Int ern a tio na l Jo u rna l of Appli ed R esea rch 201 6; 2(6): 660 -6 6 4
ISSN Print: 2394-7500
ISSN Online: 2394-5869
Impact Factor: 5.2
IJAR 2016; 2(6): 660-664
www.allresearchjournal.com
Received: 20-04-2016
Accepted: 21-05-2016
Merlin Golda
Associate. Professor, Medical
Surgical Nursing, Narayana
College of Nursing, Nellore,
Andhra Pradesh, India.
D Revathi
Asst. Professor, OBG
Department. Narayana College
of Nursing, Nellore, Andhra
Pradesh, India.
N Subhashini
Asst. Professor, Medical
Surgical Nursing, Sree
Narayana Nursing College,
Nellore, Andhra Pradesh,
India.
Josme Mathew
Medical Surgical Nursing,
Narayana College of nursing
Nellore, Andhra Pradesh,
India.
Dr. Arumugam Indira
Principal, Narayana College of
nursing. Nellore, Andhra
Pradesh, India.
Correspondence
N Subhashini
Asst. Professor, Medical
Surgical Nursing, Sree
Narayana Nursing College,
Nellore, Andhra Pradesh,
India.
Assess the effectiveness of cold application on pre
procedure (AV fistula puncture) pain among hemodialysis
patients in tertiary care hospital, Nellore
Merlin Golda, D Revathi, N Subhashini, Josme Mathew and
Dr. Arumugam Indira
Abstract
Arteriovenous fistulas (AVFs) are common form of chronic hemodialysis access. Pain during
areteriovenous fistula (AVF) cannulation remains a common problem in hemodialysis patients. This
study was undertaken to assess the effect of cold application on pre procedure pain due to arteriovenous
fistula puncture in hemodialysis patients. A simple random sampling technique was used for selecting
sample of 60 patients (30 each in experimental and control groups) who were undergoing hemodialysis
by using AVF. Hemodialysis patients, who met the inclusion criteria, were randomly assigned to
experimental and control groups. The tools used were sociodemographic data and subjective pain
scoring was done by using numerical rating scale. Descriptive statistics and inferential statistics such as
paired t-tests, Independent t-test, Chi square were used. The study finding reveals that the subjective
pain scores were found to be significantly (P = 0.01) reduced within the experimental group by cold
application. This study highlights the need for adopting the alternative methods for reducing the pain at
AV fistula cannulation site in health care settings.
Keywords: Effectiveness, Cold application, AV fistula puncture pain, Hemodialysis patients
Introduction
Chronic kidney disease is emerging and most devasting medical, social and economic
problem for both patients and their families of our country. Chronic kidney disease is a
progressive, irreversible deterioration in renal function in which the body’s ability to
maintain metabolic, fluid and electrolyte balance fails. Most patients are in the final stage of
chronic kidney disease where the glomerular filtration rate is less than 15 ml/hr. At present
scenario approximately 100 per million people in a year globally, there could be 1, 00,000
patients from India. Most chronic kidney disease patients, reporting to tertiary care centers in
India are in the final stage where renal replacement therapy (RRT) is the only option at this
stage. The availability of various renal replacement therapies helps in reducing the severity
of symptoms and results in longer survival of end stage renal disease patient’s. These
patients largely depends on hemodialysis as a renal replacement therapy. Dialysis is a
common method of treatment for removing toxic waste products when the kidney unable to
perform its function due to impairment Vascular access is the vital life line for hemodialysis.
The most common vascular access sites are arteriovenous fistula, arteriovenous graft and
venous catheter. According to National Kidney Foundation Dialysis Outcome Quality
Initiative [DOQI] (2005) report, AV fistula remains as the gold standard for vascular access
in hemodialysis patients. Once mature, the AV fistula has excellent long term patency rates
andrarelybecomeinfected.AVfistulacanprovideadequatevascularaccessforover20years.
Figueiredo AE et al, (2008) [5] conducted a study on the pain perception with AV fistula
cannulation. Pain was assessed by using visual analogue scale for 75 patients during the three
consecutive sessions of hemodialysis. The result of the study was that most of the patients
experiences moderate to severe pain during AV fistula cannulation.
Mechanism of action
Cold application as a cutaneous stimulation technique is an inexpensive nursing intervention
that is advocated to minimize pain in patients. The effect of cutaneous stimulation is best
explained through gate control theory proposed by Melzac in 1965.
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International Journal of Applied Research
According to this theory touch impulse are transmitted to
the spinal cord greatly by A- delta fibers and pain impulse
by the C-fibers. If the impulse transmission in thick fibers
(touch) can be increased, this selectively blocks conduction
in the thin fibers (pain) by closing a gate consisting of
specific nerve cells in dorsal horn of spinal cord. The
impulse from cold application is also transmitted by the
touch fibers.
