Using distraction to reduce reported pain, fear, and behavioral distress in children and adolescents: a multisite study

ISSUES AND PURPOSE

Distraction during painful procedures has been shown to be effective in previous studies, yet this simple intervention is not used routinely. This study examined the effectiveness and feasibility of distraction in reducing behavioral distress, pain, and fear during venipuncture or intravenous insertion.

DESIGN AND METHODS

A two-group randomized design with 384 children in 13 children's hospitals.

RESULTS

Age was a significant factor in observed behavioral distress, reports of fear, and self-reported pain. The use of a kaleidoscope, however, did not significantly reduce pain or distress during venipuncture or i.v. insertion.

PRACTICE IMPLICATIONS

Failure of the distraction intervention to reach statistical significance in this study is puzzling, given anecdotal reports of clinical efficacy. Methodological issues may have obscured actual differences between experimental and control groups.

Factors Affecting Hemolysis Rates in Blood Samples Drawn From Newly Placed IV Sites in the Emergency Department

INTRODUCTION

To decrease the number of hemolyzed samples in the emergency department, performance improvement activities were implemented, including phlebotomy classes for staff, evaluation of blood draw equipment, and a study to evaluate factors attributed to hemolysis of blood samples when drawn at the time a new intravenous catheter is inserted.

METHODS

In a study with an observational design conducted in June and July 2004, researchers examined the cases of 100 randomly chosen patients who had blood drawn through newly placed peripheral intravenous access.

RESULTS

In this study, the blood draw collection factors with the highest hemolysis rates included blood samples drawn between 12:00 am to 5:59 am; samples drawn by patient care technicians; right-hand site; 22-gauge intravenous catheters; syringe draws; blue tubes; 6.0 mL tubes; difficulty drawing blood; 2 tries for intravenous placement; resistance when aspirating blood using a syringe; and respiratory discharge diagnoses. Statistically significant (P < .05) blood draw factors included intravenous placement sites of right hand/forearm and antecubital; intravenous catheter size 22 gauge; blood drawing categorized as difficult; number of tries for intravenous placement; blood tube size 1.8 mL; and discharge diagnoses of respiratory, gastrointestinal, reproductive, dermatologic, and endocrine.

DISCUSSION

Clinically meaningful factors associated with hemolysis rates included the use of a 22-gauge intravenous catheter size, which resulted in a hemolysis rate of 60%; in addition, intravenous placement sites on the right side had statistically significant higher hemolysis rates than the left side, a finding that merits further research. As a result of the study we modified our standard operating procedure to discontinue the use of a 22-gauge or smaller intravenous catheter in adults. If required for small vein sticks, the use of a straight needle stick to obtain blood samples should be considered. The results of this study underscore the importance of education and training and the consideration for regular competency testing for staff with phlebotomy responsibilities.

Parents’ Positioning and Distracting Children During Venipuncture

The purpose of this study was to determine the effectiveness of parental positioning and distraction on the pain, fear, and distress of pediatric patients undergoing venipuncture. An experimental-comparison group design was used to evaluate 43 patients (20 experimental and 23 comparison) who were 4 to 11 years old. Experimental participants used parental positioning and distraction. All participants rated their pain and fear; parents and child life specialists (CLS) rated the child’s fear, and CLS rated the child’s distress. Self-reported pain and fear were highly correlated (p < .001) but not significantly different between the two groups. Fear rated by CLS (p < .001) and parents (p = .003) was significantly lower in experimental participants. Although no difference was found in distress between the two groups, a significant time trend was discovered (p < .001). The parental positioning-distraction intervention has the potential to enhance positive clinical outcomes with a primary benefit of decreased fear. Further research is warranted.

Cost Containment and Infusion Services

The implementation of the Medicare Prospective Payment System (MPPS) has placed pressure on healthcare organizations to decrease patient length of stay without adversely affecting outcomes. This article discusses the impact of the MPPS on clinicians who provide infusion therapy, and examines methods for containing costs related to infusion care such as advanced planning and accurate vascular access device selection.

