RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF STUDENT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

MS.KAVITHA

SRI LAKSHMI COLLEGE OF NURSING,

NO.127/1, SRI GANDHADAKAVAL,

MAGADI MAIN ROAD,

VISWANEEDAM POST, SUNKADAKATTE,

BANGALORE-560091

2. NAME OF THE INSTUTION SRI LAKSHMI COLLEGE OF NURSING,

NO.127/1, SRI GANDHADAKAVAL,

MAGADI MAIN ROAD,

VISWANEEDAM POST,

SUNKADAKATTE,

BANGALORE-560091

3. COURSE OF STUDY AND SUBJECT M.SC., NURSING 1ST YEAR PAEDIATRICS

4.

DATE OF ADMISSION TO COURSE

01-06-2011

5. TITLE OF THE TOPIC A STUDY TO ASSESS THE EFFECTIVENESS

OF MANUAL PRESSURE ON LUMBAR

REGION TO REDUCE PAIN DURING

INTRAMUSCULAR INJECTION FOR INFANTS

IN SELECTED HOSPITAL, BANGALORE,

KARNATAKA

1

6.0 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

“When I hear a baby’s cry of pain change to a normal cry of hunger, to my ears, that is the most beautiful music.”

-Albert Schweitzer

Over the centuries, the humans have searched for ways to give meaning

of the pain, to explain its causes and to find the pain itself. Pain is one of the

most basic and complex of civilization. Philosophers, theologists,

neurophysiologists and psychologists have attempted to explain the

phenomenon of pain.

Pain prompts people to seek health care more often than any other

symptom. It is one of the most important areas of care because people cannot

function fully when they are in pain. Pain is a complex phenomenon. It is

elicited by threatened or actual tissue damage that stimulates pain sensitive

receptors. Pain is a sensation with strong emotional association. Pain is a

commonly used and individually defined term. The word pain comes from the

Greek word “poine”, which means punishment or penalty. The modern

standard definition of pain is “an unpleasant sensory and emotional experience

associated with actual or potential tissue damage” (International association,

1999)

Routine immunizations, bruises and childhood illness mean that pain is

a part of everyday experiences of all children and infants. Because infants can

not describe their pain and emotions, it is important to observe the behavioural

responses of the children to assess the pain. (Quens, 1984)

The dual challenge of pain is to understand the diverse aspect of pain

perception and to provide adequate relief for all sorts of pain. The external and

2

6.1

internal factors that cause pain and the physiological mechanisms that convey

pain messages must be understood in which healthy infants perceive pain.

Accurate knowledge about pain perception in infants helps to provide

interventions that modify the perception of pain. (Patricia A. McGrath, 1990)

In the hospital pain causing procedures are blood collection,

intramuscular injection, and intravenous infusion etc. this procedural pain is

relieved by non pharmacological measures. These simple interventions seem to

maintain the oxygenation of blood and stabilize the heart rate. (Carbajal,

1999)

NEED FOR THE STUDY:

Pain in early infancy has only recently been recognized as an area

requiring systematic study in nursing. This has emerged in part because of

recognition of the need for an empirical base for paediatric pain management.

(Robinson, 1979)

Research has shown that the infant do feel and remember pain. Induced

pain from diagnostic tests or therapeutic procedures is most frequently referred

to as procedural pain. Each infant has an individual pattern of capability and

reactivity to painful procedures. Children’s experience of pain is recognized as

one of the most complex human stressors, which may have consequences for

later pain related behaviour and perception. Despite an increase in research on

pain in children, studies still report hospitalized children experiencing

unacceptable levels of pain.(Kortesluoma, et.al., 2004)

Research in the area of children’s pain is now receiving increase

attention in the literature as untreated pain has immediate and measurable

negative effects when the child had pain distress. Preliminary data suggests

that early expressions of pain may produce permanent structural and

reorganization for developing nociceptive pathway and it may affect the future

experience of pain. Neuroanatomical studies have shown that cortical and sub

cortical centres involved in the perception of pain and the pain pathway is well

developed by 29 weeks of gestation itself during fetal life. Behavioural and 3

physiological studies shown that even young infants respond to painful stimuli.

