Effectiveness of
Cryotherapy on Arteriovenous Fistula Puncture related Pain among Hemodialysis
Patients in Selected Hospitals, Mangalore
Miss. Lijiya Jose, Mrs. Diana Lobo
MSc. Nursing, Laxmi Memorial College of
Nursing, A.J Towers, Balmatta, Mangalore- 575 002
Associate Professor, Department of Medical
Surgical Nursing, Laxmi Memorial College of Nursing,
A.J Towers, Balmatta, Mangalore -575 002
*Corresponding
Author’s Email: lijiyajose3@gmail.com, sinorad@rediffmail.com
ABSTRACT:
AIM: The purpose of the study is to assess the
effectiveness of cryotherapy during arteriovenous fistula puncture related pain
among hemodialysis patients.
BACKGROUND: Hemodialysis is one of the most frequently
used modality for renal replacement therapy. Pain inflicted by the insertion of
large cannulae into the arteriovenous fistula is a significant cause of concern
for both the children and adults on regular hemodialysis. Cryotherapy as a non
pharmacological pain management is a complimentary therapy has the advantage of
being effective, less cost, easy to provide and safe.
METHOD: The study consist of total 50 samples, 25
in experimental group and 25 in control group
DESIGN: The design adopted for the study was
Quasi experimental time series design. Using the purposive sampling technique,
50 (experimental=25, control=25) chronic renal failure patients were selected
and data was collected using the demographic proforma, numerical rating scale
and observational checklist for behavioral response during arteriovenous
fistula puncture. On next cycle after 1st assessment of arteriovenous puncture
related pain, cryotherapy was given to the experimental group with ice pack on
the web between the thumb and index finger of the hand not having the
arteriovenous fistula (contralateral arm). The procedure was started 5 minutes
before venepuncture and continued throughout the puncturing procedure
approximately 10 minute. Pain and behavioral response to pain was assessed in
both the control and experimental group using the numerical rating scale and
observational checklist during arteriovenous fistula puncture. On next cycle of
hemodialysis same procedure was repeated among the experimental group and pain
and behavioral response to pain was assessed in both the experimental and
control group.
RESULTS: There was a significant difference
between the pre-test and post- test behavioral response scores and pain scores
in the experimental group (F2,72= 3.15, p<0.05). The mean post-test
behavioral response scores of the experimental group (3.2±1.05, 2.8±1.11) was
lower than the mean post-test behavioral response scores of the control group
(4.6±1.22, 4.5±0.86) in the post-test 1 , 2 respectively. The calculated ‘t’
values (t1=4.21, t2=6.21) were more than the table value (t48=1.96) at 0.05
level of significance. The mean post-test pain scores of the experimental group
(3.3±1.37, 2.8±1.09) were lower than the mean post- test pain scores of the
control group (4.32±0.9, 4.56±1) in the post-test 1, 2 respectively. The
calculated ‘t’ values (t1=3.04, t2=5.66) were more than the table value
(t48=1.96) at 0.05 level of significance.
CONCLUSION: The findings of the study concluded that
cryotherapy was effective in reducing subjective pain and objective behavioral
response scores of arteriovenous fistula puncture related pain.
KEYWORDS: Effectiveness; arteriovenous
fistula puncture related pain; cryotherapy; hemodialysis patients.
INTRODUCTION:
“The aim of the wise is not to secure pleasure but to avoid pain”
“Bones can break, muscles can
atropy, glands can loaf, even the brain can go to sleep without immediate
danger to survival. But should the kidney fail…neither bone, muscle, gland, nor
brain could carry on.” This statement underlines the importance of kidneys in
our lives. Adequate functioning of the kidneys is essential for the maintennce
of a healthy body. If there is complete kidney failure and treatment is not
given, death is inevitable.1
In India, according to survey conducted by
National Kidney Foundation, the kidney diseases rank third amongst
life-threatening diseases and estimates approximately 200,000 people in India
to go into terminal kidney failure annually and millions more suffer lesser
forms of kidney disease.2 Technological advances in the care of renal failure
patients provide several renal replacement therapies such as hemodialysis,
peritoneal dialysis, hemofiltration and transplantation3,4.
