A Study to Assess the Effectiveness of Distractor on Pain Among Children During Selected
A study to assess the effectiveness of distractOr on
pain among children during selected invasive
procedures in hospitals at kolar district.
proforma for registration of students for dissertation
koninty chandrakala lucas
A.e& c.s.pavancollege of nursing, kolar
6.0brief resume of the intended work:
introduction
“Bitter are the tears of a child: sweeten them.
Deep are the thoughts of a child: quiet them.
Sharp is the grief of a child: take it from him.
Soft is the heart of a child: Do not harden it.”
Pamela Glenconner
The word pain is derived from the latin word ‘poena’ which means punishment, which in turn derived from the Sanskrit root ‘pu’ meaning puification. The international association for the study of pain defines, “pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, ar described in terms of such damage”. The international association for the study of pain further states that, “pain is subjective. Each individual learns the application of the word through experiences related to in early life.” This definition emphasizes the individuality of each person’s pain response and the importance of pain experiences, especially those in early life, in shaping that response. thus, a child experience during painful medical procedures likely plays a significant role in shaping that individuals pain response to future events.24
Pain in children is often under treated. The reasons for the lack of adequate pain control may include: myths about pain and pain management, fears held by parents and health professional, and the lack of appropriate pain assessment. Myths surrounding pain management may prevent the timely and appropriate treatment of children. Nurses are in a unique position to improve the management of childrent pain because children and parents will often tell them things they do not tell physicians and they are often the professionals who have the most contact with an ill child in and out of the hospital. Nursing intervention can alleviate some of the fear and pain caused by painful procedures (Eland 1990)
Relief of pain is a basic need and right of all children. Management of pain in the child must be individualized. Age, sex, birth order, cultural background, parents, caregiver’s response and past experiences affects the child’s response. The newborn baby, the infants, and the toddler are unable to localize and describe the severity of pain.25
The nurse must be aware of the child’s response to pain through assessment of behavioral responses and differentiation of crying. During the pre-school period, the child acquires the ability to verbally describe the pain experience. Dependending on the cause of the pain experience, non pharmacologic or pharmacologic interventions or both may be utilized. The nurse should provide explanation for what is happening to the school-age child. The nurse should explore ‘adolescents’coping pattern and encourage their use in helping this young people deal with pain.26
A study was conducted on management of injection pain in children. The groups were designated as: distraction, distraction with suggestion, suggestion and control. The study supported the use of music distraction in the reduction of injection pain in children.1
A study was conducted by using parents as distraction coaches during I.V insertion. Parent –child dyads were ramdomized onto two groups experimental and control group. The experimental group children showed decreased behavioral distress over time than did the control group.2
A study was conducted by using virtual reality and audio-visual eyeglass system as adjunct analgesic techniques to reduce pain. The study revealed that both virtual reality and audio- visual distraction can be promising analgesic technique that may be used safely and effectively for the reduction of pain and discomfort during medical procedures.3
6.1 Need for the study:-
The pain response is individual and is learned through social learning and experience. Early pain experience may play a particularly important role in shaping an individuals pain responses. In adequate relief of pain and distress during childhood painful medical procedures may have long- term negative effects on future pain tolerance and pain responses [ann Emerg medical 2005; 45:160-171].
Many hospitalized children have to undergo painful procedures. Understanding the study of the pediatric pain experience has increased exponentially during the part 2 decades. Besides the negative experience of pain itself, growing evidence supports the occurrence of long- term negative effects from inadequately treated pediatric pain, especially in infants. Significant short-term adverse outcome have also been demonstrated, including hypoxemia, altered metabolic stress responses, even mortality
The developing brains neuronal architecture may be permanently altered by repeated noxious stimuli such as painful procedures. Children consistently name the invasive procedures as the cause of the most painful experiences (Hester,1993)
Challenges to the nurses who provide their care, co- operation of children during painful invasive procedures is very important. Nurses are in a unique position to improve the management of children’s pain because children and parents will often tell them things they do not tell physician, and they are often the professionals. Pain is often associated with fears, anxiety and stress. A number of non- pharmacological techniques to reduce pain and distress with procedures such as, techniques, distraction, deep-breathing, blowing, suggestion, superhero – imagery.
Memory for the painful event is another factor influencing long-term negative effects. Children even thou who display low distress, tend to have a distorted negative recall of the pain they experienced with procedures. Recall is further distorted if children were distressed at the procedure.
These fragmented traumatic memories easily become exaggerated memories of the pain experienced, resulting in increased distress at subsequent procedures. Thus, inadequate treatment of a child’s distress at an initial procedure produces a negative ongoing cycle of distress at subsequent procedures. Altering there distorted memories to more realistic ones through postevent suggestion and feedback may break this cycle. The first step to adequate pain management is adequate assessment. Assessment instruments used must be practical, reliable, valid and appropriate for the Childs developmental stage.