Variables
Independent variable: cold application
Dependent variable: AV fistula puncture pain.
Title of the study
A study to assess the effectiveness of cold application on pre
procedure (AV fistula puncture) pain among hemodialysis
patients in NMCH, Nellore
Part II
Standardized numerical rating scale for pain assessment.
Method of data collection
Part 1
It deals with the demographic data which includes age, sex,
education, occupation, family income and clinical data.
Content validity
Validity obtained from experts in Nursing and ethical
committee and 1 from HOD of department of Nephrology
Objectives
To assess the intensity of AV fistula puncture pain
among hemodialysis patients.
To assess the effectiveness of cold application on AV
fistula puncture pain among hemodialysis patients of
experimental group.
To compare post interventional score on pain
perception between experimental and control group.
To associate the post test pain score of hemodialysis
patients with selected socio demographic variables
Reliability
Reliability of the tool tested by using Karl Pearson
coefficient correlation method. The ‘r’ value is 0.93
Pilot study
Pilot study was conducted and finding revealed that tool was
feasible for conducting main study
Data Collection Procedure
Permission was obtained from the Medical
superintendent, HOD of Nephrology department,
ethical committee and the nursing superintendent.
Data collection was done for a period of 4 weeks.
The patients who fulfilled the inclusive criteria were
selected for the study.
Informed consent was obtained.
Assessed the level pain by using pain scale for both
experimental and control group during AV fistula
puncture for hemodialysis on the first visit.
Applied cold application for experimental group on the
next visit.
3 ice cubes (made with 30ml of water) were taken and
wrap on the unsterile glove.
Make the patient in a comfortable position.
Find out the LI-4 meridian point on the contra lateral
hand of AV fistula.
Apply ice cubes on that point 10 minutes prior to the
insertion of the catheter needle and which is continued
while another staff performing AV fistula cannulation.
Assessed the level pain by using same pain scale for
both experimental and control group during AV fistula
puncture after the intervention.
Methodology
An experimental study design with pre test - post test,
control group was adopted for this study. The study was
conducted at Narayana General Hospital, Nellore. Sample
consists of patients with chronic kidney disease those who
are undergoing hemodialysis via an AV fistula in the
dialysis unit of NMCH, Nellore. The sample size is 60 in
which 30 patients are in experimental and 30 control group
respectively. Samples selected by using simple random
sampling through lottery method.
Criteria for Sample Selection
Inclusion Criteria
1. Patients with chronic kidney disease who are
undergoing hemodialysis via AV fistula in
hemodialysis unit of NMCH, Nellore.
2. Patients with age between 39 and 61 years.
Exclusion Criteria
1. Contraindications to cold application such as radiation
injury, peripheral vascular disease, connective tissue
disorders, diabetic neuropathy.
2. Patients who are unconscious or disoriented.
3. Patients who require more than one attempt for fistula
puncturing.
4. Patients who suffers from pain other than AV fistula
pain.
S. No.
Data Analysis
1
Descriptive
statistics
Method
Frequency, percentage,
mean and standard
deviation
Paired t- test
2
Inferential
statistics
Independent t-test
Chi-square test
Data Analysis and Statistical Methods Used
The data was analyzed in terms of objectives of the study by
using
Purpose
Distribution of the Demographic variables.
To assess the intensity of AV fistula puncture pain
among hemodialysis patients
To assess the effectiveness of cold application on AV
fistula puncture pain among experimental group.
To compare the post test level of pain between
experimental and control group.
To associate the post test level of pain of hemodialysis
patients with selected demographic variables.
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International Journal of Applied Research
Section II: Assessment of the intensity of AV fistula
puncture pain among hemodialysis patients.
Section III: Comparison of the pretest and post test level of
pain among hemodialysis patients in experimental group.
3. Results
The data was organized, tabulated, analyzed and interpreted
by using descriptive and inferential statistics based on the
objectives of the study. The findings were presented in the
following sections.
Section IV: Comparison of the post test level of pain
between experimental and control group.
The analysis of the data was mainly classified as
Section-I: Frequency and percentage distribution of socio
demographic variables of caregivers
Section V: Association of post interventional pain scores
with selected socio-demographic variables among
hemodialysis patients.