Learning intravenous cannulation: a comparison of the conventional method and the CathSim Intravenous Training System

Intravenous cannulation is a nursing procedure carried out in some clinical units that may induce trauma and discomfort. Nurses should be well prepared before practising the procedure with clients. Conventionally, a plastic arm was used for practice but, with innovative developments in technology, a computer program called the CathSim Intravenous Training System (CathSim ITS) is available for this purpose. This study was conducted to compare the effectiveness of learning using a plastic arm with the CathSim ITS. Twenty-eight nurses were divided into two groups and randomly assigned to the two different methods: plastic arm (control group) or CathSim ITS (experimental group). Both groups were provided with 1 hour of theory input and 2 hours of nursing laboratory work. When the nurses felt ready to practise on clients, their performances were assessed by researchers with an intravenous cannulation qualification using a validated checklist. Prior to the assessment, trait and state anxiety levels were measured using the State-Trait Anxiety Inventory (Hong Kong Chinese adaptation) to check whether anxiety would affect the performance. Following the assessment, a semi-structured interview was conducted to reveal my knowledge acquired through using the selected method. Both the control and CathSim ITS groups demonstrated a high success rate, scoring 100% and 92.86%, respectively, with their first client. The semi-structured interviews revealed that the CathSim ITS group appreciated several features of their assigned method. However, there is room for further development.

[Protocol for the preparation of preschool children to venous puncture using therapeutic play]

This exploratory-descriptive study aims at elaborating a protocol, using therapeutic play, for the preparation of preschool children to venous puncture and also at testing its efficiency and applicability. The children that attended the play session were more cooperative when they were punctured. They understood the need and technical aspects of this clinical procedure; manifested their feelings, elaborated familiar and hospital situations that resulted in a better relationship with the other children and the nursing team. Authors concluded that this protocol is feasible and useful and suggested that it should be incorporated in the nursing care plan to hospitalized children.

Needle phobia--changing venepuncture practice in ambulatory care

Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.

Peripheral venepuncture in infants and children

Venepuncture can be a painful and frightening experience for children. Nurses play an active role in helping them to cope with this experience and in reducing the adverse effects of venepuncture. This article explains how infants, children and their families can be supported and cared for before, during and after venepuncture.

Blood gas analysis: a study of blood loss in intensive care

This paper describes a quantitative study conducted on an intensive care unit in the north of England. It involved the collection of data from the existing records of 65 patients consecutively sampled from a predetermined date provided that they stayed more than 24 hours and had an arterial line in situ. As patient records were used, ethical approval was not necessary. The objectives of the study were to quantify the mean number of blood gas samples taken per patient and estimate the mean blood loss resulting from this, including discard volume. Limitations include reliance on records and lack of an economic evaluation. The results show that blood loss in this study was greater than that reported elsewhere. Patients who were ventilated for 24 hours or more had a statistically significant greater blood loss when compared to those who were not (P < 0.001). A subgroup of patients undergoing renal replacement therapy had the greatest blood loss (mean 55.18 ml per day). This loss was statistically significant when compared to patients not in acute renal failure (P=0.007). When patients undergoing multiple therapies normally associated with increased sampling were compared to patients not receiving such therapies, there was no statistically significant difference in blood loss. The need to change current nursing practice to reduce iatrogenic anaemia is emphasized.

Risks and benefits of needle use in patients after axillary node surgery

Lymphoedema may be triggered by any type of injection. This is not just an issue for the cured breast cancer patient but for any patient who has undergone under-arm (axillary) lymph node removal to any degree for any type of cancer. Standard advice given to patients following axillary node removal is to avoid any injection or blood pressure measurement on the ipsilateral arm. The evidence base in this area is severely lacking. Patients have reported frustration that nurses are not informed of contraindications in carrying out such procedures on patients at risk of developing swelling. This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphoedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures.

Ameliorating adults' acute pain during phlebotomy with a distraction intervention

This study evaluated the effectiveness of a distraction intervention on subjects' perceptions of pain. During phlebotomy, 96 adults received either usual care or used a kaleidoscope as a distraction. After phlebotomy they rated their level of experienced pain with each of three instruments: Wong-Baker FACES Pain Scale, pain visual analogue scale, and Present Pain Intensity Scale. Statistical analyses revealed significantly lower perceptions of experienced pain among subjects using the kaleidoscope and concurrent validity for using the FACES Pain Scale with adults. Because the distraction intervention is effective, inexpensive, and easy to implement, its routine use during phlebotomy is recommended.