Hemodialysis (HD) is the most frequently
used renal replacement treatment with the arteriovenous fistula (AVF) being the
gold standard for vascular access in HD patients.5 Patients with end
stage renal disease undergoing hemodialysis are repeatedly exposed to stress
and pain from approximately 300 punctures per year to their AVF. Considerable
patient discomfort and stress can be associated with the insertion of large
gauge needles into an AVF. Alleviation of this pain might improve their
acceptance of the procedure and thus, their quality of life.6
Pain is an unpleasant feeling and
emotional experience that is related to real or potential tissue damage or a
damage that is defined similarly7. From many points of view, the
pain is a common symptom intended for seeking aid8. International
Association for the Study of Pain (IASP) defines the pain as “an unpleasant
emotional situation which is originating from a certain area, which is
dependant or non-dependant on tissue damage and which is related to the past
experience of the person in question”7.
A combination of pharmacological and
non-pharmacological methods of pain control probably yield the most effective
pain relief for the patient.9 Non-pharmacological interventions to
reduce pain such as behavioral cognitive strategies as distraction, relaxation,
biofeedback, thought stopping, positive self talk, guided imagery and
biophysical interventions such as massage, pressure, transcutanous electrical
nerve stimulation (TENS), and heat and cold application.10
Cryotherapy is the local or general use of low temperatures in medical
therapy. Studies have also thrown light on the fact that cold therapy
(cryotherapy) is one of the effective cutaneous stimulation techniques in
alleviating pain. Cryotherapy is defined as the use of a substance that applied
to the body to decrease tissue temperature.11
Pain is one of the most common cause of
human suffering and it serves as a mechanism to warn us about the potential for
physical harm.12 A comparative study was conducted to quantify the
level of pain reported by patients during arterial puncture with or without
local anesthesia. The study included 270 consecutive patients undergoing
arterial puncture divided into 2 groups. In Group A (n=210), assessed the level
of pain with and without local anesthesia and with placebo. In group B (n=60),
compared pain of arterial and venous puncture. Mean level of pain for all
arterial punctures without anesthesia or placebo was slight to moderate
(3.01±1.94 cm). subcutaneous anesthetic infiltration before arterial puncture
significantly reduced pain by more than 50%, to 1.50±1.54 cm, a level that was
significantly lower than pain level reported after conventional venous puncture
(1.80±1.10 cm) .The pain reported by patient who received no anesthesia was not
significantly different (P=0.45) from than perceived by those who received subcutaneous
infiltration of saline solution (placebo).13
Cryotherapy is common and useful
therapeutic modality often used in treating a wide range of conditions. It is
easy to apply and if care is taken over cautions and contraindications it is
very safe and patients can be instructed to self treat to manage their
conditions.14The use of cryotherapy prior to venipuncture as an easy
and effective intervention for reducing venipuncture related pain.15
The investigator, during her clinical
experience has come across chronic renal failure patients having pain during
arteriovenous fistula puncturing. From the findings of literature, the
researcher realized the importance of administering cryotherapy for the
reduction of the arteriovenous fistula puncture related pain and designed a
study on the effectiveness of cryotherapy on arteriovenous fistula puncture
related pain among hemodialysis patients in selected hospitals at Mangalore.
OBJECTIVES OF THE STUDY:
1. To determine the pain and
behavioral response to pain during arteriovenous fistula puncturing among the
experimental group and the control group.
2. To evaluate the effectiveness
of cryotherapy on pain during arteriovenous fistula puncture among the
experimental group.
3. To determine the post-test pain
and behavioral response to pain scores among hemodialysis patients in the
experimental andcontrol group.
MATERIALS AND METHODS:
The Quasi
experimental study was conducted to evaluate the effectiveness of cryotherapy
on arteriovenous fistula puncture related pain among hemodialysis patients. Prior
to the data collection, permission was obtained from the concerned hospital
authorities for conducting the study.By using purposive sampling technique 50
hemodialysis patients were selected and patients were randomly assigned to the
experimental group (n 1 =25) and control group (n 2 =25).