Pain may be described as a feeling of hurt or strong discomfort and is the body’s way of sending a message to the brain that an injury has occurred. The unrelieved pain causes the body to release certain chemicals that may actuallydelay healing. Inadequate prevention treatment of children’s pain and distress responses to medical procedures may have long-term negative effects on their future pain responses.
Distraction is a proven effective psychological intervention. Distraction is a power relief intervention that children are accoustomed to using. Distraction can be used as one of the strategies to gain co-operation of the child. Distraction is the ability to focus attention on something other than pain and does not mean that the pain is gone.24
A study was conducted, using nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent and nurse distress during immunization. The intervention consisted of children viewing a popular cartoon movie and being coached by nurses and parents to attend to the movie. Therefore, nurses coaching of children to watch cartoon movies has great potential for dissemination in pediatric setting.4
A study was conducted to evaluate the validity and reliability of FLACC tool for assessing pain in children with CI (cognitive impairment). the child 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. One–hundred Forty observations were recorded from 79 children. FLACC scores correlated with parent scores (P<0.001) and decreased after analgesics (P=0.001) suggesting good validly. Correlations of total scores(r=0.5-0.8;p<0.001) and of each category (r=0.3-0.8; p<0.001), as well as measures of exact agreement (R=0.2-0.64),suggest good reliability. test- retest reliabilility was supported by excellent correlations (r=0.8-0.883; p<0.001)and categorical agreement (r=0.617-0.935R=0.400 - 0.881; p<0.001). There data suggest that the FLACC tool may be useful as an objective measure of past operative pain in children with CI.5
As distraction is a promising, cost effective, non-pharmacological technique in reducing pain and distress among children undergoing painful medical procedures. The researcher in this study is, intented to use cartoon movies, an audio visual aid as a distractor among children during painful invasive procedures.
6.2 Review of literature
Review of literature is a key step in research process. The review of literature is defined as a broad, comprehensive in depth, systematic and criitical review of scholarly publications, unpublished scholarly print materials, audio-visual materials and personal communication.
emphasishas been placed on pharmacologic procedural sedation and analgesics, but environmental and non pharmacologic therapis contribute greatelyto distress reduction.
Review of literature is organized under the following section.
Section-I studiesrelated to pain and behavioral distress during
painful procedures.
Section-II studies related to non-pharmacological interventions
during painful Procedures.
Section-III studies related to distraction during painful
procedures.
Section- IVStudies related to flacc scale.
Section - I
Studies related to pain and behavioral distress during painful
procedures.
A study was conducted on pain reduction during pediatric immunizations. the pain associated with immunizations is a source of anxiety and distress for the children receiving the immunization, their parents, and the providers who must administer them. A number of studies suggest that the ventrogluteal area is the most appropriate for all age. Longer needles are usually associated with lees pain and less local reaction. During the injection, parental demeanor clearly affects the child’s pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, where humor and distraction tend to decrease distress. Immunizations are stressful for many children; until new approaches are developed, systematic use of available technique can significantly reduce the burden of distress associated with these procedures.6
A study was conducted on the effectiveness of complementary therapies on the pain experience of hospitalized children. pain is a complex phenomenon for children, and the concepts of hospitalization and pain are often linked in the minds of children. Despite best-practice guidelines and standard related to pain management, many hospitalized children continue to have unrelieved pain.This suggests that analgesics alone do not sufficiently relieve their discomfort. Complementary therapies may have an important role in holistic pediatric pain management. This review of literature,evaluates available evidence related to the use and effectiveness of complementary therapies on the pain experience of children in hospital settings. Thirteen recent research articles relative to this topic were located and included in this review. A variety of complementary therapies, including relaxation, distraction, hypnosis, art therapies and imagery are included.7
A study was conducted, to reveal, the effect of music versus non- music on behavioral signs of distress and self- report of pain in pediatric injection patients. music has been examined as a potential distraction during pediatric medical procedures. Subsequent analysis indicated that children who received more injection tended to benefit more from the music intervention, in terms of their perceived pain.8
A study was conducted, that allowing 1or both parents to be present during invasive procedures reduces the anxiety that parents experience while their child is in the pediatric intensive care unit; to evaluate if the parents presence helpful to the
child and parent; and to determine whether this presence was harmful to the nurses or physicians. A 12-bed pediatric intensive care unit in upstate new york. the study population consisted of the parents of 16 children undergoing 1or more procedures; Allowing parental presence during procedures decreases procedure-related anxiety.9
A study was conducted to investigate the effectiveness of a distraction technique in reducing a child’s perceived pain and behavioral distress during an acute pain experience. During venipuncture, the central subjects receives standard preparation,. Which consisted of being comforted by physical touch and soft voices, while experimental subjects were encouraged to use a kaleidoscope as a distraction technique. results confirmed that the experimental group perceived less pain and demonstrated less behavioral distress than the control group.10
