Chronic kidney disease is now recognized as a major medical problem worldwide. Dialysis effectively treats the signs and symptoms of uremia and fluid overload (some of which may be life threatening), it is a lifelong therapy that is associated with discomfort. Arteriovenous Fistula punctures cause pain; the aim of this study is to assess the effectiveness of cold application on arteriovenous fistula puncture pain among hemodialysis patients at Erode and Namakkal district. The conceptual frame work adopted for this study was Modified Orlando’s Nursing Process of research use. The research approach adopted for the study was non-randomized control group post-test only design. Quasi experimental design is the powerful tool for testing of hypothesis, causes, effect and relationship between the variables. The study was conducted in Dr. K. M. Nallasamy Hospital, Erode and VMCH hospital, Namakkal District, Tamil Nadu. Non-purposive sampling technique was used to select the sample. After that, the samples were equally divided into experimental and control group. The samples consisted of 25 in experimental group and 25 in control group. The tool used for data collection was semi structured interview schedule. Findings related to sociodemographic variables. About 13(52%) subjects belong to the age group of 41-60 years. Most of the subjects 19(76%) were males. About 14(56%) subjects studied up to primary education. Chi-square test was used to assess the post-test score of pain in experimental and control group with socio demographic variables. It was concluded that age, gender, educational status, occupational status, marital status, type of family, duration of sleep at night time, dietary pattern, personal habits recreational activities during dialysis procedure were non-significant at 0% level.

Keywords: Arteriovenous, Fistula puncture, Hemodialysis, Sociodemographic 

INTRODUCTION

Each kidney dialysis was first utilized in 1960 by means of an artificial kidney with chronic intermittent hemodialysis, when the irreversibility of renal damage was established, treatment was withdrawn. Dialysis occurs with the movement of fluids and particles across a semi permeable membrane [1]. This treatment is used to restore fluid and electrolyte balance and acid base balance and to remove wastes and toxic materials from the body. This treatment is an augmentation of renal function to sustain life in acute and chronic situations.

In hemodialysis, blood is removed from a vascular access site. The blood is heparinized, pumped, through a dialyzer and then returned to the patient’s circulation, diffusion and ultra-filtration occurs allowing the blood to be filtered [2].

AV fistula or graft is surgically prepared to access the client’s circulatory system. A fistula is created by a joining an artery and a vein. The most common site for an AV fistula is in the fore arm. This type of fistula is created by anastomosing the radial or brachial artery to the cephalic vein. A graft is created by using synthetic material to join an artery to a vein. A fistula is preferred over a graft because a graft has a higher incidence of blood clotting and rejection of the synthetic material [3].

Dialysis prevents the waste products and removes excessive fluids from blood when the kidneys cannot do the job properly that reaching to hazardous levels. It can also remove toxins or drugs from the blood in an emergency setting [4].

A study to assess the effectiveness of cold application on arteriovenous fistula punctures pain among hemodialysis patients at Erode and Namakkal district.

OBJECTIVES

Ø  To assess the arteriovenous fistula puncture pain among hemodialysis patients in experimental and control group

Ø  To compare the effectiveness of cold application on arteriovenous fistula puncture pain among hemodialysis patients between experimental and control group

Ø  To find out the post-test score of arteriovenous fistula puncture pain with socio-demographic variables in experimental and control group

Ø  To find out the post-test score of arteriovenous fistula puncture pain with selected clinical data in experimental and control group.

HYPOTHESIS

H₁: There is a significant difference in the arteriovenous fistula puncture pain among hemodialysis patients in experimental group.

H₂: There is a significant association between the post-test score of arteriovenous fistula puncture pain with socio-demographic variables in experimental and control group.

H₃: There is a significant association between the post-test score of arteriovenous fistula puncture pain with selected clinical data in experimental and control group.

The conceptual frame work adopted for this study was Modified Orlando’s Nursing Process of research use, which addresses the implementation of existing research knowledge [5]. The research approach adopted for the study was non-randomized control group post-test only design. Quasi experimental design is the powerful tool for testing of hypothesis, causes, effect and relationship between the variables [5].

MATERIALS AND METHODS

The study was conducted in Dr. K. M. Nallasamy Hospital, Erode and VMCH hospital, Namakkal district, Tamil Nadu. Non-purposive sampling technique was used to select the sample. After that, the samples were equally divided into experimental and control group. The samples consisted of 25 in experimental group and 25 in control group. The tool used for data collection was Semi structured interview schedule. It has 3 sections.