On day 1, pain
during arteriovenous fistula puncture related pain was assessed using the
numerical rating scale and observational checklist for behavioral response
during arteriovenous fistula puncturing in the experimental and control
group.Next cycle after 1st assessment of arteriovenous puncture
related pain, cryotherapy was given to the experimental group with ice pack on
the web between the thumb and index finger of the hand not having the
arteriovenous fistula (contralateral arm). The procedure was started 5 minutes
before venepuncture and continued throughout the puncturing procedure
approximately 10 minutes. Pain and behavioral response to pain was assessed in
both the control and experimental group using the numerical rating scale and
observational checklist during arteriovenous fistula puncture.
Same procedure was
repeated on next cycle of hemodialysis among the experimental group and pain
and behavioral response to pain was assessed in both the experimental and
control group. The collected data was analyzed using the descriptive and
inferential statistics.
RESULTS:
Section 1: Description of the Demographic
Variables
Highest percentage of subjects in the
experimental (48%) and control group (60%) were in the age group of 40-59.
Majority of the subjects in the experimental group (60%) and control group
(72%) were males. Majority of the subjects in the experimental group (64%) and
control (68%) were Hindus. Maximum percentage of the subjects (36%) in the
experimental group and control group (52%) were on hemodialysis for 1-3 years.
Most of the subjects in the experimental group (72%) and control group (60%)
were having hypertension. Highest percentage of the subjects in the experimental
group (56%) were having duration of arteriovenous fistula for less than 1year
where as in control group majority of subject(56%) were having duration of
arteriovenous fistula for 1-3 years.
Section 2: Description of Level of Pain of
Arterovenous Fistula Puncture Related Pain before and after Cryotherapy in
Experimental and Control Group
The data in Figure 1 reveals
that in the pre-test majority of the subjects in experimental group (76%) had
moderate behavioral response to pain but in the post-test 1 (64%) and post-test
2 (72%) had mild behavioral response to pain.
Figure 1: Bar Diagram showing Percentage
Distribution of Hemodialysis Patients in Terms of Behavioral Response scores in
the Pre-test, Post-test 1 and Post-test 2 in the Experimental Group
Figure 2: Bar Diagram showing Percentage
Distribution of Hemodialysis Patients in terms of Behavioral Response scores in
the Pre-test, Post-test 1 and Post-test 2 in the Control Group
The data in the Figure 2
reveals that in majority of the subjects in control group in pre-test (60%),
post-test 1(76%) and post-test 2 (92%) had moderate behavioral response to
pain.
Figure 3: Bar Diagram showing Percentage
Distribution of Hemodialysis Patients in terms of Level of Pain in the
Pre-test, Post-test 1 and Post-test 2 in the Experimental Group
Figure 3 shows that in the pre-test
majority of the subject (72%) in the experimental group had moderate pain where
as majority of subject in post-test 1(60%) and post-test 2(84%) had mild pain.
Figure 4: Bar Diagram showing
Percentage distribution of Hemodialysis Patients in Terms of Level of Pain in
the Pre-test, Post-Test 1 and Post-test 2 in the Control Group
The data in the Figure 4
reveals that the majority of the subjects in pre-test (68%), post-test 1 (84%),
and post-test 2 (84%) in the control group had moderate pain.
Section 3: Effectiveness of Cryotherapy on
Pain during Arteriovenous Fistula Puncture among the Experimental Group
Table 1: F Value showing the Significant
Difference between the Pre-test and Post-test Behavioral Response scores during
Arteriovenous Fistula Puncture among the Experimental Group N=25
|
Experimental group
|
Sum of squares
|
df
|
Mean squares
|
F value
|
|
Between group
|
138.7
|
2
|
69.3
|
54.7*
|
|
Within group
|
91.2
|
72
|
1.2
|
|
Total
|
229.9
|
|
|
|
F2,72=3.15; *=significant
The data depicted in Table 1 shows that
there was a significant difference between the pre-test and post-test pain
scores in the experimental group (F2,72=3.15, P<0.05).
