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Effect of Cold Application
Effect of Cold Application
Effect of Cold Compresses on Pain Intensity and Ecchymosis Among Patients Receiving
Subcutaneous Anticoagulant Injection
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
Injection time, injection site, injection negative effects of injectable drugs. (El-
dose, needle size, and use of cold therapy Deen DS, Youssef NFA,2018)
are all factors that affect pain and bruising
caused by subcutaneous anticoagulants.
Significance of the study:
The use of cold compresses lowers tissue
temperature, blood flow, and cellular Today, non-pharmacological pain
metabolism. Because these difficulties management approaches such as
might threaten patient safety and drive relaxation, touch therapy, music therapy,
patients to avoid future injections, imagery therapy, and the use of heat and
caregivers must utilize ways to limit the cold are popular. Non-pharmacological
occurrence of these adverse effects to treatments are simple to use, patient-
improve patient satisfaction and trust in acceptable and can be employed by nurses
healthcare providers (Hu L, 2019). themselves. Some nurses prefer non-
Cryotherapy is another name for cold pharmacological techniques because they
therapy. It works by restricting blood flow are low-risk and allow patients to take an
to certain locations, lowering pain- active role in their pain relief. Cold
inducing inflammation and swelling, therapy is a non-drug, low-cost way to
particularly around joints and tendons. It relieve pain (Thijs E et al., 2019).
can temporarily diminish nerve activity as
well as discomfort. Cold therapy can be Anticoagulant injections are being given
applied to the affected area in a variety of to an increasing number of individuals. Is
methods, including B. Ice packs or a class of anticoagulants used to prevent
cryogel packs, ice massages, and ice baths and treat venous thromboembolism (deep
(Ozkan & Cavdar, 2021). vein thrombosis and pulmonary
The use of cold compresses lowers tissue embolism) and other cardiovascular
temperature, blood flow, and cellular illnesses, as well as deep vein thrombosis
metabolism. Cold compresses are a before and after surgery. The injection
nonpharmacological technique that process causes fears in people of all ages,
reduces catecholamine levels, increases from newborns to the elderly. Pain is the
endorphin levels, and delays the primary source of this phobia.
transmission of pain signals to the central Anticoagulant injections under the skin
nervous system, all of which serve to are a regular technique that frequently
lessen pain severity. Cold compresses results in bruising, discomfort, and
help alleviate discomfort and ecchymosis hematoma at the injection site(Amaniyan
by constricting peripheral blood arteries S, 2016).
and reducing blood flow to tissues
(Quinlan P, et al. 2017). Cold compresses are one of the simplest
The caregiver has a significant level of and most inexpensive non-drug
authority for administering safe and approaches to pain treatment. Cold
correct doses. As a result, they should be compresses are a simple and efficient
aware of acceptable and effective treatment. The benefits of cold
techniques for reducing possible damage compresses for pain relief are widely
and complications in hospitalized patients recognized, and they have few negative
that are based on scientific evidence. effects. There are no dangers or negative
Applying pressure before injection, effects with cold therapy. Cold has been
cooling the needle, injecting at a precise shown to reduce pain and lower pain
moment, and cooling the injection site thresholds in studies. To satisfy analgesic
before and/or after it is heated are some of needs, clinicians have reportedly used
these tactics. Furthermore, caregivers several pain control medicines, such as
must be well-versed in the potential opioids, nonsteroidal anti-inflammatory
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
container by the researchers. The study & Adler, 1975). Patients were
group received a cold compress before asked to rate their current pain
receiving an anticoagulant injection sensation on a scale of 0 to 10 at
subcutaneously, while the control group the time of the injection.
received standard treatment. Scoring system: There were four
Tools of data collection levels of pain intensity: none,
Data was gathered using the following mild, moderate, and severe: no
tools: After reviewing relevant literature, pain (0), mild pain (1-4), moderate
the researcher designed them. It has three pain (5-7), and severe pain (8-10).
sections and is written in simple Arabic: 3. Ecchymosis Formation Scale:
1. A Structured Interview This scale was adopted from a
Questionnaire previous study to measure
Patient assessment tool: The ecchymosis (Andersen,
researcher developed the tool. It is Bregendahl, Kaestel, Skriver, &
divided into two sections: Ravkilde, 2015). Ecchymosis was
demographic information and medical measured 48 and 72 hours
information. following the injection by the
researchers.
