Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation 
Kate Bell 
School of Nursing and Midwifery 

Important Copyright Notice for 
Western Sydney University Students 
The material in this presentation has been made available to you by and on 
behalf of Western Sydney University for your personal use and study only. 
The material contained in this recorded lecture is subject to copyright 
You may not make any further copies and share the recorded lectures in whole 
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Learning outcomes 
By the end of this slide show the student will be 
able to 
• describe non‐pharmacological strategies to 
provide comfort and relieve pain in the 
perioperative period 
• discuss the safe and effective use of 
pharmacological agents to support people 
who are experiencing pain in the 
perioperative period 

Non pharmacological strategies to 
provide pain relief and comfort‐that‐worx‐american‐ 
acupuncture massage 

Knowledge and information 
 providing clear information about the individuals 
condition and plan of care will help to alleviate anxiety, 
fear and pain 
 distracts the person 
 lessens the effects of stress and pain 
 increases pain tolerance 
 increases the effectiveness of analgesia 
 increases perception of pain control 
• Strategies include 
• diaphragmatic breathing 
• progressive muscle relaxation 
• guided imagery (creative visualisation) 
• meditation (Critchlow, 2014) 

• redirects person’s attention away from the pain 
• activity may stimulate pleasure or laughter 
• 20 minutes of laughter sƟmulates endorphin release → 
• provides a visual representation of brain activity measured 
• person can learn to recognise stress cues and responses 
and replace them with relaxation 
• a trance state in which the mind becomes extremely 
(Critchlow, 2014) 

• Exercises to improve strength and flexibility 
• Therapeutic massage 
• Therapeutic ultrasound 
• Reduces impact/unpleasantness of pain 
Heat and cold therapy 
• Involves the stimulation of specific points on the body 
to enhance the flow of vital energy (Chi) along pathways 
called medians to provide relaxation and analgesia 
(Critchlow, 2014) 

Transcutaneous electrical nerve stimulation (TENS) 
• low voltage transmitter connected by wires to electrodes 
placed on the person’s body 
• believed to stimulate nerve fibres activating inhibitory 
networks in the dorsal horn which reduces nociception 
Hyperbaric oxygen therapy 
• the intermittent inhalation of 100% oxygen in a hyperbaric 
chamber at a pressure higher than 760mmHg 
• successful in reducing neuropathic pain 
(Critchlow, 2014) 

Narcotic analgesics 
Narcotic analgesics were all originally derived from crude extracts 
from the opium poppy‐poppies.html 9 

Narcotic analgesics 
• the preferred treatment for moderate to severe pain 
• originally derived from crude extracts from the opium 
• Opiates – compounds derived directly from opium 
(dried exudates of the opium poppy) 
• Opiods – compounds prepared synthetically 
(Bullock & Manias, 2014) 
Narcotic analgesics 
• alter the affective response to pain 
• alter the perception of pain and the emotional 
response to pain 
• increase both the pain threshold and pain 
( Mims online) 
Mechanism of action 
• All narcotic analgesics are opioid agonists – they 
stimulate opioid receptors in the CNS 
• four opioid receptors 
– Mu receptors in the dorsal horn of the spinal cord and 
– Delta receptors found in the limbic system 
– Kappa receptors found in the hypothalamus 
– Epsilon receptors found in the hippocampus and amygdala 
• the mu receptor are the most significant in 
modulating pain 
• the stimulation of Kappa receptors also produces an 
analgesic effect (Bullock & Manias, 2014 ) 

At cellular level, the opiod receptors are G‐protein coupled receptors 
linked to both the membrane bound enzyme adenlyate cyclase and 
potassium channels in the nerve membrane 
• Adenylate cyclase controls the levels of second messenger cyclic 
adenosine monophosphate (CAMP) 
• Opioid receptor activation 
– inhibits adenylate cyclase → reduced intracellular CAMP levels → 
– the movement of potassium from intracellular spaces (within the cell) 
to the extracellular spaces (outside the cell) resulting in nerve 
membrane hyperpolarisation 
– → inhibiƟon of the acƟon potenƟal (impulse) thus inhibiƟng the 
transmission of information about pain 
• → decreased neuronal excitability and reduced nocicepƟve (pain) 
transmission from the dorsal horn to the thalamus – inhibition of 
the spinothalmic (ascending) pathway 
• the descending (efferent) pathway from the brain is activated and 
exerts an inhibitory control of the dorsal horn 
(Bullock & Manias, 2014) 
• As some opioid receptors are in the limbic 
system of the brain, euphoria can be produced 
• This feeling of wellbeing can be of benefit as it 
pushes the pain away and assists the person 
cope with the experience 
(Bullock & Manias, 2014) 
Adverse effects of narcotics 
(Bullock & Manias, 2014 ) 

