Assess the Effectiveness of Ice Pack Application on Pain Prior to Chest Tube Removal among Post Operative Patients.

Ms. Sruthimol V.S¹, Dr. Prof. S. Aruna²

¹Lecturer, Amrita College Of Nursing, Amrita Vishwa Vidyapeetham University, Amrita Institute of Medical Sciences, Kochi, Kerala.

²Vice Principal, Saveetha College of Nursing, Saveetha University, Chennai

*Corresponding Author’s Email: sruthyanl@gmail.com

ABSTRACT:

Background: Pain is the unpleasant sensory and emotional experience associated with actual or potential tissue damage. The removal of chest tubes has been describes as one of the worst experiences in the Intensive Care Unit for the patients.

Objectives: To assess the effectiveness of icepack application on the level of pain after to chest tube removal among post operative patients in experimental group and to associate the post test level of pain with selected demographical variables in experimental and control group.

Methodology: Quasi experimental post test only design were adopted for the study. The study was conducted at Bharath Hospital, Kerala. Non probability convenient sampling technique was chosen to select the fifty sample who met the inclusion criteria. Data were collected by using Numeric Pain Rating Scale.

Results: The findings of the study indicates that there was significant reduction in pain in experimental group after icepack application than the control group among post operative patients(at p< 0.001). There is no significant association between the demographic variables with the post test level of pain among patients in both experimental and control group.

KEYWORDS: Ice pack application, Pain, Prior to Chest tube removal, Post operative patients.

INTRODUCTION:

Cardiovascular diseases are the world largest killers, claiming 17.1 million lives in a year.. By 2030 more than 23 million people will die annually from cardiovascular diseases.(World Health Organisation, WHO 2009). According to American Heart Association, annually more than 448,000 patients underwent cardiothoracic surgery including coronary artery bypass grafting (CABG), valve replacement or repair, or repair of structural defects.[1] Inserting chest tubes (CT) after CABG was aimed to maintain heart and lung functioning and essential to prevent from pleural effusion, pneumothorax and hemothorax.[2,3]Keeping CTs in place, however, is associated with increased pain and discomfort for the patient, mechanical irritation of the heart and pericardium, and an increased incidence of infection.[4]

The chest tubes are typically removed within 24-48 hours after surgery or when the excess air, blood, or fluid has been properly drained.[5,6] Chest tubes removal (CTR) after surgery has been described as one of the worst experiences among these patients.[2,5,7,8] Studies showed that moderate to severe pain has been reported by patients who experienced Unrelieved pain in addition to causing suffering, may be associated with the absence of sound breath, distress, decreased chest expansion, hyper-resonance on the injured side, impaired respiratory performance producing hypoxemia, increased sympathetic response provoking myocardial ischemia, and activation of a generalized stress response that can trigger tachycardia, increased cardiac output, and vasoconstriction.[11] Cardiovascular surgical patients may be particularly vulnerable to the physiological effects.[9] Although analgesic drugs are the most effective tool available to nurses but there are many other ways to relieve pain. Analgesics have some side effects and there are individual differences in their effects, so non-pharmacological methods may attract some attention.[12,13]CTR and unfortunately their pain was managed very poorly.[5,6,9,10] Cold application is a non-pharmacological pain-relieving method. It has been utilized for years.[9,10,11,12,13,14] Regarding the activity of inflammatory enzymes rises with increasing temperatures.[15]Ice is believed to help control pain by inducing local anesthesia around the treatment area. Investigators have also shown that it decreases oedema, cellular metabolism, and local blood flow.[16] The main beneficial effect of cold during recovery is the cold-related vasoconstriction that may limit vessel permeability and thus inflammatory processes, reducing muscle pain.[17] Based upon this framework, also, based on laboratory and clinical studies, cold decreases the nerve conduction velocity and increases the pain threshold.[15,18,19] Several studies have shown a decrease in peripheral blood flow caused by different methods of application of cold.[20] Looking on the importance of pain management as the highest nursing priority, there is no consensus about controlling pain following Chest tube removal.[18] While the usual way to pain management is prescription of analgesics but research has showed that despite of using analgesics and anesthetics, Chest tube removal is still painful.[5,9] In addition, pharmacological methods are costly and may leads to complications. From the investigators personal experience of working in the cardio thoracic post operative intensive care unit, she observed several patients verbalises that pain during chest tube removal was not effectively controlled inspite of analgesics. Hence the investigator felt the need for the effective pain management during chest removal as part of the nursing care.