Section A consists of socio demographic variables. Section-B consists of clinical data. Section C consists of Numerical Pain Assessment Scale to assess the pain response of subjects during arteriovenous fistula cannulation.

The data gathered were analyzed and interpreted in terms of objectives. Descriptive and inferential statistics were used in data analysis. The result of the study revealed that, after cold application, the mean pain score in the experimental group was 2.4 where as in control group the mean pain score was 3.6. In the experimental group, maximum pain score was 5, where in control group the maximum pain score was 9. Chi-square test was used to assess the post-test score of pain in experimental and control group with socio demographic variables (Figure 1). Chi-square test was used to assess the post-test score of pain in experimental and control group with selected clinical data (Tables 1-3).

Figure 2 shows the post-test score of pain among subjects in the experimental group and control group. Majority of the subjects in the experimental group, 4 (16%) experienced no pain, 16 (64%) experienced mild pain, 5 (20%) experienced moderate pain. Well, none of them experienced severe and worst pain during arteriovenous fistula puncture (cannulation). Majority of subjects in the control group 2 (8%) experienced no pain, 12 (48%) experienced mild pain, 8 (32%) experienced moderate pain, 3 (12%) experienced severe pain and none of them experienced worst pain during arteriovenous fistula puncture.

RESULTS AND DISCUSSION

Findings based on objectives

1.       To assess the arteriovenous fistula puncture pain among hemodialysis patients in experimental and control group

The post-test score of pain among subjects in the experimental group and control group. Majority of the subjects in the experimental group 4 (16%) experienced no pain, 16 (64%) experienced mild pain, 5 (20%) experienced moderate pain. None of them experienced severe and worst pain during arteriovenous fistula puncture (cannulation). Majority of subjects in the control group 2 (8%) experienced no pain, 12 (48%) experienced mild pain, 8 (32%) experienced moderate pain, 3 (12%) experienced severe pain and none of them experienced worst pain during arteriovenous fistula puncture.

2.       To compare the effectiveness of cold application on arteriovenous fistula puncture pain among hemodialysis patients between experimental and control group

H₁: There is a significant difference in the arteriovenous fistula puncture pain among hemodialysis patients in experimental group.

It shows that the mean, mean %, standard deviation pain score of patients during arteriovenous fistula puncture (cannulation) in the experimental group found 2.4(9.230%) with standard deviation 1.46. In control group, was found 3.6(13.846%) with standard deviation 2.37. The calculated t’ test value 2.14 was significantly greater than the table value 1.96 at p ≤ 0.05. It was evident that cold application is effective on arteriovenous fistula puncture pain. Hence the hypothesis H₁ was accepted. This study was supported by the experimental study conducted by Amer et al. [6] to determine the effect of cryotherapy on reducing pain during AVF cannulation among HD patients in the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. The sample size was 62 patients. Randomization was used to assign the patients into the experimental (received cryotherapy) and control (no cryotherapy) groups. Descriptive and retrospective methods were used. The Arabic version of Wong-Baker pain rating scale was used to determine the pain score. The t-test result revealed that no significant difference in the three-paired observations with the P=0.476, 0.202 and 0.103, respectively, at 0.05 level of confidence. The result implies that cryotherapy administered before the procedure is effective in reducing the level of pain experienced during AVF cannulation among the patients undergoing hemodialysis 0.05 level of confidence. The result implies that cryotherapy administered before the procedure is effective in reducing the level of pain experienced during AVF cannulation among the patients undergoing hemodialysis [6].

Findings related to socio demographic variables

About 13 (52%) subjects belong to the age group of 41-60 years. Most of the subjects 19 (76%) were males [7-10]. About 14 (56%) subjects studied up to primary education. Most of the 18 (72%) subjects were unemployed [11-16]. Majority of subjects 24 (96%) were known case of chronic renal failure. Majority 21 (84%) of the subjects having arteriovenous fistula in their left arm. Nearly half of the subjects 14 (56%) had brachio-cephalic site of arteriovenous fistula. For all of subjects 25 (100%), attending duration of hemodialysis is 4 h. Chi-square test was used to assess the post-test score of pain in experimental and control group with socio demographic variables [12-14]. It was concluded that age, gender, educational status, occupational status, marital status, type of family, duration of sleep at night time, dietary pattern, personal habits and recreational activities during dialysis procedure were non-significant at 0% level. Chi-square test was used to assess the post-test score of pain in experimental and control group with selected clinical data. It was concluded that co-morbid conditions, period of hemodialysis in months, presence of arteriovenous fistula in an arm, site of arteriovenous fistula, duration of present arteriovenous fistula site use, frequency of attending dialysis in a week, number of dialysis per month, patients weight in kilograms, techniques of arteriovenous cannulation, size of arteriovenous cannula used were non-significant at P ≤ 0.05 level.