Section I: Frequency and percentage distribution of socio demographic variables of caregivers
S. n
demographic variable
1
Age
A. 40-45 Years
B. 46-50 Years
C. 5i-55years
D. 56-60years
Sex
A. Men
B. Women
Education
A. Illiterate
B. Primary Education
C. Secondary Education
D.Graduate
Occupation
A. Unemployed
B. Permanent Employee
C. Daily Wage
Family Income Per Month
A. Rs.<3000
B. Rs.<3001-5000
C. Rs.<5001-7000
D. Rs.>7001
Period Of Av Fistula Use
A. 1-6 Months
B. 7-12 Months
C. 13-18months
D. 19-2 Months
No. of Hemodialysis Per Week
A. Once
B. Twice
C. Thrice
Sources Of Psychological Support
A. Health Professionals
B. Family Members
C. Friends
Use of Diversional Therapy
A. Yes
B. No
2
3
4
5
6
7
8
9
experimental group
frequency
%
Control group
frequency
%
3
6
12
9
10
20
40
30
4
7
11
8
13.33
23.33
36.67
26.67
20
10
66.67
33.33
19
11
63.33
36.67
9
12
6
3
30
40
20
10
7
11
8
4
23.33
36.67
26.67
13.33
16
9
5
53.33
30
16.67
19
8
3
63.33
26.67
10
6
7
12
5
20
23.33
40
16.67
11
8
5
6
36.67
26.67
16.66
20
6
9
10
5
20
30
33.33
16.67
8
8
8
6
26.67
26.67
26.67
19.99
2
24
4
6.67
80
13.33
6
18
6
20
60
20
22
5
3
73.33
16.67
10
20
5
5
66.66
16.67
16.67
7
23
23.33
76.67
6
24
20
80
Section II: Assessment of the intensity of AV fistula puncture pain among hemodialysis patients.
Frequency and Percentage Distribution of Pre-Test and Post-Test Score of Av Fistula Puncture Pain among Experimental Group
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International Journal of Applied Research
Frequency and Percentage Distribution of Pre-Test and Post-Test Score Of Av Fistula Puncture Pain
among Control Group
Section III: Comparison of the pretest and post test level of pain among hemodialysis patients in experimental group.
Criteria
Pre test
Post test
Level Of Pain
MEAN
6.3
1.53
Paired ‘T’ Test
‘T’ Cal Value
SD
1.15
0.77
“t”=12.36**
Section IV: Comparison of the post test level of pain between experimental and control group.
S.N
Criteria
Post - test level of pain among hemodialysis patients in experimental group
1
2
Post-test level of pain among hemodialysis patients in control group
**= significant at 0.01 level
MEAN
1.53
5.7
SD
0. 768
1.79
“t” cal value
“t” tab value
11.58**
2.39
Section V: Association of Post Interventional Pain Score
With
Socio
–Demographic
Variables
among
Experimental and Control Group
Thechi-square test revealed that there was no statistically
significant association between the post interventional pain
score with the selected socio demographic variables such as
age, sex, education, occupation, income of the family,
period of AV fistula use, hemodialysis per week, sources of
psychological support and use of diversional therapy among
experimental group.
Sample size was 60; 30 in experimental and 30 in control
group. Pain was assessed using visual analogue scale and
observational check list. Data was analyzed using
descriptive and inferential statistical method. Pain score was
categorized as mild pain, moderate pain and severe pain.
The statistical analysis showed that 24(80%) children
experienced mild pain and only 6(20%) experienced severe
pain after IM injection among experimental group whereas
in control group 28 (93.3%) children experienced severe
pain and 2(16.7%) had moderate pain
Discussion
The main common access for hemodialysis is AV fistula. It
is surgically created communication between the artery and
vein. Pain is the common experiencing problem during each
cycle of hemodialysis. The present study was conducted
with an aim to elicit pre procedure cold application on AV
Fistula cannulation site reduces the intensity of pain. 30
patients who receiving hemodialysis were divided into
experimental and control groups. The study finding revealed
that during the pre test, 13(43.33%) clients had severe pain
and 17(56.67%) clients had moderate pain. In the post test
pain score level was reduced as 1(3.33%) clients had severe
pain and 4(13.33%) had moderate pain, 11(36.67%) had
mild pain and 14(46.67%) had no pain and in control group
during the pre test 13(43.33%) had severe pain and
17(56.67%) had moderate pain. In the post test 11(36.67%)
had severe pain, 15(50%) had moderate pain and 4(13.33%)
had mild pain. Showed that there was no reduction in pain
scores without intervention. These results are consistent
with the study conducted by Elsharawy MA (2000) [1] with
an aim to assess the effectiveness of ice application on the
LI-4 meridian point prior to intramuscular injection in
reducing pain among children. It was a post test only design.
Conclusion
This study showed that samples in both experimental and
control group had moderate to severe pain during pre test
but after the cold application there was a significant
reduction in pain scores among the experimental group. The
pain scores remains same and even some clients’ pain level
got increased among control group. This implies that cold
application is helpful in reducing AV fistula puncture pain
among hemodialysis patients.
5. References
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of IM injection pain among children, Acta Chir Belg,
2000; 105(4):355-8.
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Bjordal. Cryotherapy for acute ankle sprains: a
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3. Bruno CS Carvalho, Isabel CF da Cruz. Chronic Renal
Patients In Whom The Effect Of Application of Cold
Compress As Compared With The Use of Topical
Anesthetics Before The Punch of Fistula-Arteriovenous
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International Journal of Applied Research
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