Pharmacological versus nonpharmacological techniques in reducing venipuncture psychological trauma in pediatric patients

Peripherally inserted central catheters (PICCs) provide reliable access for pediatric patients requiring infusion therapy. Our multidisciplinary team includes nurses, physicians, child life specialists, and radiology technicians. In preparing and educating the patient and parent for the procedure, cultural and developmental levels are assessed and planned accordingly.

Look, learn, and be satisfied: video playback as a learning strategy to improve clinical skills performance

The study investigated the viability of video playback as a means to maintain and enhance nursing skills in today's healthcare environment. The purpose was to determine if video playback would improve performance of psychomotor clinical skills and increase participant satisfaction with the leaning process. A two-group sample of registered and student nurses participated in the study. Each participant performed a nursing procedure. Two nursing procedures were used, one for each group. Each nursing procedure was recorded on videotape and played back to the participant who then repeated the procedure and completed a satisfaction assessment questionnaire. Results showed improved performance and learner satisfaction.

Reducing the pain of venipuncture

Patient satisfaction with nursing care is the strongest predictor of overall satisfaction. Reducing discomfort of routine procedures, such as venipuncture for an intravenous insertion, can contribute to perceived satisfaction. This article reviews three common pharmacological interventions that can be used by perianesthesia nurses to reduce the pain of venipuncture.

Local anesthesia prior to the insertion of peripherally inserted central catheters

Using a randomized, controlled study, the investigators evaluated and compared the effects of local anesthesia versus no anesthesia on pain associated with peripherally inserted central catheter (PICC) insertion. A sample of 42 subjects was selected and divided into three groups. Group 1 received EMLA cream. Group 2 received buffered lidocaine. Group 3 (the control group) did not receive a local anesthetic. The short form of the McGill Pain Questionnaire was used to measure pain quality and intensity. A numerical Visual Analogue Scale accompanied the questionnaire and measured overall pain intensity. Results showed that buffered lidocaine was statistically superior to EMLA cream or no anesthetic in relieving pain associated with PICC insertion.

Venipuncture versus central venous access: a comparison of methotrexate levels in pediatric leukemia patients

Patients receiving methotrexate (MTX) therapy for treatment of acute lymphocytic leukemia (ALL) consistently have venipuncture MTX levels drawn twice during each hospitalization. The purpose of this study was to compare MTX levels drawn from central venous catheters (CVCs) with those drawn by venipuncture. A convenience sample of 14 pediatric patients was used, with a total of 33 peak levels and 33 trough level sample pairs collected. Venipuncture and CVC levels were compared by using the paired t-test and analyzing the peak and trough data pairs separately. Results confirmed there was no difference in MTX level results (peak, p = .502; trough, p = .114). However, the CVC trough levels would have changed clinical management for 5 of the 33 patients. Therefore, it is recommended that all MTX levels be drawn from the CVC but that trough MTX levels that would alter clinical management be verified by a venipuncture sample. This method will safely minimize the number of venipunctures for children with ALL.

Venous envy: the post-World War II debate over IV nursing

After World War II, a debate ensued over whether nurses should perform intravenous (IV) therapy. The debate was resolved by permitting nurses to do venipunctures as physicians' agents and by recirculating the familiar tautology: if nurses were already doing venipunctures, they must be simple enough for nurses to do. The vein was a portal of entry for nurses, but one with limited access. What was ultimately ceded to nurses was not full jurisdiction over a domain of nursing practice, but rather a limited settlement in a domain of medical practice. The debate over IV therapy demonstrated how technology, in combination with ideology, can both create and destroy nursing jurisdictions.

Application of computer simulation analysis to assess the effects of relocating a hospital phlebotomy department

BACKGROUND

This study describes a systematic approach to assess the effects of relocating a hospital department.