the study was conducted to reveal, that acute painful medical procedures frequently engender anxiety reactions in children and sensitize them to future medical interventions. Techniques that reduce pain and anxiety, including behavioral distraction (e.g bubbles and pop-upbooks), kinesthetic methods ( e.g hypnosis). these pain reductions techniques are synergistic with analgesics and long term benefits for pediatric patients.11
Section-II
Studies related to non-pharmacologic interventions during
painful procedures
a study was conducted using Guided imagery and distraction therapy and distraction Therapy in paediatric hospice care available evidence indicates deficits in the pain management of children with analgesic drugs used licensed boundaries, in situations where their pharmacokinetics are untested. A care series is used to demonstrate the effectiveness of more holistic techniques such as guided imagery and distraction therapy in reducing the pain experienced by children in the hospice setting. Using there techniques it may be possible to reduce the amount of analgesia or the frequency of administration.12
a study was conducted to reveal, the analgesic effect of passive or active distraction during venipuncture in children. 69 children aged 7-12 years undergoing venipuncture were randomly divided in to three groups: a control group © without any distraction procedure, a group (m) in which mothers preformed active distraction and TV group (tV ) in which passive distraction (a TV Cartoon) was used. TVwatching was more effective than active distraction or to the distracting power of television.13
a study revealed, non-pharmacologic intervention such as distraction, as powerful adjuncts in reducing pain and anxiety in children with both acute and chronic painful conditions. The use of distraction techniques is effective in reducing situational anxiety, pain intensity and pain distress (as perceived by the parents). this technique improve the quality of management of procedural pain in a pediatric setting.14
A study revealedthat,pediatric nurses are often present with children who are in discomfort or pain, and are essential to successful management of this pain. Selected non pharmacologic techniques are effective in reducing children’s discomfort and pain and thus have value in nursing practice.15
A studyconducted to assess the effect of an active distraction technique on pain in pre- school children receiving diphtheria, pertussis and tetanus immunization children were taught to blow out air repeatedly during the injection,
as if they were blowing bubbles. Children who were taught to blow out air during their shots had significantly fewer pain behaviors and reported less pain. A simple distraction technique can be effective in helping children cope with pain of immunization.16
A study was conducted to reveal, that preparation of the child for a painful procedure is an intervention that requires the provision of sensory-procedural information and coping skills. These coping skills such as relexation, distraction or imagery can be used by the child to reduce both quantitative and qualitative aspects of the pain experience.17
Section-III
Studies related to distraction during painful procedures.
A study was conducted to test the efficacy and suitability of virtual reality (VR) as a pain distraction for pediatric intravenous (I.V) placement. Twenty children (12boys,8girls) requiring I.V placement for a magnetic resonance imaging / computer tomography (MRI/CT) scan were randomly assigned to two condition,
- VR distraction using street luge (SDT), presented via a head- mounted
Display or
- standard of care (topical anesthetic) with no distraction.
Virtual reality pain distraction was positively endorsed by all reporters and is a promising tool for decreasing pain, and anxiety in children undergoing acute medical interventions.18
A study was conducted to reveal that, a distraction intervention reduce the distress of preschool children undergoing repeated chemotherapy injections. The results suggest that a developmentally appropriate, multisensory, variable – distracting activity that requires active cognitive processing and active motor responses may be a cost –effective alternative to more time – intensive parent – training programs for preschool- age children.19
A study was conducted to assess whether the use of a protocol for assessing, preparing and distracting children during procedures such as cannulation would decrease levels of pain and distress reported by children, parents and nurses. Pain thermometers and ‘scary faces’were used as tools to assess pain and anxiety levels of 82 children. Nurses have a responsibility to reduce children’s pain and anxiety as much as possible and distraction is one way of doing this.20
A study was conducted to examine nurse- directed distraction for reducing infant immunization distress. ninety infants and their parents were randomly assigned to a distraction condition (i.e. nurses used stimuli to divert infant’sattention) or a typical care condition. Results indicated that infants engaged in distraction and that distraction reduced their behavioral distress.21
A study was conducted to compare the effect of two forms of distraction on injection pain of preschool children. A quasi experimental study of 105 children (53 girls and 52 boys) age 4 to6 years needing DPT immunizations. Study children were randomly assigned to receive one of three treatments with their DPT injection: touch, bubble-blowing, or standard care. Both the forms of distraction touch and bubble- blowing significantly reduce pain perception.22
Conducted the study, to evaluate the effect of self- selected distractors (i.e. bubbles, I Spy: super challenges book, music table, virtual reality glasses, or handheld video games) on pain, fear and distress in 50 children and adolescents with cancer, ages 5 to 18, with part access or venipuncture. Using an intervention comparison group design, participants were ramdomized to the comparison group (n=28) to receive standard care or intervention group (n=22) to receive distraction plus standard care. The authors conclude that distraction has the potential to reduce fear and distress during port access and venipuncture.23