PROBLEM STATEMENT:

Assess the effectiveness of ice pack application on pain prior to chest tube removal among post operative patients at Bharath Hospital, Kerala.

OBJECTIVES:

• To assess the effectiveness of icepack application on the level of pain after to chest tube removal among post operative patients in experimental group.

• To associate the post test level of pain with selected demographical variables in experimental and control group.

HYPOTHESIS:

There is significant decrease in the level of pain after receiving the ice pack application prior to chest tube removal among the experimental group than the control group.

RESEARCH METHODOLOGY:

Research Design:

Quasi experimental post test only design was used.

Research Setting:

The study was conducted at Bharath Hospital, Kerala.

Sample:

Cardio thoracic post operative patients with chest tubes and admitted in the Bharath Hospital and who met the inclusion criteria was selected as sample in this study.

Sample size:

Sample size was 50. Out of 50 samples 25 patients were selected in experimental group and 25 patients were selected in control group.

Sampling technique:

Non probability convenient sampling technique was chosen to select the sample.

SELECTION CRITERIA:

INCLUSION CRITERIA:

1) The patients between the age group of 20 – 70 yrs

2) Extubated patients who are hemodynamically stable.

3) Patients who are willing to participate.

4) Patients who can understand Malayalam, English and Hindi.

EXCLUSION CRITERIA:

1) Unconscious patients.

2) Patients with complications.

DESCRIPTION OF THE TOOL:

It consists of three sections

Section A: Demographical Variables:

It consists of age of the patients, Gender, no of chest tubes and duration of chest tube

Section B: Intervention protocol:

It includes preliminary preparation of the patient, environment, articles, icepack, procedure and aftercare which is needed to provide the intervention in an effective manner

Section C: Numeric Pain Rating Scale:

Post test level of pain is assessed by using Numeric Pain Rating Scale Numeric pain rating scale It is a 10 point rating scale, in which subjects are requested to verbalise the subjective level of pain. The ranges include no pain, mild pain, moderate pain, and severe pain.

Data Collection Procedure:

Prior to the data collection permission was obtained from the concerned authority of the organization for conducting the study. A total of 50 samples who met the inclusion criteria were included in the study. Among them 25 patients who had chest tube removal on Monday, Tuesday, Wednesday were considered as control group and patients who had chest tube removal on Thursday, Friday. And Saturday were considered as experimental group. After selecting the sample, informed consent was obtained after assuring confidentiality. After the general instructions, the researcher collected the demographic data.

The Pain during the chest tube removal was assessed using numerical pain rating scale after 5 – 10 minutes of chest tube removal in control group. No intervention was given for the control group whereas in the experimental group, ice pack was applied over the chest tube site for 15 minutes prior to the chest tube removal. After 15 minutes of ice pack application the chest tube was removed. The pain was assessed using numeric pain rating scale after 5 -10 minutes of chest tube removal. The data were analyzed by using descriptive and inferential statistics.

RESULTS:

SECTION – A TABLE 1. Frequency and percentage distribution of demographic variables among post operative patients in both Experimental and Control group.

Sl No	Demographic Variables	Experimental Group		Control Group
Sl No	Demographic Variables	Frequency	Percentage	Frequency	Percentage
1.	No Of Chest tubes • 1 • 2 • 3	16 09 -	64 % 36 %	11 14	44 % 56%
2.	Duration Of Chest tubes • 48 hrs • 72 hrs • > 72 hrs	23 02	92 % 8 %	23 02	92 % 08 %

SECTION D:

TABLE IV : The association between the demographic variables and the level of pain among post operative patients in experimental group.