 when used therapeutically, physical dependence is rarely a problem 
 risk of addiction is high when the drugs are used recreationally 
 severe nausea and vomiting as narcotics stimulate the chemoreceptor 
trigger zone (CTZ) 
 increase in segmentation and a decrease in peristaltic movements (opiod 
receptors in the GIT) 
→ increased water absorpƟon and drier bowel contents → consƟpaƟon 
 stomach, intestinal and pancreatic secretions inhibition 
 spasm in the biliary tract due to contraction of bleary smooth muscle 
 contraction of the smooth muscle of the urinary tract can cause urinary 
colic and urinary retention 
(Bullock & Manias, 2014) 
 depression of respiratory centre of CNS (medulla) leads to 
 decreased respiratory rate 
 hypotension 
 suppression of cough reflex 
 sedation 
 reduction of the responsiveness of the respiratory centres to carbon 
 miosis 
 histamine release 
→ peripheral vasodilataƟon 
→ flushing of face and neck 
also → sweaƟng, urƟcaria and puriƟs 
(Bullock & Manias, 2014) 
Adverse effects of narcotic analgesics 
(Bullock & Manias, 2014 ) 

The narcotic drugs 
• a potent narcotic analgesic 
• used for the treatment of severe pain 
• the first narcotic agent to be introduced as a single analgesic agent 
• chemically closely related to morphine ‐ less potent 
• rarely used alone as an analgesic 
• codeine potentiates the analgesic activity of aspirin, paracetamol 
and ibuprofen, and is often combined with them 
• often used as an antidiarrhoel or antitussive 
• dihydrocodiene 
• formulated with aspirin as an over‐the‐counter analgesic 
• available as a cough suppressant 
• analgesic activity not as strong as morphine 
• may be used in labour as it does not suppress uterine contractions 
but it may depress foetal respiratory rate 
• routine and sustained use of pethidine is no longer recommended 
• used in the control of heroin and morphine addiction 
• effects are similar to other narcotics but it produces less withdrawal 
• easier to wean people off methadone than other narcotic agents 
• almost never produces euphoria, tolerance or addiction 
• effective for all pain except neurogenic pain 
• reduced incidence of respiratory depression 
• recommended for moderate to severe pain 
• slow release tablets have a duration of action of 
12 hours (not recommended for acute pain) 
• has a short duration of action 
• effective analgesia after short medical or surgical 
procedures, useful in chronic or cancer pain 
sufentanil, remifentanil and alfentanil 
• shorter acting derivatives of fentanly 
• used for anaesthesia during surgical procedures 

• more potent than morphine 
• dose must be titrated carefully 
• high risk of abuse 
• a very potent narcotic 
• therapeutic effect lasts six to eight hours 
• marked adverse effects of dizziness and nausea 
• valuable in the treatment of terminal cancer pain 
amd opioid addiction 
(Bullock & Manias, 2014 ) 
Strategy for the pharmacological 
management of pain using the 
WHO analgesic ladder 
(Plenderleith, 2015) 
An adjuvant is a substance 
that enhances the action 
of the main drug 
Narcotic toxicity 
clinical manifestations 
• pinpoint pupils 
• reduced levels of consciousness – coma 
• respiratory depression 
• Hallucinations 
• confusion 
• agitation 
• tremors 
(Bullock & Manias, 2014 ) 

