Assessment of Pain During Invasive Procedures among Children (1 to 12 years) Admitted at Pravara Rural Hospital, Loni (Bk)

 

Mr. Yogesh Dengale¹, Retd Lt Col. Dr. V. Radha²

¹Lecturer, Ganpatrao Adke College of Nursing, Nashik

²Professor and Principal, Pravara Institute of Medical Sciences (DU), College of Nursing, Loni (Bk),

Tal. Rahata, Dist. Ahmednagar, Maharashtra. 413736

 

ABSTRACT:

Background: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, described in terms of such damage”. When a child is brought to the hospital, its environment itself makes the child anxious and unsecure. Pediatric patients are often subjected to unexpected medical procedures that cause pain such as intravenous (IV) insertions, intramuscular injections and lumbar puncture etc. Thus, the investigator intended to conduct a study with the objectives of assessment of pain during invasive procedure among children and consider as a fifth vital sign. Material and Methods: A descriptive cross sectional study design was used to assess the pain during invasive procedure and outcome among children admitted at Pravara Rural Hospital, Loni (Bk). Sample consisted of 60 children selected by non-probability purposive sampling. A structured observation checklist was prepared to collect data of children during selected invasive procedure. The tool was prepared in the form of pain rating scale to assess the level of pain during selected invasive procedure among children. Descriptive and inferential statistics was used to analyse data based on objectives. Results: Statistically significant (t = 2.06) difference was found in assessment of pain of children with 1 – 3 years (FLACC scale) before-during and during - after invasive procedure. Similarly a statistically significant (t = 2.04) difference was found in assessment of pain of children with 4 – 12 years (Wong baker scale) before-during and during - after invasive procedure at p ≤ 0.05 level. The findings revealed that there was a significant (χ² = 3.84) association was found between the pain before procedure and the socio demographic variable such as age and duration of procedure at p ≤ 0.05 level. There was a significant (χ² = 3.84) association was found between the pain before procedure and the socio demographic variable such as age, duration and site of procedure at p ≤ 0.05 level. Conclusion: Findings shown that all children had severe pain during invasive procedure whereas after the procedure it was moderate level of pain. There was statically significant difference was found before during and after painful procedure at 0.05 level. Similarly significant association found between before and during invasive procedure and their socio demographic characteristics.

 

 

 

INTRODUCTION:

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, as 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.¹

 

There are two main types of pain, known as nociceptive pain and neuropathic pain. Psychogenic pain is another term that is sometimes used to describe cases of pain, although this is not an official diagnostic term. Alternatively, pain can be classified according to the duration of the pain, as acute, chronic or breakthrough pain. Nociceptive pain is caused by the activation of nociceptors in the body by noxious or potentially harmful stimuli. Activation of these receptors leads to an action potential and the propagation of nervous messages to the central nervous system and brain. This type of pain is a normal response of the body to potential harm and serves to help protect from dangers that are encountered. It can be acute or chronic in nature, depending on the specific case and the cause of the pain. Nociceptive pain can be further classified into subtypes as somatic or visceral pain.²

 

Somatic nociceptive pain originated from pain receptors located on the surface of the body or in the musculoskeletal tissues. This type of pain is usually localized to a certain area of the body and often worsens with activity but is relieved by periods of rest. Visceral pain refers to pain that results from pain receptors located in the internal organs within a cavity of the body. This type of pain is usually described as a deep, pressure like feeling that is not localized to a certain point in the body. Neuropathic pain is caused by injury to the nerves that are involved in the propagation of electrical signals that send messages of pain from the receptors to the brain. This type of pain is typically described as a sharp, shooting pain that is often more intense

 

Non-pharmacological techniques should be included in the management of children with pain, when appropriate. These techniques are particularly helpful for children undergoing frequent procedures, e.g. IV insertion, burn dressing changes, but they can also be useful in more general situations such as administering immunizations. Distraction and comfort can be provided by parents with physical touch (e.g. cradling, cuddling), books, toys, singing, storytelling or engaging in conversation. The child should be encouraged to choose the distraction, as this gives them a sense of control and will usually provide better engagement. Education about their illness or injury, such as why it hurts and when it will resolve, is useful in helping both the child and their parents feel more in control. Cognitive behavioural strategies that involve the use of breathing techniques, education and self-regulation have been shown to be effective in providing pain relief on their own or in conjunction with pharmacological pain management. Rest, ice, compression and elevation (“RICE”) and techniques to stabilize an injury, e.g. splinting a fractured limb, will also reduce pain.²