(Gary Robert,et.al., 1994)

During common treatment procedures crying or excessive handling can

lead to undesirable hypoxemia and hemodynamic changes in infants. The

administration of non pharmacological intervention helps for relief of

procedural pain. (Stevens, 1997)

A review of literature suggests that the intramuscular site is more often

associated with pain compared during intravenous or subcutaneous. The

tetanus vaccine is often singled out as a particularly painful shot due to the

nature of the tetanus bacteria itself that amounts to the pain experience. DPT

vaccination causes severe crying and unsettled behaviour in infants

(Brazeau.G.A.et.al., 1998)

Behavioural cues (i.e., facial expressions, cry, and body movements)

and physiological indicators of pain can be reliably and validly assessed either

alone or in combination. The most valid approach is facial expression. (Craig,

1998).

There are immediate and long-lasting harmful consequences to the

nervous system when infants experience severe or repetitive pain. These

effects are especially significant in preterm infants, who are vulnerable to

neurological damage during this critical time of neurodevelopment. Painful

experiences may cause structural and physiological changes within the nervous

system. Repeated painful procedures may result in decreased pain thresholds

and hypersensitivity to pain. Immediate harmful effects of pain include

physiologic instability and increased incidence of serious complications such

as intra ventricular haemorrhage. Painful stressors may lead to sleep

disturbances, feeding problems, and inability to self-regulate. Long term

effects of pain may include altered pain perception, chronic pain syndromes

and Somatic complaints. Repetitive pain in the preterm infant may be

associated with attention deficit disorders, learning disorders and behavioural

problems in later childhood. Nursing involvement with pain management is

4

crucial to achieve positive health outcomes for high risk infants, older children

and adults who have experienced repetitive or severe pain as infants.

Acupressure is very effective in relieving stress, tension and it provides

overall feeling of well being. Acupressure promotes the healing of injury and

post operative pain. Acupressure increases the blood circulation, providing

relief from severe headaches like migraine, shoulder aches, neck pain, back

pain and other body aches. Acupressure aids in the onset of labour and

decreasing the labour pain (fitness high. Com)

The gentle art of acupressure is easy to do at home for a sick or hurting

child. Massaging an acupressure point will help to relieve symptoms present

on the child. While providing acupressure treatment, the child should be calm

and relaxed as well as warmthness is necessary. Acupressure can apply

directly to child’s body or through a shirt or light sheet. After that the child is

made to breath deeply for a few moments to aid relaxation. (Janet Zand L,

1994)

The assessment and treatment of pain are important aspects of

paediatric practice and failure to provide adequate control of pain is considered

as substandard practice. (Robert Cassedy,et.al., 1994)

The investigator with experience has practically witnessed the response

of infants to painful procedures which motivated for non pharmacological

nursing interventions before intramuscular injection in infants to reduce pain.

Non pharmacological support for pain relief can be provided when it is

expected to be minimal or short duration. Avoiding over stimulation and

adopting a preventive approach by manual pressure for pain response can help

to manage pain in the infants by nurses.

Providing manual pressure promotes better health and avoiding

discomfort to the children. It helps the children to reduce the pain due to

intramuscular injection. The investigator is motivated for providing manual

pressure as a non pharmacological nursing intervention for infants who 5

6.2

receives intramuscular injection to reduce pain.

REVIEW OF LITERATURE:

Review of literature is an important step in the development of any

project. The task of reviewing literature induces the identification, selection,

analyzing and reporting of existing information and the problem chosen for the

study.

“Researchers almost never conduct a study in an intellectual vacuum;

their studies are undertaken within the context of an existing base knowledge.

(Polit and Hungler, 1999)

Review of literature refers to an extensive, exhaustive and systematic

examination of publications relevant to the research project. It helps the

investigator to analyze what is known about the topic and to describe the

methods of enquiry used in earlier work including the success and short

comings. It gives a broad understanding of the problem. The main goal is to

develop the evidence based study that will contribute to further knowledge in

development of nursing theory, education, practice and research. The

investigator has made adequate use of the available resources and has viewed

the related research and non research Literature, so as to proceed with the

study.