Table 2 :F Value showing the Significant
Difference between the Pre-test and Post-test Pain Scores of the Experimental
Group N=25
|
Experimental group
|
Sum of squares
|
df
|
Mean squares
|
F value
|
|
Between group
|
96.8
|
2
|
48.4
|
30.4*
|
|
Within group
|
114.3
|
72
|
1.58
|
|
Total
|
211.1
|
|
|
|
F2,72=3.15 ; *=significant
The data depicted in Table 2 shows that
there was a significant difference between the pre-test and post-test pain
scores in the experimental group (F2,72=3.15, P<0.05).
Significance of Difference between the
Post-test Pain Score of the Experimental and Control Group
Table 3 : Unpaired ‘t’ test showing
Significant Difference between the Post-test Behavioral Response scores in the
Experimental and Control Group on Observational
Checklist
N=25+25
|
Group
|
Observations
|
Mean Score
|
Mean Difference
|
SD difference
|
t value
|
|
Experimental
|
Post-test 1
|
3.2
|
1.4
|
0.17
|
4.21*
|
|
Control
|
4.6
|
|
Experimental
|
Post-test 2
|
2.8
|
2.3
|
0.25
|
6.21*
|
|
Control
|
4.5
|
t48=1.96; *=significant
Table 4: Unpaired ‘t’ Test showing the
Significant Difference between the Post-test Pain Scores of the Experimental
Group and Control Group N=25+25
|
Group
|
Observations
|
Mean Score
|
Mean Difference
|
SD difference
|
t value
|
|
Experimental
|
Post-test 1
|
3.3
|
1.0
|
0.47
|
3.04*
|
|
Control
|
4.3
|
|
Experimental
|
Post-test 2
|
2.8
|
1.7
|
0.09
|
5.66*
|
|
Control
|
4.5
|
t48=1.96; *=significant
The data in Table 3 shows that the mean
post-test 1 and 2 behavioral response scores of the experimental group (XE1=3.2,
XE2=2.8) were significantly lower than the mean post-test 1 and 2
behavioral response scores of control group (XC1=4.6, XC2=4.5),
respectively. There was a significant difference between experimental and
control group post-test 1 and 2 pain scores since the calculated‘t’ values (t1=4.21,
t2=6.21) were greater than the table value (t48=1.96) at
0.05 level of significance.
The data in Table 4 shows that the mean
post-test 1 and 2 pain scores of the experimental group (XE1=3.3, XE2=2.8)
were significantly lower than the mean scores of control group (XC1=4.3,
XC2=4.5)in post-test 1, 2, respectively. There was a significant
difference between experimental and control group post-test 1 and 2 pain scores
since the calculated’ values (t1=3.04, t2=5.66) were more
than the table value (t(48)=1.96) at 0.05 level of significance.
DISCUSSION:
Majority of the subjects in the
experimental group (O=76%) and the control group (O=60%) had moderate
behavioral response to pain in the pre-test but in the post-test 1 and
post-test 2 ,majority of the subject in the experimental group (O1=64%,
O2=72%) had mild behavioral response to pain where as in the control
group majority of subject (O1=76%, O2=92%) had moderate
behavioral response to pain. The result shows that in the experimental group
the behavioral response to pain has reduced from moderate to mild as a result
of cryotherapy. The present study findings are supported by the study regarding
the effect of cutaneous stimulation on arteriovenous fistula puncture pain
among hemodialysis patients revealed that in the pre-test, majority of the
subjects (55.8%) had moderate pain and in the post-test 1, majority of the
subjects (67.3%) had mild pain and post-test 2, majority of the subjects
(65.4%) reported that pain was absent .16
In the present study, in the pre-test
majority of the subjects in the experimental group (O=70%) had moderate
intensity of pain but in the control group majority of subjects (O=60%) had
mild pain. Where as in the post-test 1 and post-test 2, majority of subjects (O1=80%,
O2=90%) in the experimental group reported mild pain where as in the
control group in post-test 1 and 2 (O1=50%, O2=60%) had
moderate type of pain. The result of the study shows that the pain scores of
the experimental group reduced from moderate to mild as a result of
cryotherapy.