 

MATERIAL AND METHODS:

The present descriptive design with cross sectional survey approach was used to assess the pain during invasive procedure and outcome among children admitted at Pravara Rural Hospital. A sample comprising 60 childrens who are undergoing invasive procedures in the age group of 1-12 years of age was taken. Those childrens satisfying the inclusion criteria and admitted in the IPD of Pravara Rural Hospital, (Loni (Bk), Maharashtra, India) were selected by using a non-probability purposive sampling technique. The Children who were Suffering from critically ill and unable to respond to tool and Mentally challenged children were not included. The structured observational checklist was prepared into three sections to collect data. demographic variables like age, gender, type of illness, diagnosis, duration of illness, type of procedure, presence of caregiver during procedure and previous exposure to invasive procedure. Face, Leg, Activity, Cry, Consolability (FLACC) scale was used to assess pain among children before, during and after procedure with the score of ‘0’ which indicates relaxed and comfortable,’1-3’ indicates mild discomfort, ‘4-6’ indicates moderate pain and ‘7-10’ indicates severe discomfort. Wong-baker rating pain scale was used to assess pain among children before, during and after procedure with the score of ‘0’-No hurt, ‘1-3’- Mild,’4-6’- Moderate and ‘7-10’- Severe discomfort.

 

RESULTS:

A total of 60 childrens were participated in the study.

 

Findings related to sociodemographic data of patient:

Socio demographic profile of children shows that nearly half (45%) were in the age group of toddler, more than half (52%) were male,most (88%) of them had acute illness, diagnosis depicts that (38%) of children had vaccination and remaining had other diagnosis like meningitis, tuberculosis,thalesemia, anaemia,etc. (85%) had less than 3 months duration of illness, type of procedure shows that most (80%) of them had IM / IV / SC / ID injection, majority (78%) had less than 15 minutes of duration of procedure, (57%) of them had procedure in upper extremities and higher percentage (58%) childrens had presence of their caregiver.

 

 

Table I: Distribution of Socio demographic profile of Children

Socio demographic profile	Freq.	Percentage
Age
1-3 years	28	47%
years	16	26.6%
years	8	13.3%
years	8	13.1%
Gender
Male	31	52%
Female	29	48%
Type of illness
Acute	53	88%
Chronic	07	12%
Diagnosis
Vaccination	23	38%
Meningitis	07	12%
Tuberculosis	06	10%
Tuberculous meningitis	06	10%
Other	18	30%
Duration of illness
< 3 months	51	85%
3-6 months	04	07%
> 12 months	05	08%
Type of procedure
IM / IV / SC / ID	48	80%
Lumbar puncture	12	20%
Duration of procedure
< 15 minutes	47	78%
16-20 minutes	13	22%
Site of procedure
Spine	14	23%
Upper extremities	34	57%
Lower extremities	09	15%
Pelvis	03	05%
Presence of caregiver
Yes	35	58%
No	25	42%

 

 

Section II: Assessment of physiological parameters on 5 minute before procedure, during procedure and 5 minute after procedure

 

Table No. II Assessment of physiological parameter (Heart rate) on 5 minute before, during and 5 minute after invasive procedure.

n = 60

S. No	Age group	Heart rate	Before				During				After
			f	%	f	%	f	%	f	%	f	%	f	%
1	1 year 1 day-3 years	70-110 beats/min	15	54	13	46	12	43	16	57	12	43	16	57
2	3 years 1 day- 6 years	65-110 beats/min	15	94	1	6	10	56	6	38	13	81	3	19
3	6 years 1 day-9 years	65-95 beats/min	1	12	7	88	6	75	2	25	7	88	1	12
4	9 years 1 day-12 years	60-95 beats/min	6	75	2	25	6	75	2	75	6	75	2	75

 

The above mention table depicts that among the toddler age group (40%) of them had elevated heart rate before the invasive procedure while during and after the procedure (57%) had elevated heart rate. The difference was (11%). In relation to preschooler age group only (6 %) had elevated heart rate. In relation to school age group (88%) had elevated heart rate where as during the procedure (25%) had elevated heart rate. In relation to preadolescents (25%) age of them had elevated heart rate where as during and after the procedure (75%) of them had elevated heart rate.