RECOMMENDATIONS OF THE STUDY

In the light of the above study the following recommendations are put forth.

Ø  A similar study can be conducted for a large sample to draw more conclusive generalization.

Ø  A comparative study can be conducted with two different age groups.

Ø  A study can be conducted by using cold application as a pain relief measure before intravenous cannula insertion.

Ø  A similar study can be conducted by using cold application as a pain relief measure for stomach cramps for peritoneal dialysis patient.

LIMITATIONS

Ø  The study is limited to assessment of specific aspect i.e. score of arteriovenous fistula puncture pain of the patients undergoing hemodialysis.

Ø  The study is limited to two hospitals.

Ø  The study is limited to the sample size of 50.

Ø  The study is limited to five weeks.

CONCLUSION

The present study showed that samples in the control group had pain up to severe pain during post-test, but after the cold application there was a significant reduction up to moderate pain in experimental group. The pain scores remains same and even some clients’ pain level got increased among control group. This implies that cold application is effective on arteriovenous fistula puncture pain among hemodialysis patients. And this effect was demonstrated through numerical pain assessments scale.

1.       Barbara K, Nancy ET, Smith (2007) Introductory to Medical Surgical Nursing. Lippincott Williams and Wilkins Publications, pp: 1011-1012.

2.       Monahan FD, Neighbors M (1998) Medical Surgical Nursing. WB Saunders Company, pp: 1404-1405.

3.       Lois W, Gena D, Wendy B (2013) Medical Surgical Nursing. Delmar, pp: 566-567.

4.       Brazier (2018) What is dialysis, and how can it help? Medical News Today.

5.       Suresh KS (2017) Nursing research and statistics. Elsevier India, pp: 133, 162, 208-220.

6.       Amer HS, Dator WL, Abunab HY, Mari M (2017) Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 28: 1050-1056.

7.       Schinstock CA, Albright RC, Williams AW, Dillon JJ, Bergstalh EJ, et al. (2011) Outcomes of arteriovenous fistula creation after the fistula first initiative. Clin J Am Soc Nephrol: 6: 1996-2002.

8.       Demir Y, Khorshid L (2016) The effect of cold application in combination with standard analgesic administration on pain and anxiety during chest tube removal: A single-blinded, randomized, double-controlled study. Pain Manag Nurs 11:186-196.

9.       Montero RC, Arellano FR, Abad MDC, Gómez AM, Galán MIF (2012) Pain degree and skin damage during arterio-venous fistula puncture. EDTNA-ERCA Journal 30: 208-212.

10.    Ernst E, Fialka V (1994) Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. J Pain Symptom Manage 9: 56-59.

11.    Figueiredo AE, Viegas A, Monteiro M, Poli-de-Figueiredo CE (2008) Research into pain perception with arteriovenous fistula (AVF) cannulation. J Ren Care 34: 169-172.

12.    Ghods AA, Abforosh NH, Ghorbani R, Asgari MR (2015) The effect of topical application of lavender essential oil on the intensity of pain caused by the insertion of dialysis needles in hemodialysis patients: A randomized clinical trial. Complement Ther Med 23: 325-330.

13.    Varughese S, Abraham G (2018) Chronic kidney disease in India. CJASN 13: 802-804.

14.    Chailimpamontree W, Dmitrienko S, Li G, Balshaw R, Magil A, et al. (2009) Probability, predictors, and prognosis of post transplantation glomerulonephritis. J Am Soc Nephrol 20: 843-851.

15.    National Kidney Foundation (2017) 2020 Spring Clinical Meetings.

16.    Moran PA, Scott A, Darbyshire P (2009) Communicating with nurses: Patients views on effective support while on hemodialysis. Nurs Times 105: 22-25.