RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,
1. / NAME OF THE CANDIDATE AND ADDRESS / CHIDAMBARA V N ,#3; SRI VEERABADHRA SWAMY NILAYA,
NEAR MEERA VIDYANIKETHAN SCHOOL,
1ST MAIN ROAD, CHAMUNDESHWARI LAYOUT,
VIDYARANYAPURA POST, BANGALORE-560097.
2. / NAME OF THE INSTITUTION / SRI DEVARAJ URS COLLEGE OF NURSING, TAMAKA,
KOLAR-563101.
KARNATAKA.
3. / COURSE OF THE STUDY AND SUBJECT / I YEAR MSc. NURSING
PEDIATRIC NURSING SPECIALITY
4. / DATE OF ADMISSION TO COURSE / 29-07-2011.
5. / TITLE OF THE TOPIC / A STUDY TO ASSES THE EFFECTIVENESS OF CARTOON THERAPY ON PAIN REDUCTION AMONG TODDLERS AND PRESCHOOLERS UNDERGOING PAINFUL PROCEDURE IN A SELECTED HOSPITAL, KOLAR.
KARNATAKA.
PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
66.1 / BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“Every child comes with the message that God is not yet discouraged of man”.
Rabindranath Tagore
The health of children is of vital importance of all societies because children are basic sources of the future mankind. Today the trend has changed and the nature of care of children based on their developmental needs. Now child care is more child centered1.
From toddler to pre-school age period health supervision is important. Sound health and its care picked up during these years have a great bearing on the individual and family1.
Perception of pain in pediatrics is complex, and entails physiological, psychological, behavioral, and developmental factors. However, in spite of its frequency, pain in infants, children, and adolescent is often underestimated and under treated. It has also been shown that infants and children, who experience pain in early life, show long-term changes in terms of pain perception and related behaviors. Health care professionals in this setting have a responsibility to reduce pain and anxiety as much as possible while maintaining patient safety2.
According to the International Association for the Study of Pain, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage2”.
For pediatric patients, medical procedures are often painful, unexpected, and heightened by situational stress and anxiety leading to an overall unpleasant experience. Although the principles of pain evaluation and management apply across the human lifespan, infants and children present unique challenges that necessitate consideration of the child’s age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs2.
Pain in infants and children can be difficult to assess which has led to the creation of numerous age-specific pain management tools and scores. Health care workers need to be able to detect the symptoms and signs of pain in different age groups and determine whether these symptoms are caused by pain or other factors3.
Painful medical procedures for children begin with heel sticks and injections at birth and continue throughout childhood. By the time a child reaches the age of 6, he or she should have received 36 immunizations via intramuscular injection, with the number of vaccination injections increasing exponentially by the year 2020. In addition to routine well-child visit pain, injuries and illnesses frequently require anxiety-provoking painful procedures4.
Barriers to pain management in children are numerous and include inaccuracies regarding patho physiological mechanisms of pain with statements such as “children do not feel pain the way adults do” fears regarding the use of pharmacological agents and deficits in knowledge of methods of pain assessment. These myths and other factors such as personal values and beliefs, prevent adequate identification and alleviation of pain for all children5.
Effective care in pediatrics requires special attention to the developmental stage of the child. Current research does not adequately discuss the effectiveness of pain management strategies in children at various ages. The experience of pain and coping strategies from developmental perspective is also limited. Thus the researcher’s aim is to address potential sources of pain measurement, and responses to pain control and distraction based on pediatric developmental stages6.
NEED FOR THE STUDY
Pain is one of the most frequent complaints presented in pediatric settings. Hospitalization itself is very stressful place children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures1.
This approach promotes the right of the Child to be fully involved in the procedure, to choose, associates, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. It is essential to focus on the child rather than the procedure and avoid statements such as “let’s just get it over with”7.
Ideally procedures should be done in a child-friendly environment, using appropriate non-pharmacologic interventions with routine pain assessment and reassessment5.
Numerous modalities exist to decrease procedural pain, from topical anesthetics up to complete deep sedation. The latter requires expertise, forethought, and considerable expense and may not be available in every community. Despite ready availability, however, only 6% of pediatric offices use pain control for shots and only 2.1% of an estimated 18 million venipuncture are performed each year with pain control. Distraction for minor to moderate procedural pain is free or inexpensive, easy to perform, and an effective method of pain control6.
Untreated or undertreated pain can rob children’s ability to function and can cause depression, irritability, and disruptions in sleeping, eating and mobility6.
When performing painful procedures on children’s, it is important to take into consideration the context of the procedure (i.e., is the procedure really necessary, how many painful procedures has the child had in the past, and what was their previous pain experience). The procedural environment should also be developmentally sensitive. In fact, reducing noise and lighting, use of soothing smells and clustering procedures to avoid over handling, reduces pain reactions in infants7.
For young children, explaining the procedures with age appropriate information is useful, in addition to providing them with the opportunities to ask questions. Examples for active distraction used with this age group include, cartoon shows, allowing them to blow bubbles, providing toys with lots of color or toys that light up. Initiating distracting conservations (e.g., how many brothers and sisters do you have? What did you do at your birthday party?) And deep breathing methods are also helpful for older children. Passive distraction techniques include: having the parents or child life specialist read age appropriate books, sing songs, and practicing “blowing out birthday candles” with the child7.