It interprets that the children in toddler age group had elevated heart rate during and after the procedure indicates the increased pain perception in the age group, along side the children preschooler and school age group had elevated heart rate during invasive procedure while it was reduced after the procedure. However all the age group children had elevated heart rate during the procedure indicates that the medical procedure performed causes significant amount of pain.

 

 

Table No. III: Assessment of physiological parameter (Respiratory rate) on 5 minute before, during and 5 minute after invasive procedure. n = 60

S. No.	Age group	Respiratory rate	Before				After
			Normal		Elevated		Normal		Elevated
			f	%	f	%	f	%	f	%
1	1 year 1 day-3 years	20 – 30 breath/min	20	71	8	29	8	28	20	71
2	3 years 1 day- 6 years	20 – 25 breath/min	10	63	6	38	3	19	13	81
3	6 years 1 day-9 years	14 – 22 breath/min	5	62	3	38	3	38	5	62
4	9 years 1 day-12 years	14 – 22 breath/min	2	25	6	75	3	37	5	63

 

The above mention table depicts that all age group children under study had elevated respiratory rate after the invasive procedure where as less percentage of children had elevated heart rate before the procedure i.e. toddler from (29%) to (71%), preschooler (38 %) to (81%) and schooler (38%) to (62%). It interprets that the children had elevated respiratory rate after the procedure which is related to the effect of pain on the sympathetic and parasympathetic nervous system. It highlights that the painful procedure does have influence on the respiratory rate.

 

 

 

Table No. IV: Assessment of physiological parameter (Blood pressure) on 5 minute before, during and 5 minute after invasive procedure.

S. No.	Age group	Blood pressure	Before				During				After
			Normal		Elevated		Normal		Elevated		Normal		Elevated
			F	%	F	%	f	%	f	%	f	%	f	%
1	1 year 1 day-3 years	90 - 105/55 -70	25	89	3	17	12	61	11	39	7	61	11	39
2	3 years 1 day- 6 years	95 – 110/60 – 75	12	75	4	25	7	44	9	56	8	50	8	50
3	6 years 1 day-9 years	100 – 120/60 – 75	8	100	-	-	8	100	-	-	8	100	-	-
4	9 years 1 day-12 years	100 – 120/60 - 75	8	100	-	-	8	100	-	-	8	100	-	-

 

The above mention table depicts that the children of schooler and preadolescents age group had normal range of blood pressure before during and after the invasive procedure, it indicates the invasive procedure did not had any effect on blood pressure. However the children of toddler and preschooler age group had elevated blood pressure during and after the procedure i.e. (17%) to (39%) and (25%) to (56%) respectively. It indicates that the children less than six years had changes in the range of blood pressure during and after the invasive procedure.

 

Table No. V: Assessment of physiological parameter (Oxygen saturation) on 5 minute before, during and 5 minute after invasive procedure.

S.No.	Age group	Oxygen saturation	Before				During				After
			Normal		Elevated		Normal		Elevated		Normal		Elevated
			f	%	f	%	f	%	f	%	f	%	f	%
1	1 year 1 day-3 years	95 - 100	27	96	1	4	27	96	1	4	27	96	1	4
2	3 years 1 day- 6 years	95 - 100	16	100	-	-	16	100	-	-	16	100	-	-
3	6 years 1 day-9 years	95 - 100	8	100	-	-	8	100	-	-	8	100	-	-
4	9 years 1 day-12 years	95 - 100	8	100	1	12	8	100	1	12	8	100	1	12

 

The above mention table depicts that most of the children of different age group had normal oxygen saturation (95 - 100 %) before during and after the invasive procedure. It interprets that the invasive procedure carried out on the these children did not had any effect on oxygen saturation.