The above findings are supported by a
study conducted to assess the impact of cryotherapy on pain intensity at
puncture site of arteriovenous fistula among children undergoing hemodialysis
using Wong Backer Scale also shows that more than one third of children in the
control group (O1=35%, O2=37%) had moderate pain or mild
pain during artery needle puncture, while less than half of children in the
experimental group (O3=42.5%,O4=45%) had mild pain or no
pain respectively.17 Another study on the effect of cutaneous
stimulation on arteriovenous fistula puncture pain among the hemodialysis
patients shows that in the pre-test majority of the subjects (51.9%)
had moderate pain and in the post-test 1 majority of the subjects (46.2.%) had
mild pain and in post-test 2 majority of the subjects (51.9%) reported that
pain was absent.16
There was a significant difference between
the experimental and control group post-test 1and 2 pain scores since the
calculated ‘t’ values (t1=3.04, t2=5.66) were greater
than the table value (t48=1.96) at 0.05 level of significance. The
present study findings were supported by a study on impact of cryotherapy on
pain intensity at puncture sites of arteriovenous fistula among children
undergoing heamodialysis shows that Wong Backers pain rating scales during
artery needle punctures had differences between the control group (day 1) and
study group (days 3, 4) (c2=24.89, p=0.05, c2=25.61, p=0.04 respectively).17
There is a significant difference between
the pre-test and post-test behavioral response scores during arteriovenous
fistula puncture among the experimental group since the calculated ANOVA value
(F=54.7) was more than the tabled value (F2,72=3.15) at 0.05 level
of significance. The study findings are supported by the study regarding the
effect of cryotherapy on arteriovenous fistula puncture related pain among the
hemodialysis patients shows that the arteriovenous fistula puncture pain scores
on days 1 and 2 of hemodialysis within the experimental group were found to be
reduced (P=0.001) from an
average of 3.8 on day 1 of hemodialysis (when the patient received routine
care) to 0.7 on day 2 of hemodialysis (when cryotherapy was given).15
In the present study, there is a significant
difference between the pre-test and post-test pain scores during arteriovenous
fistula puncture among the experimental group since the calculated ANOVA value
(F=30.4) was significantly more than the tabled value (F2,72)=3.15)
at 0.05 level of significance. Similar findings were seen in a study on effect
of cryotherapy on arteriovenous fistula puncture related pain among the
hemodialysis patients shows that there was a significant reduction (P=0.001) in the arteriovenous fistula
puncture pain scores (1−2.5) on day 2 of hemodialysis as compared to the
scores (2−7) on day 1 of hemodialysis.15 The present study
findings are also supported by another study regarding the effect of cutaneous
stimulation on arteriovenous fistula puncture pain among the hemodialysis
patients shows that there was a significant reduction (P=0.001) in the
arteriovenous fistula puncture pain scores in the 2nd and 3rd
visit of hemodialysis.16
CONCLUSION:
The current study concluded
that cryotherapy was effective in reducing subjective pain and objective
behavioral response scores of arteriovenous fistula puncture related pain.
The following conclusions were
drawn from the study:
·
Most of the
patient had moderate type of pain during arteriovenous fistula puncture.
·
Majority of
the subject in the experimental and control group had moderate behavioral
response to pain in pre-test but in the experimental group it reduced to mild
behavioral response in post-test 1 and 2 where as in the control group it
remains same.
·
Majority of
the subject in the experimental group had moderate pain in the pre-test but in
the post-test 1and post-test 2, pain was reduced to mild pain where as in the
control group majority of subject in the pre-test had mild pain but it
increased to moderate in the post-test 1 and post-test 2.
·
The mean
post-test 1 and post-test 2 pain scores were lower than the mean pre-test pain
score. The result showed that cryotherapy was effective in reducing
arteriovenous fistula puncture related pain.
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