Skill 10-3

Applying and Caring for a Patient Using a Transcutaneous Electrical Nerve Stimulation Unit

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique for providing pain relief that involves the use of low-voltage electrical stimulation. This electrical stimulation is thought stimulate nerve cells that block the transmission of painful impulses and/or stimulation raises the level of endorphins that block the perception of pain (Cleveland Clinic, 2020; NHS, 2021). The TENS unit consists of a battery-powered portable unit, lead wires, and cutaneous electrode pads that are applied to or around the painful area (Figure 1). TENS therapy is used to treat acute and chronic pain related to multiple health problems, including osteoarthritis-related problems, fibromyalgia-related problems, bursitis, low back pain, and tendonitis (Cleveland Clinic, 2020).

TENS should not be applied to wounds due to osteomyelitis; areas recently treated with radiation; on the head; near reproductive organs or genitals; or in persons who have trouble communicating or who have mental impairment (Cleveland Clinic, 2020). Never place electrodes over the carotid sinus nerves; laryngeal or pharyngeal muscles (the front or sides of the neck); the eyes or temples; chest and upper back at the same time; irritated, infected, or broken skin; numb areas or areas of the body that lack or have reduced sensation; or varicose veins (NHS, 2021).

TENS therapy prescribed by a health care provider. The TENS unit can be applied intermittently throughout the day or worn for extended periods. There are many different manufacturers of TENS units.

Nurses need to be familiar with the particular unit in use by their patient and to refer to the specific manufacturer's recommendations for use.

Delegation Considerations

The application and monitoring of use of a TENS unit is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the application and monitoring of use of a TENS unit may be delegated 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

TENS unit
Self-adhering electrodes
Pain assessment tool and pain scale
Disposable cleansing washcloths or skin cleanser, water, towel, and washcloth
PPE, as indicated

Assessment

Review the patient's health record and plan of care for specific instructions related to TENS therapy, including the prescribed intervention and conditions indicating the need for therapy. Review the patient's health record for conditions that might contraindicate therapy or require modifications of therapy, such as the presence of an implantable device, (cardioverter/defibrillator, neurostimulator, bone growth stimulator, and indwelling blood pressure monitor); diagnosis of cancer; pregnancy; epilepsy; deep vein thrombosis or thrombophlebitis; bleeding disorder; heart disease, heart failure, or arrhythmias (Cleveland Clinic, 2020). Determine the location of electrode placement in consultation with the prescribing health care provider and based on the patient's report of pain. Assess the patient's understanding of TENS therapy and the rationale for its use.

Inspect the skin of the area designated for electrode placement for irritation, redness, or breakdown. Assess the patient's pain and level of discomfort using an appropriate assessment tool. Assess the characteristics of any pain. Assess 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 the patient's response to a particular intervention to evaluate effectiveness and presence of any adverse effect. Refer to assessment details included in Fundamentals Review 10-1, 10-2, 10-3, and 10-4.

Check the unit to ensure proper functioning and review the manufacturer's instructions for use.

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:

Acute pain
Chronic pain
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve is that the patient verbalizes decreased discomfort and pain without experiencing any injury or skin irritation or alteration in skin integrity. Other appropriate outcomes may include the patient verbalizing an understanding of the therapy, use of the device, and the reason for its use.

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 that the right patient receives the intervention and helps prevent errors.
3. Show the patient the TENS device, and explain its function and the reason for its use.	Explanation encourages patient understanding and engagement and reduces apprehension.
4. Assess the patient's pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4).	Accurate assessment is necessary to guide treatment and relief interventions and evaluate the effectiveness of pain control measures.
5. Inspect the area where the electrodes are to be placed. Clean the patient's skin using the disposable cleansing wipe or skin cleanser and water. Dry the area thoroughly.	Inspection ensures that the electrodes will be applied to intact skin. Cleaning and drying help ensure that the electrodes will adhere.
6. Remove the adhesive backing from the self-adhering electrodes and apply them to the specified location (Figure 2).	Application to the proper location enhances the success of the therapy. Gel is necessary to promote conduction of the electrical current.
7. Check the placement of the electrodes; leave at least a 2-inch (5-cm) space between them.	Proper spacing is necessary to reduce the risk of burns due to the proximity of the electrodes.
8. Check the controls on the TENS unit to make sure that they are off. Connect the wires to the electrodes (if not already attached) and plug them into the unit.	Having controls off prevents flow of electricity. This connection completes the electrical circuit necessary to stimulate the nerve fibers.
9. Turn on the unit and adjust the intensity setting to the lowest intensity (Figure 3) and determine if the patient can feel a tingling, burning, or buzzing sensation. Then adjust the intensity to the prescribed amount or the setting most comfortable for the patient. Secure the unit to the patient.	Using the lowest setting at first introduces the patient to the sensations. Adjusting the intensity is necessary to provide the proper amount of stimulation.
10. Set the pulse width (duration of each pulsation) as indicated or recommended.	The pulse width determines the depth and width of the stimulation.
11. Assess the patient's pain level during therapy.	Pain assessment helps evaluate the effectiveness of therapy.
a. If intermittent use is ordered, turn the unit off after the specified duration of treatment and remove the electrodes. Clean the patient's skin at the electrode sites.	TENS therapy can be ordered for intermittent or continuous use. Skin care reduces the risk for irritation and breakdown.
b. If continuous therapy is ordered, periodically remove the electrodes from the skin (after turning off the unit) to inspect the area and clean the skin, according to facility policy. Reapply the electrodes and continue therapy. Change the electrodes according to the manufacturer's directions.	Periodic removal of electrodes allows for skin assessment. Skin care reduces the risk for irritation and breakdown. Reapplication ensures continued therapy.
12. When therapy is discontinued, turn off the unit and remove the electrodes. Clean the patient's skin. Clean the unit and replace the batteries.	Turning off the unit and removing electrodes when therapy is discontinued reduces the risk of injury to the patient. Skin care reduces the risk for irritation and breakdown. Cleaning the unit and replacing the batteries ensures that the unit is ready for future use.
13. Remove 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.