 

Section III

Comparison of pain level of before, during and after invasive procedure with their selected socio demographic variables.

 

Table No. VI: Assessment of pain among children before, during and after procedure by using Face, Leg, Activity, Cry, Consolability (FLACC)

S. No.	Before				During		After
	1 - 3		4 – 6		7 – 10		4 - 6		7 - 10
	f	%	f	%	F	%	f	%	f	%
1	3	11	24	89	27	100	15	56	12	44

 

Above mention table shows that before invasive procedure majority (89%) had moderate level of pain, whereas during procedure all the children had (100%) severe pain however after the procedure (56%) had moderate pain and (44%) severe pain. It highlights that the children under study had severe pain during the procedure whereas after procedure it was moderate to server pain.

 

Table No. VII: Assessment of pain among children before, during and after procedure by using Wong-baker rating pain scale

n = 60

S. No.	Assessment	Before		During		After
		F	(%)	f	%	f	%
1	No hurt	15	46	-	-	-	-
2	Hurts little bit	1	3	-	-	2	6
3	Hurts little more	6	18	1	3	5	15
4	Hurts even more	8	24	1	3	6	18
5	Hurts whole lot	3	9	10	30	11	33
6	Hurts worst	-	-	21	64	9	28

 

The above mention table shows that according to Wong baker pain scale assessment reveals that higher percentage (46 %) of children “did not had any hurt” while 24 % had “ hurt even more” whereas during procedure majority (64 %) had pain which “hurts worst” similarly after the procedure (28 %) of them had the same, while (33 %) had pain which “hurts whole lot”. It shows that the children (4 - 12 years) who underwent the painful procedure had pain which “hurts whole lot’.

 

Table No. VIII: Item wise analysis of pain before, during and after invasive procedure among less 3 years children

S. No.	Item	Before		During		After
		F	(%)	f	(%)	f	(%)
Face
1	No particular expression or smile	21	78	0	0	0	0
2	Occasional grimace/frown, withdrawn, disinterested	6	22	3	11	1	96
3	Frequent to constant quivering chin/ clenched jaw	0	0	24	89	1	4
Legs
1	Normal position or relaxed	14	52	0	0	0	0
2	Uneasy, restless, tense	13	48	0	0	23	85
3	Kicking or les draw up	0	0	27	100	4	14
Activity
1	Lying quietly, normal position, moves easily	22	81	0	0	2	7
2	Squirming, shifting back and forth, tense	5	19	3	11	18	67
3	Arched, rigid or jerking	0	0	24	89	7	23
Cry
1	No cry (awake/ asleep)	26	96	0	0	0	0
2	Moans or whimpers: occasional complaint	1	4	3	4	6	22
3	Crying steadily, screams or sobs, frequent complaints	0	0	29	96	21	78
Consolability
1	Content, relaxed	0	0	0	0	1	4
2	Reassured by occasional touching, hugging or being talked to, distractible	22	81	7	26	20	74
3	Difficult to console or comfort	5	19	20	74	6	22

 

The above mention table shows that, in relation to “face” aspects of pain scale – before the invasive procedure majority (78 %) of children had “no particular expression or smile” whereas after the procedure most (96 %) had “occasional grimace/frown, withdrawn, disinterested”.

 

In relation to “leg” aspects of pain scale – before the invasive procedure half (52 %) of children had “normal position or relaxed” whereas during procedure all of children (100 %) had “kicking or legs draw up” and after procedure majority children (85 %) had “uneasy, restless, tense”.

 

In relation to “activity” aspects of pain scale – before the invasive procedure majority (81 %) of children were “lying quietly, normal position, moves easily” whereas during procedure most of the children (89 %) had “arched, rigid or jerking” and after procedure majority of them (67 %) were “squirming, shifting back and forth, tense”.

 

In relation to “Cry” aspects of pain scale – before the invasive procedure most (96%) of children “did not cry” whereas during after the procedure (96 %) and (78 %) respectively were “crying steadily, screams or sobs, frequent complaints”.

 

In relation to “Consolability” aspects of pain scale – before the invasive procedure majority (81 %) of children were “reassured by occasional touching, hugging or being talked to, distractable” whereas during and after procedure (74 %) were “difficult to console or comfort”.