Part I: Demographic Data:
Processes patient sociodemographic Scoring system: Ecchymosis are
data such as age, gender, educational classified into four groups based on their
level, occupation, marital status, and surface area: no Ecchymosis (less than 2
location of residence. cm in diameter), tiny Ecchymosis(less
than 2 cm in diameter), large
Part II: Medical Data: The Ecchymosis (greater than 5 cm in
researchers created this tool to collect diameter), and marked
information from patient admission Ecchymosis (greater than 10 cm in
records on patient care units, medical diameter).
history, patient weight, and laboratory
tests such as prothrombin time, Administrative design :
prothrombin concentration, and The hospital director and the cardiac care
international normalized ratio (INR)). unit manager were permitted to perform
At the same time, the researchers took this study by the authorities of Benha
measurements of height and BMI. University Hospital's Faculty of Nursing
(to obtain their approved study letter).
Bruising Category Scale: This scale
was adopted from (McGowan and Face-to-face discussions with nurses and
Wood, 1990) and is used by doctors were also held to explain the
researchers to measure contusion. At study's goal and to ensure the greatest
48 and 72 hours after the injection, the possible teamwork. Patients' oral
researchers measured bruises. informed agreement to participate in the
study was also acquired once the purpose
Scoring system: Based on the surface and methods were explained to them.
area, bruising was categorized into
Operational design:
three categories: no bruising (less than
2mm2), light bruising (2-5mm2), and The preparation phase, content validity
severe bruising (more than 5mm2). and reliability, pilot studies, and
fieldwork are all part of operational
2. Visual Analogue Scale for pain design.
(VAS): This pain intensity scale,
adopted, was used by the examiner Preparatory phase:
to assess pain intensity (Ohnhaus
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
The researchers used books, papers, and before evaluating and arranging the
the Internet to review current relevant intervention. The researchers underlined
literature and theoretical knowledge on the necessity of active participation while
many topics of this study to build maintaining the right of the patient to
adequate data collection tools. withdraw at any moment. Embarrassment
or a negative influence on patient care are
3.6. Validity of the proposed tools by
both possibilities.
using face and content validity. Face
validity aimed at inspecting the items to Researchers will consider all newly
determine whether the tools measure what admitted patients receiving subcutaneous
supposed to measure. Content validity anticoagulants for inclusion once the
was conducted to determine whether the required approvals are obtained to
content of the tools cover the aim of the proceed with the proposed trial. Patients
study. Validity tested it was tested by a who satisfy the research's requirements
jury of 5 expertise as follow, Three of should be given detailed information
them were professors and two are about the trial and asked whether they
assistant professors of medical surgical accept to participate. For all actual work,
nursing at faculty of nursing, Benha researchers were accessible at the heart
University, The expertise reviewed the station three days a week from 9:00 a.m.
tools for clarity, relevance, to 3:00 p.m. till interviewing people. The
comprehensiveness, simplicity and data were collected over six months by
applicability, All necessary modification the researchers (from early February 2021
were carried out accordingly. to late July 2021).
Reliability of tools is the ability of a tool The equipment used in this study
to produce stable and reliable outcomes consists of a 15 x 15 cm refillable cold
measured by its reliability. The visual bag; a thermometer for determining
analog scale's dependability was assessed package temperature; a disposable towel
statistically using intraclass correlation to cover the refillable cold bag; a clock
coefficients (ICCs), which were 0.97. with a second hand to determine the
(Bijur, Silver & Gallagher, 2001). The length of anticoagulant injection Cold
intraclass correlation coefficients (ICCs) compress time and duration; a permanent
with an ICC of 0.962 were used to marker to identify injection site; To
determine the reliability of the measure the diameter of bruises and
ecchymosis and bruising scales (Cosman, ecchymoses, use a transparent millimeter
2012). ruler.
