RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS (IN BLOCK LETTERS) / MS. ZENCY MATHEW,
FIRST YEAR M.Sc. NURSING,
BGS COLLEGE OF NURSING ,
KUVEMPUNAGAR,MYSORE-23.
2 / NAME OF THE INSTITUTION / BGS COLLEGE OF NURSING ,
MYSORE.
3. / COURSE OF STUDY AND SUBJECT / M.Sc. NURSING
CHILD HEALTH NURSING.
4. / DATE OF ADMISSION / 08.06.2010
5. / TITLE OF THE TOPIC:
“A STUDY TO EVALUATE THE EFFECTIVENESS OF FLASH OF LIGHT ON PAIN REDUCTION DURING VENOUS CANNULATION AMONG 3-8 YEARS OLD CHILDREN IN SELECTED HOSPITALS AT MYSORE”

6.BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

Children are the pride of a nation ,it is the duty of every adult citizen to keep up this unit of pride safely for the benefit of the country.So we should be sensitive to the feelings ,needs and tastes of children to build a better tomorrow.We should not only show love and affection and provide protection and security to children but also ensure them a sound health Health care experiences ,including hospital and medical procedures can be very stressful for children of all ages.Child receive both traumatic and non traumatic experiences in hospital.Pain is one such experience that child fears when taken to hospital.1

“Pain is such an uncomfortable feeling that even

a tiny amount of it is enough

to ruin everything”

-Will Rogers

Pain is a highly unpleasant and very personal sensation that cannot be shared with others .It can occupy of all of a person’s thinking ,direct all activities and change a person’s life.Yet pain is a difficult concept for a client to communicate.A nurse can neither see nor feel a client’s pain. No two people experience in exactly the same way. In addition, the differences in individual pain perception and reaction as well as the many causes of pain ,present with a nurse with a complex situation ,when developing a plan and provide comfort.2

The pain caused by common minor procedures such as venipuncture is a major source of concern for children and their caretakers. Too little attention has been paid to relieve such pain. Most children find having a needle stressful.Child have the right to be pain free and relief of pain is the basic need of children.Beyond early infancy all children fear bodily injury and manipulating procedural techniques minimizes fear of bodily injury.So recognition of pain and its treatment of pain is as important as that of other diseases.3

Pain management is an important facet of nursing care.and it involves pain assessment as its critical component. Behavioural observation is the primary assessment approach for pre-verbal and non-verbal children, and is an adjunct to assessment for verbal children.Observations focus on vocalisations (e.g., crying, whining, or groaning), verbalisations, facial expressions, muscle tension and rigidity, ability to be consoled, guarding of body parts, temperament, activity and general appearance. Adequate reliability and validity documentation is lacking for behavioural observations, even though clinicians often attribute greater importance to non-verbal expression than to self-report.4

Effective pain management requires a number of interventions to achieve optimum results.Pain reduction methods can be grouped in to 2 categories: pharmacologic and non pharmacologic methods.To ensure adequate pain relief or to make pain tolerable and to give a sense of control over the situation non pharmacologic methods are widely accepted.It includes physical and cognitive and behavioural pain management strategies.

Distraction is a non pharmacologic technique that draws person’s attention from away from noxious stimuli through passively redirecting the subject’s attention or by actively involving the subject in the performance of diversion task.It is useful for younger children and is easy to administer.The type of distracters are visual(reading ,watchingTV,imagery),auditory(humuor,music),tactile(breathing,massage),intellectual(crosswords,puzzles)etc. Other distractors like kaleidoscope,blowing bubbles,flashing light counting out aloud are being used.5

So we can understand that pain can be effectively managed by non pharmacologic methods like distractions in children.

6.2NEED FOR THE STUDY

Children have the way of touching hearts and never seen of seasoned professionals.So when you are performing procedures like venipuncture ,concern should be to minimize discomfort and pain for children.Surveys of parents, staff direct observation, and children's drawings and self-ratings have suggested that venipuncture is associated with considerable distress in children,with between 34% and 64% of children experiencing moderate stress from the procedure. Other studies have suggested that almost 50% of children 7-18 years of age report needlestick experiences as unpleasant and painful, which causes subsequent high levels of anticipatory fear and distress.