METHODS

Using the phlebotomy service as an example, computer simulation was applied to predict changes in performance indicators, such as patient turn-around time (TAT), when planning a procedural and/or architectural redesign.

RESULTS

Average patient TAT fell from 12 to 8 min, enabling the department to cope with any increase in numbers of patients.

CONCLUSION

This type of study can provide useful information in assessing the consequences of future changes in the location of a hospital department.

Effects of Tellington touch in healthy adults awaiting venipuncture

Many natural-healing modalities administered by professional nurses are provided without adequate scientific scrutiny. Tellington touch (TTouch), a form of gentle physical touch originally developed for the calming of horses, is an emerging nursing intervention. However, the safety and efficacy of human TTouch has not yet been established. The purpose of this study, which used a pretest, posttest repeated-measures control group design, was to identify patterns of mean blood pressure (MBP), heart rate (HR), state anxiety (SA), and procedural pain (PP) in healthy adults receiving a 5-min intervention of TTouch (n = 47) just before venipuncture versus a no-touch control group (n = 46). There were statistically and clinically significant decreases in the TTouch group in MBP and HR. There were no significant differences between groups in SA and PP. Further research is essential to determine the safety and efficacy of this modality for acutely or critically ill patients.

Hemolysis from a nurses' standpoint--survey from four Croatian hospitals

INTRODUCTION

Hemolysis can occur during sample collection, handling and transport. It is more frequent when the non-laboratory staff performs sampling. The aim of this study was to assess nurses' knowledge on the causes of hemolysis and consequential impact on the laboratory tests results. Additionally, the differences in knowledge, related to work experience, professional degree and previous education about hemolysis were explored.

MATERIALS AND METHODS

An anonymus survey, containing 11 questions on demographics, causes of hemolysis, its impact on biochemical parameters and nurses' attitude towards additional education in preanalytics, was conducted in four Croatian hospitals. The answers were compared by Chi-squared and Fischer exact test.

RESULTS

In total, 562 survey results were collected. Majority of nurses declared familiarity with the term "hemolysis" (99.6%). There were 77% of correct answers regarding questions about the causes of hemolysis, but only 50% when it comes to questions about interference in biochemical tests. The percentage of correct answers about causes was significantly lower (P=0.029) among more experienced nurses, and higher (P=0.027) in those with higher professional degree, while influence of previous education was not significant. Also, higher percentage of correct answers about interferences was encountered in nurses with longer work experience (P=0.039). More than 70% of nurses declared that additional education about preanalytical factors would be beneficial.

CONCLUSION

Croatian nurses are familiar with the definition of hemolysis, but a lack of knowledge about causes and influence on laboratory test results is evident. Nurses are eager to improve their knowledge in this field of preanalytical phase.

Comparison of two blood sampling methods in anticoagulation therapy: venipuncture and peripheral venous catheter

AIM

To compare prothrombin time and activated partial thromboplastin time values in concurrent blood samples obtained by direct venipuncture and from a peripheral venous catheter.

METHOD

Concurrent blood samples obtained from catheters and by direct venipuncture were studied. Venipuncture samples were labelled as the reference (control) group and the peripheral venous catheter samples as the experimental group. A 21-gauge needle was used in the venipuncture method and 18G, 20G, 22G catheters were used in the peripheral venous catheters method. In each case, after the blood samples were drawn by venipuncture and peripheral venous catheter the needles were drawn out, 1.8 ml of blood was added to 0.2 ml of citrate to give a 2 ml sample. The tube was shaken gently to mix the blood and citrate well.

RESULTS

No clinically significant difference between prothrombin time and activated partial thromboplastin time values were seen in the blood samples drawn by venipuncture and peripheral venous catheter methods.

DISCUSSION

It is recommended that peripheral venous catheter can be used for patients with high bleeding risk if they have a long hospital stay and frequent blood samples are needed.

RELEVANCE TO CLINICAL PRACTICE

In clinical applications, nurses may prefer the use of peripheral venous catheter to venipuncture both for the comfort of the patients who get anticoagulation therapy and for the prevention of the risks as a result of venipuncture. Application of peripheral venous catheter eliminates the risks of superficial bleeding, irritation, pain and anxiety caused by venipuncture.