Narcotic antagonist 
• has a very strong affinity to opioid receptors 
• used to reverse the action of opioids in the case 
of an overdose 
• recovery is rapid 
• has a short half‐life ‐ about one hour – much 
shorter than the narcotic agonists 
• people need to be closely monitored 
(Bullock & Manias, 2014) 
Narcotic analgesic administration – 
nursing responsibilities 
Prior to the administration of a narcotic drug the nurse should 
• assess the characteristics of the person’s pain 
• assess for any history of previous experiences with narcotic 
analgesics ‐ effectiveness, allergic reactions and adverse effects 
• ask the person about other strategies they may have found 
effective in providing pain relief 
• review the person’s medical history and ask the person if they have 
any respiratory conditions for example asthma or sleep apnoea 
• have a knowledge and understanding of the mechanism of action, 
desired and undesired effects and appropriate doses of the drug 
• measure and record vital signs 
Nursing responsibilities continued 
Legal responsibilities 
• witness must accompany the nurse administering the drug 
through all steps of administration 
• Validate the order 
• 3drug checks 
• 2 patient checks, allergy and previous adverse reactions 
• nurse and witness to record patient’s name, amount of 
drug given and/or discarded, prescriber’s name, printed 
names and signatures of the administering nurse and 
witness in the S8 register 
• The administering nurse and witness must complete and 
sign the medication chart. 
Nursing responsibilities continued 
After the administration of a narcotic drug the nurse should 
• monitor vital signs and compare with baseline measurements, monitor level of 
consciousness, papillary response 
• ensure the person’s safety – person to remain in bed, use of bed rails 
• complete an assessment of the person’s pain 
• encourage deep breathing and coughing 
• monitor for signs of CNS toxicity, e.g. pinpoint pupils, respiratory depression, 
restlessness, tremors, twitching, changes in level of awareness/consciousness, 
agitation, confusion, hallucinations 
• keep a narcotic antagonist – such as naloxone, immediately available to treat 
respiratory depression 
• monitor nausea and vomiting 
• ensure the person has been ordered an anti‐emetic medication and that it is 
administered as ordered 
• monitor bowel function 
• monitor urinary function 
Non‐steroidal anti‐inflammatory 
drugs (NSAIDs) 
Mechanism of action 
Most NSAIDs have an anti‐inflammatory, antipyretic and analgesic 
Mechanism of action 
• Inhibit the synthesis of prostaglandins by inhibiting the activity of 
the COX (cyclo‐oxygenase) enzyme 
• Prostaglandins – inflammatory mediators 
– augment the actions of histamine and other compounds 
– → vasodilataƟon and ↑ vascular permeability of fluids → swelling, 
oedema (inflammatory responses) 
– act directly on peripheral pain pathways to enhance the transmission 
of pain 
• COX is a key enzyme involved in the synthesis of prostaglandins 
– there are three variants of COX enzyme – COX 1, COX 2, COX 3 
– COX enzymes are also involved in the biosyntheses of thromboxine A 
(TXA)which facilitates platelet aggregation 
• NSAIDs relieve the symptoms of inflammation – they 
do not cure the causes of that inflammation 
• prostaglandins are found in the hypothalamus ‐ 
responsible for raising body temperature in some 
• most COX inhibitors have an antipyretic effect 
• NSAIDs are also believed to decrease the inflammatory 
response by reducing the accumulation of neutrophils 
(immunosuppressant cells) at the proinflammatory site 
(Bullock & Manias, 2014 ) 
Adverse effects 
(Bullock & Manias, 2014 ) 
This image highlights 
some desired and 
undesired effects 
of NSAIDs 
Non‐selective COX inhibitors 
• NSAIDs increase hydrochloric acid and pepsin secretion in 
the stomach and a decrease in mucus (protective) secretion 
leading to an increased risk of peptic ulcers and 
• fluid and sodium retenƟon which may → hypertension and 
consequent renal failure over time, caused by 
– Inhibition of the prostaglandin control over renal flow rate 