A survey conducted among 1385 high school adolescents,reported that a high level of fear during dental and medical injections, which directly led to avoidance of subsequent treatment in 5%-7% by these young people.an evidence-based review of approaches to pain reduction for immunizationsreported that longer needles were associated with less pain; that parental reassurance, criticism, or apology increased distress; and that humor and distraction reduced distress.6

Health care professionals regard injections and venipunctures as routine procedure. For children, however, needles arouse fear and may be perceived as stressful and unpleasant.Venipunctures are usually performed by nurses and sometimes anticipated with great anxiety by patients in this case, children, if initial attempts are unsuccessful, patients especially children will not allow further venipunctures due to frustration and pain. The majority of health care professionals recognize that there is a lack of interventions to decrease the unpleasantness of procedural pain.Unnecessary pain can also erode the nurse-patient relationship. The knowledge of alternative techniques in pain management can improve patient care and satisfaction.7

In a workbook developed by Royal College of Nursing,London to assist practitioners in developing competence in peripheral venous cannulation in children and young people, suggests that children perceive pain as a physical experience and need parents and health care professionals to help them to cope by providing distraction and topical analgesia.and also says that when procedures are planned, and pain can be predicted, the opportunity should be taken to prepare children through play and education, to plan pain relief for use during the procedure. The use of psychological therapies, including distraction, coping skills and cognitive-behavioural approaches, provides some benefit.8

A randomized controlled study was conducted at the University Hospital of Maastrich ,Netherlands to assess the influence of distraction on pain and anxiety during venipuncture in children aged between 8 -11 years of age. The study was conducted in a research population of 20 ambulatory patients aged between 8 and 11 years old, who were referred to the specialised department for child venipuncture The distraction intervention was completing a find-the-hidden-items puzzle. Control patients did not receive any distraction and the study showed that children with high anxiety reported more pain than children with low anxiety. Distraction lowers anxiety in children who do not watch the venipuncture, but not in children who prefer to watch the venipuncture and concluded that distraction can be an effective intervention to decrease pain and anxiety.9

When pain is poorly managed, it may have significant negative sequelae. A child who is not in control of his emotions and has experienced multiple unpleasant experience will be fearful, less cooperative, have more anxiety for the next procedure and may have a series of nightmares that are all based on the procedure itself.10

The health care facility or hospital is an unfamiliar environment for children and parents and may upset or intimidate them.the procedures performed may be threatening to the child. To minimize this stress,the field of child health has developed the concept of ‘Atraumatic care’ which is defined as the therapeutic care that minimizes the psychological and physical distress experienced by children and their families .The concept is based on the underlying premises of “do no harm”.One of the most important basic principles of Atraumatic care is to control pain via frequent assessments and use of pharmacologic and non pharmacologic interventions.To promote this concept also this study will be useful.11

As advocates for children, nurses are obligated to minimize the emotional and physical effects of painful procedures and provide comfort to children.Optimal management of pain is critical to achieve this goal. Children are less likely to fear health personnel if their contact with them are not associated with pain12.

The researcher’s personal experience with children during venipuncture have also given an insight to this topic.The responses shown by the children and the anxiety of the parents to painful procedures provoked to have an attempt of this study. Also distraction appeared to be the better way to reduce the level of perception of pain in children.

“it is perfectly normal for children to dislike needles(many adults don’t like them either)”

-Action for sick children (1994)

Considering all the above mentioned facts,the researcher found it very essential to conduct the study and contribute one more type of distractor that can be used to reduce pain among children.

6.3REVIEW OF LITERATURE

Literature review is an essential step in the whole process of research. The term review of literature refers to the activities involving in identifying and searching for information on a topic and developing an understanding of the state of knowledge on that topic. It is also used to designate a written summary of the state of the art on a research problem.In this study it was organized and presented under the following headings:

a)Pain related to Medical procedures and its long term effects.

b)Non pharmacologic interventions to reduce pain experienced by children.