Sl No

Demographic Variables

No of Sample

Level of Pain

Chi Square

Mild

Moderate

Severe

Age

• 20 – 40 yrs

• 41 – 60 yrs

• > 60 yrs

X ²= 0.78

2 df

P = 0.67 (N.S)

Gender

• Male

• Female

X ²= 0.32

1 df

P = 0.57 (N.S)

No Of Chest tubes

• 1

• 2

• 3

X²= 0.62

1 df

P = 0.43 (N.S)

Duration Of Chest tubes

• 48 hrs

• 72 hrs

• >72 hrs

X²= 0.32

1 df

P = 0.57 (N.S)

TABLE V: The association between the demographic variables and the level of pain among post operative patients in control group.

Sl No

Demographic Variables

No of Sample

Level of Pain

Chi Square

Mild

Moderate

Severe

Age

• 20 – 40 yrs

• 41 – 60 yrs

• > 60 yrs

X ²= 1.32

2 df

P = 0.52(N.S)

Gender

• Male

• Female

X ²= 0.71

1 df

P = 0.39(N.S)

No Of Chest tubes

• 1

• 2

• 3

X²= 2.23

1 df

P = 0.14(N.S)

Duration Of Chest tubes

• 48 hrs

• 72 hrs

• > 72 hrs

X²=0.032

1 df

P = 0.85(N.S)

Note: P< 0.01 Level of Significant, N.S – Not Significant

The above table showed that there was no association between the demographic variables and the level of pain among post operative patients in control group.

DISCUSSION:

The first objective was to assess the effectiveness of icepack application on the level of pain after to chest tube removal among post operative patients in experimental. Present study findings revealed that, In experimental group, out of 25 samples 8( 32%) were having mild pain, where as in control group out of 25 samples none of them had mild pain.17 ( 68 % ) were having moderate pain in the experimental group where as in the control group 14 ( 56 % ) were having moderate pain, non of them had severe pain in the experimental group where as in the control 11 ( 44 % ) had severe pain. Here, the control group continued to report very high pain ratings 10 minutes after chest tube removal, where as the group receiving ice pack application demonstrated a significant decrease in their pain ratings. This was supported by a study conducted by Raiza Abdoullah Al Otaibi., Fatma M Mokabel and Yasser AL Ghuneimy (2014) which showed a reduction in pain after icepack application for the experimental group(20) Present study revealed that the independent’ t’ value between the experimental and control group was t = 10.77 and the p value was p= 0.00001 which was significant at p< 0.001.The findings of the study clearly indicates that there was significant reduction in pain in experimental group after icepack application than the control group among post operative patients. Hence the null hypothesis was rejected at 0.001 level of significance. The finding of the study was supported by Ertuq N and Ulker S( 2012). They conducted a research to determine the effect of cold application on the pain owing to chest tube removal for patients with single pleural chest tube with controlled clinical trial research design. The study was conducted with 140 patients, of whom 70 patients were in the experimental group and 70 patients were in the control group, in a thoracic hospital in Turkey. There were significant differences on pain with cold application between the two groups prior and after the intervention (2) The second objective was to associate the post test level of pain with selected demographical variables in experimental and control group. The findings of the study shows that there is no significant association between the demographic variables such as age, gender, no of chest tubes, and duration of chest tubes with the post test level of pain among patients in both experimental and control group.

CONCLUSION:

This study indicates that icepack application is a simple non pharmacological and cost effective method. It can be used effectively for the management of pain during chest tube removal.

ACKNOWLEDGEMENT:

I would like extend my sincere gratitude towards Mrs. Dr. P. Mangala Gowri, Principal, Saveetha College of Nursing and Mrs. Dr. S. Aruna HOD of Medical Surgical Nursing to their constant guidance and support for the study. I thank everyone who directly and indirectly contributed a lot for this study.

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Received on 12.05.2016 Modified on 21.05.2016

Int. J. Nur. Edu. and Research. 2016; 4(4): 406-410.

DOI: 10.5958/2454-2660.2016.00073.9

Experimental group		POST TEST				Independent ‘t ‘test, P Value
		Control group		Effective Score
Mean	Standard Deviation	Mean	Standard Deviation	Mean	Standard Deviation	t = 10.77 p= 0.00001***
3.9	0.63	10.4	0.74	6.5	0.11

Level of Pain	Post Test Level of Pain
	Experimental group		Control Group
	Frequency	Percentage	Frequency	Percentage
Mild	17	68 %	-
Moderate	08	32 %	14	56 %
Severe	-		11	44 %