralgia, an incision, focal chest-wall pain). Cancer-pain evidence is mixed. It is an adjunct, never a pain-crisis plan.

Do not place electrodes over a pacemaker or implanted defibrillator, over the carotid sinus, over broken skin or active radiation dermatitis, or over a pregnant uterus. If home hospice does not stock a unit, do not delay the opioid while equipment is ordered.

Palliative radiation for bone metastases and cord compression

External-beam palliative radiation is disease-directed comfort care, not cure, for painful bone metastases and malignant spinal cord compression. For uncomplicated painful bone mets, a single 8 Gy fraction produces pain relief comparable to longer courses (20 Gy in 5 fractions, 24 Gy in 6, or 30 Gy in 10) with far less travel. Multi-fraction regimens have a modestly lower retreatment rate but require repeated trips that can erase benefit for a hospice patient.

Malignant cord compression is an emergency: start dexamethasone, keep the spine aligned, and arrange urgent radiation. Selected patients with good performance status, limited compression, and a goal of preserving ambulation may also undergo surgical decompression plus radiation. The aim is function and pain, not survival for its own sake.

When radiation is appropriate on hospice

Three filters decide most CHPN stems:

1. Goals. The patient wants less pain or preserved walking, not another month of disease-modifying therapy they already declined.
2. Burden. One trip for an 8 Gy fraction may be acceptable. Ten daily visits, nothing-by-mouth for simulation, and a day on a hard table may not.
3. Time-to-benefit. Bone-pain relief often starts within days to two weeks. A patient with hours-to-days prognosis will not live to enjoy it. Optimize positioning and opioids instead.

Advocate for single-fraction treatment when radiation is chosen. Do not stop the opioid the day of simulation. Hospice programs differ in whether they contract radiation as a related service. The exam tests goals, travel burden, and not abandoning analgesia — not a capitation spreadsheet.

Palliative surgery for obstruction and fracture

Surgery is palliative when the goal is comfort or function. Classic indications:

• Impending or completed pathologic fracture — orthopedic stabilization to stop movement-related agony
• Malignant bowel obstruction — endoscopic stent, diverting ostomy, or venting gastrostomy when the lumen cannot be restored
• Selected cord compression — decompression plus radiation in patients who still have a walking or pain-control goal that surgery can meet

A venting gastrostomy decompresses intractable vomiting; it is not a feeding tube in this context. Surgery is not first-line for opioid-induced constipation without mechanical obstruction. Match the procedure to the pain generator and to goals. If the goal is to remain home and avoid the operating room, medical management of obstruction (opioids, anticholinergics, octreotide, venting if wanted) is the plan.

Psychological therapy, relaxation, and activity pacing

Total pain includes nociception plus fear, depression, meaning, and family distress. Cognitive behavioral therapy (CBT) targets catastrophizing and fear-avoidance: the belief that any movement will snap the bone becomes a deconditioning and incident-pain cycle. Activity pacing splits tasks, schedules rest, and pairs movement with premedication rather than pushing until collapse.

Relaxation, guided imagery, and paced breathing reduce muscle guarding and the affective load of pain. A nurse can teach box breathing at the bedside. These techniques help incident pain, anxiety-amplified pain, and insomnia. They do not replace titration for severe nociceptive cancer pain.

Matching modality to pain type

Use the table as an exam map. If the stem names a generator — lytic hip, cord compression, obstruction, fear of movement — pick the matching tool and keep the opioid on board for severe pain.

Exam pattern: a family asks for radiation because they heard it shrinks tumors. Translate to goals: if the aim is comfort and the patient can travel once, single-fraction bone radiation is reasonable. If the patient is actively dying, the kind answer is more opioid and better positioning, not a bunker appointment.