A prospective, randomized, placebo-controlled study was done at Sanjay Gandhi Post GraduateInstituteof Medical Sciences, Lucknow,India, to assess the roleofaflashof light for attenuation of venous cannulation pain Randomly selected ninety children between 15–18 years, ofeither sex, undergoing elective laparoscopic cholecystectomy wereincluded. Patients were dividedinto three groupsof30 each. Group I (control); Group II (distraction): photographed without aflashof light; and Group III (flash): photographed with aflashoflightjust before venous cannulationofa veinon the dorsumofthe nondominant hand. Severityofvenous cannulation painas assessed by the Visual Analog Scale scores .The results showed that theincidenceof venous cannulation painintheflashgroup was lower, i.e., 50% (14of28) when compared to 100% (28of28) observedinthe other two study groups. The severityofvenous cannulation painwas also reducedintheflashgroup compared with the distraction group (P< 0.01) and concluded that aflashoflightbefore venous cannulation is a safe, effective, and easy-to-usemethod for minimizing venous cannulation pain.13

A prospective, randomized study was done at Sree Chitra Tirunal Institute for Medical Sciences &Technology, Trivandrum, India to assess the efficacy of the valsalva maneuver on venous cannulation pain Seventy-five samples of either sex, undergoing elective surgery included in this study were randomized into 3 groups of 25 each. Group I (C): control; Group II (V): blew into sphygmomanometer tubing and raised the mercury column up to 30 mm Hg for 20 s; Group III (B): pressed a rubber ball. Twenty seconds later, peripheral venous cannulation was performed. Venous cannulation pain was graded using a 4-point scale: 0–3, where 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain, and Visual Analog Scale of 0–10, where 0 = no pain and 10 = worst imaginable pain. Incidence of pain was less in the Valsalva group: 18 of 25 (72%) patients, whereas 25 of 25 (100%) experienced pain in the other two groups (P< 0.001) and concluded that the Valsalva maneuver performed at the time of venous cannulation greatly decreases this pain.14

A prospective, randomized, controlled study was done in Lucknow,India to evaluate the efficacy of balloon inflation on venous cannulation pain in children.Purposively selected seventy-five pediatric patients aged 6-12 yr, ASA physical status I-II, of either sex, undergoing elective surgery were included and randomly divided into 3 equal groups of 25 each; Group I (control), Group II (distraction) pressed a rubber ball, and Group III (balloon) inflated a balloon.. Pain was self-reported by a pain face scale with a 10-cm visual analog scale (VAS) placed at its back, where 0 = "no pain" and 10 = "worst imaginable pain." The result showed that median (interquartile range) VAS score in the balloon group was 1 (3), which was reduced as compared with 2 (2) and 4 (2) observed in the distraction and control groups, respectively .The study concluded that there was significant reduction in the incidence and severity of venipuncture pain in the balloon group when compared with the other 2 groups (P < 0.05) .15

A prospective randomized control study was conducted at Seth GS Medical College and KEM Hospital, Mumbai, India to determine comparative efficacy of local anesthetic cream, Indian classical instrumental music and placebo,in reducing pain due to venipuncture in children.Purposively selected children aged 5-12years requiring venipuncture at a tertiary care center were enrolled in the study. They were randomly assigned to 3 groups: local anesthetic (LA), music or placebo (control) group. Eutactic mixture of local anesthetic agents (EMLA) and Indian classical instrumental music (raaga-Todi) were used in the first 2 groups, respectively. Pain was assessed independently by parent, patient, investigator and an independent observer at the time of insertion of the cannula (0 min) and at 1- and 5 min after the insertion using a Visual Analog Scale (VAS). Kruskal- Wallis and Mann-Whitney U tests were used to assess the difference amongst the VAS scores. The results indicated that higher VAS scores were noted in control (placebo) group by all the categories of observers (parent, patient, investigator, independent observer) at all time points. The VAS scores obtained in EMLA group were lowest at all time points. However, the difference between VAS scores in EMLA group were significantly lower than those in music group only at some time-points and with some categories of observers (parent: 1min; investigator: 0-, 1-, 5 min and independent observer: 5 min).The study concluded that pain experienced during venipuncture can be significantly reduced by using EMLA or Indian classical instrumental music.16

An experimental study was conducted at the paediatric OPD of Father Muller College of Nursing, Mangalore, to evaluate the effectiveness of kaleidoscope as a distraction technique among hospitalised children during their acute pain experience.Using convenient sampling, 60 subjects were selected – 30 in the control and 30 in the experimental group. The findings revealed that children in Group I (37%) reported less intensity of pain, and most of the children in Group II (43%) perceived high intensity of pain. The mean behavioural response pain showed significant difference in the behavioural response and intensity of pain between Group I and Group II (t58 = 6.383 and 6.66 respectively; p < 0.001) and concluded that kaleidoscope as an effective distractor for pain 17