Skill 10-2

Giving a Back Massage

Massage has many benefits, including general relaxation; improved circulation; decreased symptom distress and anxiety; improved sleep quality; and provision of a means of communicating with the patient through the use of touch (Ahmadidarrehsima et al., 2018; Ayik & Özden, 2018; Hsu et al., 2020; Jagan et al., 2020; Kudo & Sasaki, 2020; Taylor et al., 2023; Westman & Blaisdell, 2016). A back massage can be incorporated into the patient's bath, as part of care before bedtime, or at any time to promote increased patient comfort.

An effective back massage should take 4 to 6 minutes to complete. A lotion is usually applied; warm it before applying to the back. Be aware of the patient's health issues when considering giving a back massage. A back massage may not be appropriate for patients with burns or healing wounds, deep vein thrombosis, fractures, severe osteoporosis, or severe thrombocytopenia (MFMER, 2021). Position the patient on their abdomen or, if this is contraindicated, on their side for a back massage.

Delegation Considerations

Providing a back massage may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Pain assessment tool and pain scale
Lotion or oil, to which the patient has no allergy or aversion (Westman & Blaisdell, 2016)
Bath blanket
Towel
Nonsterile gloves, if indicated
Additional PPE, as indicated

Assessment

Review the patient's health record and plan of care for information about the patient's status and contraindications to back massage. Ask the patient about any conditions that might require modifications or that might contraindicate a massage. Inquire about any allergies, such as to lotions or scents. Ask if the patient has any preferences for lotion or has their own lotion. Assess the patient's pain using an appropriate assessment tool and pain scale. Assess the characteristics of any pain and for other symptoms that often occur with the pain, such as headache or restlessness. Ask the patient what interventions have and have not been successful in the past to promote comfort and relieve pain. Assess the patient's vital signs. Check the patient's medication administration record for the time an analgesic was last administered. Assess cultural beliefs and influences related to the pain experience. Assess the patient's response to a particular intervention to evaluate effectiveness and presence of adverse effects. If appropriate, administer an analgesic early enough prior to the massage so that it has time to take effect. Refer to assessment details included in Fundamentals Review 10-1, 10-2, 10-3, and 10-4.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Discomfort
Acute anxiety
Impaired sleep

Outcome Identification and Planning

The expected outcomes to achieve are that the patient reports increased comfort and/or decreased pain, and that the patient is relaxed. Other outcomes that may be appropriate include that the patient experiences decreased anxiety and improved relaxation, and the patient verbalizes an understanding of the use of back massage.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Offer a back massage to the patient and explain the procedure.	Explanation encourages patient understanding and engagement and reduces apprehension.
4. Put on gloves, if indicated.	Gloves are not usually necessary. Gloves prevent contact with blood and body fluid.
5. Close the room door and/or the curtain around the bed. Turn down the lights, if possible, and adjust the room temperature for patient comfort (Westman & Blaisdell, 2016).	Closing the door or curtain provides privacy, promotes relaxation, and reduces noise and stimuli that may aggravate pain and reduce comfort (Aparício & Panin, 2020; Goeren et al., 2018). Lowering the lights, reducing noise, and adjusting the temperature of the room create a calming environment (Westman & Blaisdell, 2016).
6. Assess the patient's pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4). Ask the patient if they have any aversion to touch (Westman & Blaisdell, 2016).	Accurate assessment is necessary to guide treatment and pain relief interventions and to evaluate the effectiveness of pain control measures. Patients with posttraumatic stress disorder or previous negative experience with massage may not want to receive massage (Westman & Blaisdell, 2016).
7. Raise the bed to a comfortable working position (VHA Center for Engineering & Occupational Safety and Health [CEOSH], 2016), and lower the side rail.	Having the bed at the proper height prevents back and muscle strain.
8. Assist the patient to a comfortable position, preferably the prone or side-lying position. Remove the covers and move the patient's gown just enough to expose the patient's back from the shoulders to sacral area. Drape the patient, as needed, with the bath blanket.	This position exposes an adequate area for massage. Draping the patient provides privacy and warmth.
9. Warm the lubricant or lotion in the palm of your hand, or place the container in small basin of warm water. During the massage, observe the patient's skin for reddened areas or injury. Avoid areas of injury, such as wounds, burns, and pressure ulcers and areas with rashes, tubes, and IV access/lines (Westman & Blaisdell, 2016). See Chapter 8 for detailed information regarding skin assessment.	Cold lotion causes chilling and discomfort. Massage of these areas could result in further injury and is contraindicated (Westman & Blaisdell, 2016).
10. Using light, gliding strokes (effleurage), apply lotion to patient's shoulders, back, and sacral area (Figure 1).	Effleurage relaxes the patient and lessens tension.
11. Place your hands beside each other at the base of the patient's spine and stroke upward to the shoulders and back downward to the buttocks in slow, continuous strokes (Figure 2). Continue for several minutes.	Continuous contact is soothing and stimulates circulation and muscle relaxation.
12. Massage the patient's shoulders, entire back, areas over iliac crests, and sacrum with circular, stroking motions, keeping hands in contact with the patient's skin. Continue for several minutes, applying additional lotion, as necessary.	A firm stroke with continuous contact promotes relaxation.
13. Knead the patient's back by gently alternating grasping and compression motions (pétrissage) (Figure 3).	Kneading increases blood circulation.
14. Complete the massage with additional long, stroking movements that eventually become lighter in pressure (Figure 4).	Long, stroking motions are soothing and promote relaxation; continued stroking with gradual lightening of pressure helps extend the feeling of relaxation.
15. If excess lotion remains, use the towel to pat the patient dry.	Drying provides comfort and reduces the feeling of moisture on the back.
16. Remove gloves, if worn, and perform hand hygiene. Reposition patient's gown and covers. Raise side rail and lower bed. Assist patient to a position of comfort.	Removal of gloves and hand hygiene prevent transmission of microorganisms. Repositioning bedclothes, linens, and the patient helps to promote patient comfort and safety.
17. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
18. Evaluate the patient's response to this intervention. Reassess level of discomfort or pain using original assessment tools. Reassess and alter care plan, as appropriate.	Reassessment allows for individualization of the patient's plan of care and promotes optimal patient comfort.