 

Table No: IX Assessment of significant difference in level of pain among children before, during and after procedure

S. No.	Assessment of pain	1 – 3 years (FLACC Scale)	4 – 12 years (Wong-baker Scale)
1	Before -During	9.15*	5.56*
2	During - After	3.96*	3.50*
3	Before - After	2.07	1.25

 

(df - 26) Table value - 2.06 (df - 32) Table value - 2.04

P < 0.05 *significant

 

 

Paired ‘t’ test was calculated to analyze the difference in before, during and after selected invasive procedure among children. A statistically significant difference was found in assessment of pain of children with 1 – 3 years (FLACC scale) before-during and during - after invasive procedure. Similarly a statistically significant difference was found in assessment of pain of children with 4 – 12 years (Wong baker scale) before-during and during - after invasive procedure at p ≤ 0.05 level. It interprets that the difference found was a true difference and not by a chance.

 

Table No X: Assessment of significant association of level of pain with their selected socio-demographic variable

S. No.	variable	χ2 value Before	χ2 value During	χ2value After
1	Age	4.02*	0.58	1.27
2	Gender	1.90	0.44	0.89
3	Type of illness	0.61	0.52	1.3
4	Duration of illness	0.68	0.52	2.11
5	Duration of procedure	4.21*	3.06	2.50
6	Site of procedure	1.35	0.81	0.19

 

(df - 1) Table value 3.84 p ≤ 0.05 *significant

 

Chi-square values calculated to find out association between pain (1 – 3 years (FLACC Scale) before, during and after the invasive procedure with their selected socio demographic variable. The findings revealed that there was a significant association was found between the pain before procedure and the socio demographic variable such as age and duration of procedure at p ≤ 0.05 level. However their was no association was found between the pain during and after procedure and the socio demographic variables.

 

Table No XI: Assessment of significant association of level of pain with their selected socio-demographic variable

S. No.	Variable	Before	During	After
1	Age	8.75*	3.88*	2.43
2	Gender111	0.49	0.41	0.48
3	Type of illness	1.11	0.70	0.24
4	Duration of illness	0.56	0.67	1.22
5	Duration of procedure	4.62*	5.27*	1.05
6	Site of procedure	3.87*	2.66	7.28*

 

(df - 1) Table value 3.84 p ≤ 0.05 *significant

 

Chi-square values calculated to find out association between pain (3 – 12 years (Wong Baker pain Scale) before, during and after the invasive procedure with their selected socio demographic variable. The findings revealed that there was a significant association was found between the pain before procedure and the socio demographic variable such as age, duration and site of procedure at p ≤ 0.05 level. Similarly pain during procedure had association with age and duration of procedure whereas pain after procedure had association with site of procedure.

 

DISCUSSION:

Section I: Description of demographic profile of children

Nearly half (47 %) were in the age group of toddler followed by (27 %) were preschooler and equal proportion (13 %) of them were Schooler and Preadolescent age group respectively. It was consistent with a study carried out by Bettyg, Lebona G, Radhika M, Indira S noted that majority of the children were 10 (33.33 %) belongs to age group of 3 - 5 years. Majority were 18 (60 %), With regard to developmental age majority were 19 (63.33 %) belongs to term maturity of child.⁷⁴

 

More than half (52 %) were male and remaining (48 %) were female. This finding was supported by Zahra P, Khadije D, Asghar S that mean age of the population under study was 9.45 ± 2.80 years of which 42 % were girls and 58 % boys. ⁷⁵

 

Majority (57 %) of them had procedure in the upper extremities, while (15 %) had the same in lower extremities. However a significant percent (23 %) had spine as site of procedure. Similarly this fact was observed by Devi P, Shinde J noted that all the preschoolers in both experimental and control groups 32(100 %) had underwent venipuncture in upper extremities.⁷⁶

 

Higher percentage (58 %) children had presence of their care giver and remaining (42 %) of children did not had the presence of caregiver. It was well supported by Tariq A, Raghad A, Noordeen S and Hala O that distribution of sample in regard to parental presence was 53 (52 %) children having parental presence, and 49 (48 %) not having it (during intravenous insertion).⁷⁷