The review of literature has been described under the following headings:

6.2.1 Studies related to incidence and prevalence of pain during

IM injection for infants

6.2.2 Studies related to infants respond to pain during IM injection

6.2.3 Studies related to effectiveness of manual pressure during

IM injections

6.2.4 Studies related to non pharmacological measures used to

control pain

6

6.2.1

6.2.2

Studies related to Non pharmacological measures used to control pain:

A study was conducted to assess the importance of injection. Injections

are among the most common health care providers. With least 16 billion

administered in developing and transitional countries each year.95% of

injections are administered in curative care, 3% for immunizations and least

for other purposes such as blood transfusion.

A study was conducted to assess the infant's anatomical and functional

requirements for pain processing by mid to late gestation. According to this

study, term neonates have the same sensitivity to the pain, as older infants and

children. Preterm neonates may have greater sensitivity to pain than term

neonates as older children. Pain requires no Prior experience. It need not be

learned from earlier painful experience. Pain is present with the first insult.

A study was conducted to assess the significant complications after IM

injections of Vit-K to new-borns. It has been reported that pain experienced

during the neonatal period may have long term effects.

Studies related to infants respond to pain during IM injection:

A comparative study was conducted on infant pain response to IM

injection. For this study a sample of 113 infants are participated those who are

all 4-6 months of age receiving immunizations. This study included two

groups which is standard of care group and pragmatic group. In this study

comparison of Modified behaviour pain scale scores between standard group

and pragmatic group were used .Standard of care group means slow aspiration

prior to injection, slow injection and slow withdrawal. Pragmatic group means

no aspiration, rapid injection and rapid withdrawal. This study indicates that

MBPS scores were higher for the standard group compared to the pragmatic

group. The standard group was more likely to cry, and to take longer to have

the vaccine injected compared to pragmatic group.

A study was conducted to determine the factors associated with infant 7

6.2.3

pain response following an immunization injection. For this study a sample of

100 infants of 4-6 months age group were included. The finding suggests that

parental behaviour in the treatment room has a key role of influencing how

infants respond to painful procedure.

A study was conducted to assess the facial expressions and I

verbalization of pain during immunization. In this study 58 infants of 4-6

months are participated. Among them 53 infants are showing the brief facial

expressions.

A study was conducted to explore how infants express pain, on

receiving their routine immunizations. In this study 150 infants are

participated. Among them 90 infants are exploring the pain by facial

expressions. 60 infants are exploring the pain by other ways like crying and

body movements. The results revealed that the most common pain expression

is the facial expression, following immunization.

Studies related to effectiveness of manual pressure during IM injections

A study was conducted on the use of manual pressure to reduce pain.

An experimental study with intrasubject comparison was conducted using

manual pressure to reduce pain associated with intramuscular injection. 74

subjects, participating in an immunization vaccination campaign. They were

required to receive two doses of vaccines via intramuscular injections. One

was given in a conventional way, i.e. without manual Pressure being applied

prior to the injection (control condition). The other was given with manual

pressure being applied prior to the injection (Experimental condition) for 10

seconds. The two conditions were randomly allocated for each subject. The

instrument for measuring the Perceived pain intensity was the Pain Intensity

Verbal Rating Scale (Cantonese). To ensure the consistency of manual

pressure being applied to the injection site, a mechanical pressure sensor

device was used to record the manual pressure being applied. The mean

manual pressure applied was 190.82 mnHg(SD:5.25). Results demonstrated a

significant difference in the perceived pain intensity for experimental and

8

6.2.4

control conditions. Subjects with manual pressure applied before injections

reported lower pain intensity scores, whilst those without the application of

manual pressure before injections reported higher pain intensity scores.

Applying manual pressure to an injection site before performing an injection

could be an effective means of decreasing pain intensity.