Evaluation

The expected outcomes have been met when the patient reports increased comfort, decreased pain, and/or feelings of relaxation; the patient experiences decreased anxiety and improved relaxation; and the patient verbalizes an understanding of the use of back massage.

Documentation

Guidelines

Document pain assessment and other significant assessments. Document massage use, length of time of massage, and patient response.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient cannot lie prone, so you are giving them a back massage while they are lying on their side. However, as you begin to massage the back, the patient cannot maintain the side-lying position: If possible, have the patient hold on to the side rail on the side to which they are facing. If this is not possible or the patient cannot assist, use pillows and bath blankets to prevent the patient from rolling. If necessary, enlist the help of another person to maintain the patient's position. If possible, experiment with other positions based on the patient's condition and comfort, such as leaning forward against a pillow on the bedside table while sitting in a chair.
While massaging the patient's back, you notice a 5-cm reddened area on the patient's sacrum: Note this observation in the patient's health record and communicate it to the health care team. Do not massage the area. When the back massage is completed, position the patient off the sacral area, using supports to maintain the patient's position, and institute a turning schedule.

Special Considerations

General Considerations

Before giving a back massage, assess the patient's body structure and skin condition, and tailor the duration and intensity of the massage accordingly. If you are giving a back massage at bedtime, have the patient ready for bed beforehand so the massage can help them fall asleep.
Massage only the hands, feet, or scalp of patients with sepsis, fever over 100°F, sickle cell or HIV crisis, thrombocytopenia, or meningitis (Westman & Blaisdell, 2016).
Check in frequently with the patient during the massage, asking how the massage feels and adjust the pressure and technique based on the patient's preferences (Westman & Blaisdell, 2016).

Infant and Child Considerations

Hold infants and small children in a comfortable, well-supported position, such as against the chest or across the lap.
Oil or lotion should be odorless and edible in case the infant or child gets some in their mouth (MFMER, 2020).

Older Adult Considerations

Be gentle with massage. The skin on older adults is often fragile and dry.
Reduce pressure, provide short massage sessions, and consider alternative positions, such as supine or seated positions for massage with older adults (Durand, 2020).

EVIDENCE FOR PRACTICE

Massage and Anxiety and Sleep

Patient comfort is attained through management of many factors. Pharmacologic interventions alone may not address all of the factors involved in the patient's experiences with discomfort and pain. Can alternative approaches to managing patient discomfort help improve patient experiences and outcomes?

Related Research

Ayik, C., & Özden, D. (2018). The effects of preoperative aromatherapy massage on anxiety and sleep quality of colorectal surgery patients: A randomized controlled study. Complementary Therapies in Medicine, 36, 93-99. https://doi.org/10.1016/j.ctim.2017.12.002

The aim of this study was to examine the effects of aromatherapy massage on anxiety and sleep quality in patients undergoing colorectal surgery in the preoperative period. Eighty patients undergoing colorectal surgery were randomly assigned to experimental and control groups. Participants in the experimental group (n = 40) received aromatherapy back massage using 5% lavender oil for 10 minutes the night before surgery and the morning of surgery. The control group (n = 40) received standard nursing care. The preoperative anxiety level and sleep quality of the participants was measured in the afternoon on the day prior to surgery and again in the morning of surgery. Participants in the experimental group received the two massages after baseline measurement and prior to the second measurement. There was no baseline difference between the groups. A statistically significant difference was found between the experimental and control group in terms of the anxiety and sleep quality mean scores recorded on the morning of surgery. It was determined that the anxiety and sleep quality mean score of the experimental group after aromatherapy massage on the morning of surgery decreased when compared to that of the evening before surgery. The researchers concluded that aromatherapy massage with lavender oil increased the sleep quality and reduced the level of anxiety in patients with colorectal surgery in the preoperative period.

The authors suggested the use of lavender oil massage may be recommended to reduce anxiety and increase sleep quality and patient satisfaction in the preoperative period.

Relevance to Nursing Practice

Massage is an economical intervention that is easily incorporated into nursing practice. Evidence suggests that massage can be an important part of decreasing discomfort and increasing patient's well-being. Nurses should consider making time to incorporate this intervention into their practice.

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Skill 10-2

EVIDENCE FOR PRACTICE