Distraction is the most frequent intervention used in the pediatric department to guide children’s attention away from the painful stimuli and reduce pain and anxiety. It is most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure. Distraction has also proven to be more economical than using certain analgesics. Distraction is divided into two main categories: passive distraction, which calls for the child to remain quiet while the health care professional is actively distracting
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8 / the child (i.e., by singing, talking, watching cartoon shows, or reading a book). Active distraction, on the other hand, encourages the child’s participation in the activities during the procedures. Interventions used to minimize pain are classified into three main categories (cognitive, behavioral, or combined) 8.
Distraction techniques used with this age group are mostly passive. Cognitive strategies used to reduce pain perception in children’s are either visual or auditory interventions. Visual aids can include pictures, cartoons, mobile phones, and mirrors. Auditory aids include music, lullabies sung by parents or health care professionals9.
Current studies are beginning to take into consideration children’s different responses to distraction interventions based on their developmental stage, maturity level, and age. Our goal in this section is to provide various forms of distraction that are proven effective with different age groups9.
REVIEW OF LITERATURE:
Review of literature refers to the activities involved in identifying or searching for information on a topic and developing an understanding of the state of knowledge of the topic. (Polit & Hungler, 1993)
Studies related to:
1. Assessment of pain by using FLACC pain scale.
2. Effectiveness of cartoon therapy on intensity of pain during painful procedure.
SECTION 1: Studies related to assessment of pain by using FLACC pain scale.
A randomized controlled trial of audiovisual distraction of pain management in toddlers and preschoolers children receiving vein puncture in pediatric department. 300 children’s (2–6years) were randomized into audiovisual distraction group (n = 100, watching cartoon films), intervention Group (n = 100, receiving psychological intervention) and control group (n = 100, without any Intervention). There was no significant difference (P >0.05) between the audiovisual distraction and the intervention groups for cooperation, venipuncture times and pain intensity (assessed with FLACC scale). However, cooperation in the control group was more passive. Than in the intervention group (P <0.05) but not apparently different to the audiovisual distraction Group (P >0.05). Venipuncture time was significantly higher in the control group than in the other two groups (P <0.05). Venipuncture caused moderate pain in children (FLACC score: 5.22 ± 2.53 in the control group). FLACC scores indicated that procedures were more painful in the control group than in the audiovisual distraction or the intervention group (FLACC score: 4.55 ± 2.26 and 4.38 ± 2.32 in the audiovisual distraction and intervention groups respectively, P<0.05). Audiovisual distraction was demonstrated to be effective in reducing Pain, improving patient cooperation and increasing success rate in venipuncture procedures11.
This study, evaluated the validity and reliability of the Face, Legs, Activity, Cry, Consolability (FLACC) tool for assessing pain in children. Each child’s developmental level and ability to self-report pain were evaluated. The child’s nurse observed and scored pain with the FLACC tool before and after analgesic administration. Simultaneously, parents scored pain with a visual analog scale, and scores were obtained from children who were able to self-report pain. Observations were videotaped and later viewed by nurses blinded to analgesics and pain scores.140 observations were recorded from 79 children. FLACC scores correlated with parent scores (P 0.001) and decreased after analgesics (P =0.001), suggesting good validity. Correlations of total scores (r=0.5– 0.8; P0.001) and of each category (r=0.3– 0.8; P 0.001), as well as measures of exact agreement (k= 0.2– 0.65), suggest good reliability. Test-retest reliability was supported by excellent correlations (r =0.8–0.883; P 0.001) and categorical agreement (r =0.617– 0.935; k= 0.400–0.881; P0.001). These data suggest that the FLACC tool is useful as an objective measure of pain in children12.
A comparative study was done child’s self report to test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale for use with children. 30 children aged 3-7 years who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20 + 2 hours after surgery. FLACC scores were assigned by one of the nurse investigators, and a self-report of pain using the FACES scale was obtained from the child. There were significant and positive correlations between the FLACC and FACES scores for the entire sample. The interaction was significant (F = 5.04, p< 0.001)13.
A evaluative study was conducted on reliability and validity of FLACC pain scale in assessing acute pain in critically ill patients Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the procedure. Two nurses used the FLACC scale; the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children). For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P< .001)14.
A descriptive study was conducted on 60 preschool children who were reported to be easily completed and scored in an analog situation, for measuring children's distress and coping style during actual painful medical procedures. 60 preschool children who were receiving immunizations at a health department were subjects. Objective measures and subjective measures (child, parent, and nurse-report) were used. Results of the current study support the internal consistency and concurrent validity of the Distress subscale of the BAADS15.
Assessment and treatment of procedural pain in children as a part of routine and specialized health care, children are subjected to a number of invasive medical procedures (e.g., immunizations and venipuncture). According to guidelines published by the United States Centers for Disease Control and Prevention in 2005, children are to receive roughly 29 intramuscular immunization injections by 6 years of age. These events are anxiety provoking and painful, especially for younger children, who exhibit higher distress than older children (2–3) and 45% of (4-6) year-old children experience serious or severe distresses during immunization procedures16.
A longitudinal study on Pain Reduction during Pediatric Immunizations, Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available17.
A preliminary study of Children's perception of pain was investigated in an exploratory study. Some synaesthetic aspects were examined such as the color of pain, texture, shape, pattern and continuous v/s intermittent quality. A projective test was developed using cartoons to illustrate two situations in which children commonly experience pain. Interviews were tape-recorded with 58 children in hospital outpatient clinics and school situations in Kindergarten and Grades 1 through 3 in Licking County, Ohio. Significantly more children perceived the pain of a needle as jagged rather than smooth18.