A study was conducted to assess the effectiveness of acupressure to

reduce pain in IM injections. 64 patients were recruited into the study.32

(50%) were female.50 patients were injected with penicillin 6.3.3 (78%) and

14 patients received penicillin G plus procaine (22%). The mean score for

perceived pain intensity for the acupressure injection was 3 +_ 2and the mean

score for the injection without acupressure was 5+_2. The result showed that

the perceived pain intensity was at average2.5 lower in the acupressure group

comparing to ordinary injection (p < 0.000).

A study was conducted to determine the using pressure to decrease the

pain of IM injections. The purpose of this study was to determine if applying

pressure to the site for 10 sec prior to an IM injection would reduce injection

pain, an approached suggested by anecdotal observation and the gate control

theory. The subjects were g3patients who gad dorsogluteal IM injections of

immunoglobulin at a county health department. 48 received the pressure

treatment and, 45 received a standard injection in which no pressure was

applied. The findings suggest that simple manual pressure applied to the site is

a useful technique to decrease injection pain.

Studies related to non pharmacological measures used to control pain

A study was conducted to assess the non pharmacological techniques.

For this study 90 infants are included. The techniques which are used for the

study are distraction, relaxation, guided imagery and Provide coping strategy

that may help to reduce pain perception. The findings suggest that the non

pharmacological techniques which are used to control pain, those make pain

more tolerable, decrease anxiety and enhance the effects of analgesics.

9

6.3

A study was conducted to assess effect of breast feeding on pain relief

during infant immunization injections. Using a quasi-experimental design, this

study was conducted in two maternal & child health centres in Jordan to

examine the effects of breast-feeding on pain relief during neonatal

immunization injections. Pain responses of infants during and after

immunization were assessed by using Facial pain Rating Scale and

Neonatal/Infant Pain Scale (NIPS), before, during and after the procedure.

Infant's heart rate and duration of crying for both groups were calculated.

Findings revealed that the crying time was shorter in intervention (breastfed)

group than in the control group with a statically significant difference in the

duration of crying during and after immunization. The findings show that

breast feeding and skin-to-skin contact significantly reduced crying in infants

receiving immunization.

A study was conducted to find out the various non pharmacological

therapies. A number of non pharmacological therapies have been investigated

including non nutritive sucking with or without sucrose, swaddling, kangaroo

care, music therapy, and acupressure in the management of pain in neonates.

Acupuncture and acupressure may provide an effective non pharmacological

approach for the treatment of pain in infants.

STATEMENT OF THE PROBLEM:

A Study To Assess The Effectiveness Of Manual Pressure On Lumbar

Region To Reduce Pain During Intramuscular Injection For Infants In selected

Hospital, Bangalore.

OBJECTIVES:

6.3.1 To assess the behavioural and physiological responses of pain

during intramuscular injection after providing manual pressure among

experimental group.

6.3.2 To assess the behavioural and physiological responses of pain

10

6.4

6.5

6.6

6.7

during intramuscular injection infant among control group.

6.3.3 To compare the behavioural and physiological responses of

pain in infants between the experimental and control group.

6.3.4 To associate infants behavioural and physiological responses of

pain with the selected demographic variables at the level of 0.01 and

0.05 significance.

OPERATIONAL DEFINITIONS:

EFFECTIVENESS: It is the desired outcome of providing manual pressure in

pain reduction during intramuscular injection for infants.

MANUAL PRESSURE: It is a firm pressure given by the thumb in the

lumbar region 11/2-4 for 20 seconds.

INTRAMUSCULAR INJECTION: It is the administration of D.P.T.

injection into the vastus lateralis muscle.

INFANTS: It refers to the babies between 1-4months of age who are receiving

D.P.T. injection.

HYPOTHESIS:

H1- There is a significant difference between the intramuscular

injection pains between infants receiving manual pressure and infants not

receiving manual pressure.

H2- There will be significant association between behavioural and

physiological responses of pain with the selected demographic variables

ASSUMPTIONS:

6.6.1. Infant who receives intramuscular injection experiences pain.

6.6.2. Infant needs measures to get relief from pain.

6.6.3. Providing manual pressure will reduce the intramuscular

injection pain in infants.