leading to reduced glomerular filtration rate 
• prolonged bleeding time, caused by inhibition of platelet 
• relaxation of uterine smooth muscle may prolong labour 
and alleviate dysmenorrhoea 
Selective COX 2 inhibitors 
• negligible effects on gastric and mucus secretions 
• mild GIT disorders such as dyspepsia 
• do not inhibit platelet aggregation 
• ↑ risk of cardiovascular complicaƟons and myocardial infarcƟon 
• Concurrent pharmacological therapy must be assessed for risks of 
drug interactions 
• Review of pre‐existing conditions is essential for the assessment of 
risks associated with NSAID use 
(Bullock & Manias, 2014 ) 
Effects of NSAIDS 
(Bullock & Manias, 2014 ) 
Classification of NSAIDS 
• available in numerous formulations ‐ tablets, enteric coated tablets, 
dissolving tablets, capsules, syrups (paediatric), chewable gums, 
lozenges, liquid for injection, suppositories, as an ingredient in 
liniments, gels, sprays and creams for topical administration 
• Aspirin – acetylsalyciticc acid 
• Anti‐inflammatory, antipyretic, anti‐platelet and analgesic actions 
Methyl salicylate (oil of wintergreen) 
• A common ingredient of liniments used in muscle and joint injuries 
Copper salicylate 
• Incorporated in creams for the topical relief of arthritic pain 
propionic acid derivatives 
• Ibuprofen, ketoprofen, flurbiprofen, tiaprenic acid, naproxen 
indoleacatic acids 
• Indomethacin, ketorolac trometamol, sulindac 
• ketorolac trometamol can be as effective as morphine or pethidine in the control 
of postoperative pain or other prostaglandin induced pain when administered via 
• diclofenic ‐ often used for pain associated with muscle and connective tissue 
injuries, rheumatoid arthritis and osteoarthritis 
• also used as an adjunct to other therapies in painful inflammatory conditions 
• mefenamic acid ‐ used to treat dysmenorrhoea, pain resulting from tooth 
extraction and toothache 
• piroxicam, tenoxicam 
• these medications have a very long half‐life so only require daily administration 
• meloxicam – selective COX 2 inhibitor 
• Used in the treatment of osteoarthritis 
(Bullock & Manias, 2014 ) 
• an analgesic agent (not an NSAID) 
• no significant anti‐inflammatory antiplatelet activity 
• does have an antipyretic action 
• safe and effective in treating mild to moderate pain 
associated with rheumatoid arthritis and osteoarthritis 
• the preferred analgesia in the symptomatic treatment of 
children with viral infections 
• an ingredient in many over‐the‐counter cold and flue 
• aspirin and codeine are often combined with 
paracetamolfor the synergistic analgesic effect 
(Bullock & Manias, 2014 ) 
Acupuncture [image] (2014, May 12). Retrieved 12 May, 2014 from‐that‐worx‐american‐alternative‐health‐care‐ingenuity/ 
Aspirin [image] (2014, May 12). Retrieved 12 May, 2014 from 
Bullock, S. & Manias, E. (2014). Fundamentals of Pharmacology (7th ed.). Frenchs Forest, NSW: Pearson Australia. 
Critchlow, T. (2014). Nursing care of people experiencing pain. In P. LeMone, K. M. Burke, T. Levett‐Jones, T. Dwyer, l. 
Moxham, k. Reid‐Searl, D. Raymond, Medical‐surgical nursing: Critical thinking for person‐centred care (2nd 
Australian ed. pp. 177 ‐ 202). Frenchs Forest: Pearson, Australia. 
Meditation [image] (2014, May 13). Retrieved 13 May, 2014 from‐you‐can‐use‐both‐ 
Morphine [image] (2014, May 13]). Retrieved 13 May, 2014 
Music [image] (2014, May 13). Retrieved 13 May, 2014 from 
References continued 
NCW Health (2015). Medication handling in Public Health Facilities. Retrieved from 
Panadol [image] (2014, May 13). Retrieved 13 May, 2014 from 
Plenderleith, M. (2015). Pain. In J. Craft, C. Gordon, S.Huether, K. McCance, V. Brashers, & N. Rote 
(Eds). Understanding pathophysiology (pp. 141– 154). Sydney, Australia: Elsevier Australia. 
Poppies [image] (2014, May12). Retrieved 12 May, 2014 from‐poppies.htmlA 
Therapeutic massage [image] (2014, May 12). Retrieved 12 May, 2014 from‐massage‐bodywork/ 
Transcutaneous Electrical Nerve Stimulation (TENS) [image] (2014, May 13). Retrieved 13 May, 2014 

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