 

Assessment of pain among children before, during and after procedure by using Face, Leg, Activity, Cry, Consolability (FLACC):

Majority (89 %) had moderate level of pain, whereas during procedure all the children had (100 %) severe pain however after the procedure (56 %) had moderate pain and (44 %) severe pain. This finding was concurrent with a study conducted by Amna N, Basma A, the current study found that all infants of the study group (100 %) had moderate pain compared to 71 % in the control group.⁷⁸

 

Assessment of pain among children before, during and after procedure by using Wong-baker rating pain scale:

Higher percentage (46 %) of children “did not feel any hurt” while 24 % had “hurts even more” whereas during procedure majority (64 %) had pain which “hurts worst” similarly after the procedure (28 %) of them had the same, while (33 %) had pain which “hurts whole lot”. These facts were contradictory to the study carried out by Children response according to Wong Baker Faces pain rating Sahar M, Lamiaa A scale illustrated that 10 % and 28 % of the cutaneous stimulation group had “hurts little bit” and “hurts little more” respectively, equal percent of 18 % of the same group has “hurts whole lot” and “hurts worst”. “Hurts little bit” and “hurts little more” were expressed by 20 % and 36 % of the interactive distraction group respectively, while it was 18 %“hurts whole lot” and 12 %“hurts worst”. ⁷⁹

 

Comparison of mean, SD of pain among children before, during and after invasive procedure according to their age:

The above mention table shows that children of 1-3 years of age had lower mean score (1.89 ± 1.66) indicates mild discomfort whereas it was noticed through the mean score that the during and after the invasive procedure children’s had severe pain. Similarly the children’s of 4-12 years had lower mean scores of pain indicates mild discomfort, and the during the procedure it was a severe pain. It was well supported by Sima K, Masoumeh B that mean and standard deviation of the score of behavioral responses to pain in the control and intervention group were 7.95 ± 1.084 and 2.65 ± 1.577 respectively.⁸⁰

 

Assessment of significant difference in level of pain among children before, during and after procedure.

A statistically significant difference was found in assessment of pain of children with 1 – 3 years (FLACC scale) before-during and during - after invasive procedure. Similarly a statistically significant difference was found in assessment of pain of children with 4 – 12 years (Wong baker scale) before-during and during - after invasive procedure at p ≤ 0.05 level. It was supported by Anurani A and Umarani J independent‘t’ test was used to test the effectiveness of music therapy on pain during invasive procedures in children. The independent ’t’ test in table 1 indicates that there is a statistically significant difference (‘t’ = 15.448, p ≤ 0.05, d f = 78)⁸¹

 

Assessment of significant association of level of pain with their selected socio - demographic variable:

The findings revealed that there was a significant association was found between the pain before procedure and the socio demographic variable such as age and duration of procedure at p 1≤ 0.05 level. It was supported by Melba L, Umarani J was computed to find association between the level of pain and selected demographic variables. It has been found that there was association between the level of pain and selected demographic variables in both groups p ≤ 0.05.⁸²

 

CONCLUSION:

This study creates the complete spectrum of assessment of pain during invasive procedure. The study findings showed that all children had severe pain during invasive procedure whereas after procedure it was moderate level of pain. Statistically significant difference was found before during and after painful procedure and significant association found between before and during invasive procedure and their socio demographic characteristics.

 

ACKNOWLEDGEMENT:

It gives me immense pleasure with deep sense of gratitude to thank Lt Col (Retd) Dr. V Radha, Principal, PIMS (DU), College of Nursing and guide for her support in completing the study.

 

I would like to take this opportunity to express my profound gratitude and deep regard to Dr. T Sivabalan, Vice Principal, PIMS, College of Nursing, Loni for his exemplary guidance, valuable feedback and constant encouragement throughout the duration of the research. His valuable suggestions were of immense help throughout my research work. His perceptive criticism kept me working to make this project in a much better way.

 

My special words of thanks should go to My Father and Mother, for their continuous support, cooperation, encouragement and for facilitating all the requirements, going out of their way.

 

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Received on 23.04.2019          Modified on 21.05.2019

Accepted on 24.06.2019     © A&V Publications all right reserved