11

7.0

7.1

7.2

7.2.1

7.2.2

7.2.3

7.2.4

DELIMITATIONS:

The study is limited to,

6.7.1 Infants who attend O.P.D. in selected hospital, Bangalore

6.7.2 Infants who receive D.P.T. injection.

6.7.3 Mothers who are willing to participate in this study.

MATERIALS AND METHODS

SOURCE OF DATA

Data will be collected from the infants in selected hospitals, Bangalore.

METHODS OF COLLECTION OF DATA:

RESEARCH DESTGN

Quasi experimental design will be adopted for the study.

RESEARCH APPROACH

A quantitative research approach will be to carry out for the study.

SETTING OF THE STUDY

The setting of the study is selected hospitals, Bangalore.

VARIABLES

INDEPENDENT VARIABLE:

Providing manual pressure in lumbar region.

DEPENDENT VARIABLES:

Behavioural changes such as cry, duration of cry, facial expression,

arm and leg movements and physiological changes such as heart rate and 12

7.2.5

7.2.6

7.2.7

7.2.8

7.2.9

oxygen saturation.

EXTRANEOUS VARIABLES:

Age, present D.P.T. dose, sex, significant member restraining the baby,

sweetener given with last one hour to the baby and previous history of

hospitalization.

POPULATION

The target population of this study are infants between 11/2 -4 months

SAMPLE

Infants who are receiving DPT injection in selected hospital, Bangalore

SAMPLE SIZE

For this study a sample of 60 infants, out of which 30 have received

manual pressure and 30 infants have not received the manual pressure before

administering intramuscular injection.

SAMPLING TECHNIQUE

The non probability purposive sampling technique will be adopted to

select the sample

SAMPLING CRITERIA

INCLUSIVE CRITERIA:

Infants between 11/2 -4 months-4months

Infants who receive D.P.T. injection.

Mothers who are willing to participate for their infants manual pressure

procedure

EXCLUSIVE CRITERIA:

Infants who are critically ill.

13

7.2.10

7.2.11

Pre mature and low birth infants

Baby who breast fed or ingestion of sweetener within one hour prior to

the study.

Mothers who are not willing to participate for their infants manual

pressure procedure

TOOLS FOR DATA COLLECTTON:

The tool for this study will be structured interview schedule

observational checklist.

Part 1: Demographic Data

This section consists of structured interview schedule about the

demographic details of the infant. It consists of age, sex, weight, significant

member restraining the baby, exclusive breast feeding, present D.P.T. dose and

sweetener given within last one hour.

PART 2: Modified Lawrence Infant Pain observation scale

This section is comprised of,

Assessing behavioural responses by cry, facial expression, legand arm

movements and duration of cry.

Assessing physiological responses by heart rate and respiratory rate.

METHODS OF DATA ANALYSIS AND PRESENTATION

Data analysis will be through descriptive and inferential statistics

DESCRIPTIVE STATISTICS

Demographic variables are to be analyzed in frequency term by means

of mean, median, standard deviation and percentage.

Assessing behavioural responses by cry, facial expression, legand arm 14

7.2.12

7.2.13

7.3

7.4

movements and duration of cry measure by mean, median and standard

deviation.

Assessing physiological responses by heart rate and respiratory rate.

INFERENTIAL STATISTICS

The 't' test was used to find out the significant difference in pain scores

of experimental and control groups.

The chi-square test was used to associate the pain with the

demographic variables.

Coefficient correlation (y) was used to assess the correlation between

the behavioural and physiological responses.

DURATION OF DATA COLLECTION;

Duration of data collection is 30 days.

PROJECTED OUTCOME;

There will be significant increase in the knowledge regarding impact

of mobile phone use on health status among students.

DOES THE STUDY RE QUIRE AIYY INYESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR

OTHER HUMANS OR ANIMALS? IF SO PLEASE

DESCRIBE BRIEFLY.

NO

HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

YOUR INSTITUTION?

- Yes, ethical clearance will be obtained from the research committee

15

of the

Sri Lakshmi collage of nursing, Bangalore.

- Ethical clearance will be obtained from the authorities of selected

hospitals, Bangalore.

- Informed consent will be obtained from the infants of mothers who

are willing to participate in this study.

16

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