Evaluation

The expected outcomes have been met when the patient verbalizes decreased discomfort and pain without injury or skin irritation or alteration in skin integrity, and the patient verbalizes an understanding of the therapy, use of the device, and the reason for its use.

Documentation

Guidelines

Document the date and time of application; patient's initial pain assessment; skin assessment; electrode placement location; intensity and pulse width; duration of therapy; pain assessments during therapy and patient's response; and time of removal or discontinuation of therapy.

Sample Documentation

5/28/25

1105 Patient reports severe lower back pain, rating it as 9/10 on pain scale. Identified lower sacral area as site of pain. TENS therapy ordered for 30 to 45 minutes. Electrodes applied to right and left sides of sacral area. Intensity initially set at 80 pulses/sec with pulse width of 80 microseconds. Pain rating at 7/10 after 15 minutes of therapy. Intensity increased to 100 pulses/sec, with a pulse width increased to 100 microseconds. Pain rating at 5/10 after 15 minutes at increased settings. Therapy continued for an additional 15 minutes and discontinued. Patient rated pain at 3/10 at end of session. Skin on lower sacral area clean, dry, and intact without evidence of irritation or breakdown. Patient instructed to report increasing pain.

—K. Lewin, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While receiving TENS therapy, the patient reports pain and intolerable paresthesia: Check the settings, connections, and placement of the electrodes. Adjust the settings and reposition the electrodes, as necessary.
During a TENS therapy session, the patient reports muscle twitching: Assess the patient and check the intensity setting. Readjust the intensity to a lower setting because the patient is most likely experiencing overstimulation.
While assessing the skin where the electrodes are placed for a patient receiving continuous TENS therapy, you notice some irritation and redness: Clean and dry the area thoroughly. Reposition the electrodes in the same area, avoiding the irritated and reddened area.

Special Considerations

Never place electrodes over the carotid sinus nerves; laryngeal or pharyngeal muscles (the front or sides of the neck); the eyes or temples; chest and upper back at the same time; irritated, infected, or broken skin; numb areas; or varicose veins (NHS Choices, 2021).
Whenever electrodes are being repositioned or removed, first turn off the unit.

Community-Based Care Considerations

Patient and/or family/caregiver teaching is essential and should include an explanation of the manufacturer's directions, instructions on where to place the electrodes, and the importance of placing the electrodes on clean, unbroken skin (Bauldoff et al., 2020). The patient/family/caregiver should assess the skin daily at the electrode locations for signs of irritation (Bauldoff et al., 2020).

EVIDENCE FOR PRACTICE

Tens and Postoperative Pain

Patient comfort is attained through management of many factors. Achieving pain relief and/or pain control is a large contributor to achieving patient comfort. Pharmacologic interventions alone may not address all of the factors involved in the pain experience. Do alternative approaches to managing pain that supplement medication administration help achieve effective pain management?

Related Evidence

Zhou, J., Dan, Y., Yixian, Y., Lyu, M., Zhong, J., Wang, Z., Zhu, Y., & Liu, L. (2020). Efficacy of transcutaneous electronic nerve stimulation in postoperative analgesia after pulmonary surgery: A systematic review and meta-analysis. American Journal of Physical Medicine & Rehabilitation, 99(3), 241-249. https://doi.org/10.1097/PHM.0000000000001312

The aim of this study was to identify the analgesic efficacy and safety of transcutaneous electronic nerve stimulation (TENS) in postoperative pain after pulmonary surgery. Four data bases (PubMed, Embase, Web of Science, and CENTRAL) were systematically searched from their inception to June 2019. The continuous variables were pooled as the weighted mean difference with correlated 95% confidence interval. Subgroup analyses, sensitivity analyses, and quality assessment were completed. Ten studies were included; pooled results indicated that TENS conferred lower pain intensity score when compared with the placebo group on the first through the fifth postoperative days; postoperative day 1 (P = .004), postoperative day 2 (P = .002), postoperative day 3 (P = .03), postoperative day 4 (P ; .001), and postoperative day 5 (P ; .001). There were no significant findings related to sensitivity analyses. The researchers concluded TENS might be an effective supplementary analgesic regimen in multimodal analgesia to decrease pain intensity after pulmonary surgery.

Relevance to Nursing Practice

Nurses have an important role in providing interventions to assist patients in controlling pain and educating patients about analgesic interventions. Nurses should consider the appropriateness of inclusion of nonpharmacologic interventions, such as TENS, in collaboration with health care providers and patients when planning care for patients experiencing or likely to experience pain. Nurses have a responsibility to be informed and knowledgeable regarding all methods of analgesia and work to provide a plan of care that addresses individual patient needs.

section name header

Skill 10-3

EVIDENCE FOR PRACTICE