Pilot study:
A pilot study was done on 10% of the Firstly, demographic information such as
study sample (10 patients) to examine the the individuals' age and gender, as well as
clarity and usefulness of data collection medical information, were entered in a
tools, as well as to establish the necessity data collection form.
for an applied research time tool. Because Body mass index: Weight (kg)/height2
of minor changes made following the (m) is computed by dividing the weight
pilot research, patients enrolled in the (kg) by the square of the height (meters).
pilot study were excluded from the Patients' body mass index was categorized
sample. into three categories by (Pi-Sunyer et al.,
Fieldwork: 1998): normal (18.5-24.9) kg/m2,
The researchers introduced themselves to overweight (25.0-29.9) kg/m2, and obese
the patients, described the aim of the (30.0 kg/m2).
research, and gained verbal consent
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
During the study, refillable rubber ice circle around the navel Time to inject:
packs with clips were employed. The 10 seconds Following the injection:
researchers filled the bag two-thirds For 10 seconds, apply mild pressure to
full with ice and a little water, then the injection site without massaging it.
sucked out the remaining air and
Measurement of bruise and
closed the clips. To prevent frostbite ecchymosis:
and tissue damage, the ice pack is
wrapped in a towel or cotton cloth to It was found that bruising or
function as a barrier between the ice ecchymosis caused by anticoagulant
pack and the patient's skin. According subcutaneous injection was most
to the guidelines in existing nursing noticeable 48 hours after injection and
textbooks, the temperature range for faded 72 hours later (Potter and Perry,
these ice packs is below 150°C 2007). As a result, 48 and 72 hours after
(Berman et al., 2015). injection, bruising and ecchymosis
measurements were taken. Researchers
In the control group, the researcher carry out the evaluations. A clear meter
used the SC injection technique to was inserted at the injection site to
inject an anticoagulant into the measure any skin discoloration larger than
abdomen without using a cold 2 mm2 in diameter, and the bruised area
compress, designated the injection site was calculated in mm2. The size of the
with a permanent marker, drew a ecchymosis at the injection site was
5cm2 circle around the injection site, measured with a transparent millimeter
and documented the data on the ruler, with the broadest dimension
collecting form. The pain level was measured to the nearest centimeter.
measured right after the injection. At
48 and 72 hours, ecchymosis and Assessment of pain intensity:
bruising were examined. A visual analog scale (VAS) was used to
In the study group the researcher used measure pain immediately after each
an ice pack for 5 minutes before the injection. 0 indicates no discomfort,
injection, and then performed an whereas 10 indicates severe pain and
abdominal SC injection using the SC anguish. Subjects were asked to give a
injection technique, marking the site number between 0 and 10 that represented
with a non-fading pen, and drawing a their current pain perception at the time of
circle of approximately 5 cm2 around the injection immediately after each
the insertion point and recording it in injection.
the data collection form. The pain Ethical consideration:
level was measured right after the 1. Every participant was told that tools
injection. At 48 and 72 hours, will not affect him/her and will not induce
ecchymosis and bruising were any risk or discomfort.
examined. 2. It will not induce hazards of physical
For all patients in two patient groups or psychological, social and don’t
(study and control), the subcutaneous counteract with ethical beliefs.
injection regimen is as follows: Type 3. Confidentiality was maintained during
of syringe: single dosage prefilled the study, personal information was kept
syringe It has a 27 gauge needle. safe, and will be used only for research
Alcohol Swabs: Before inserting the aim.
needle, clean the area with alcohol Each patient was told that,
and let it air dry. Inhaling: There will participation is voluntary and able to
be no inhalation. The angle of withdraw any time without effect his care
insertion: 90 degrees Abdomen in a
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Table (1): Frequency distribution of the study and control groups concerning their
demographic data.
20<30 years 2 4 1 2
0.922
30<40years 6 12 6 12 0.485
ns
40<50years 28 56 27 54
50- 60years 14 28 16 32
Mean ±SD 45.840 ±7.435 45.760±9.045 0.692
)t(=0.048
ns
Sex
0.391
Male 36 72 32 64 0.753
ns
Female 14 28 18 36
2
X : Chi-square test ns: not significant (t) paired t-test
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Orginal Articl Mansoura Nursing
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Table (2): Frequency distribution of the study and control groups concerning their
medical data
Normal 38 76 36 72
1,781 0.410ns
Over weight 9 18 13 26
Obese 3 6 1 2
Mean ±SD 23,400±2,952 24,156±2,731 )t(= -
1,329 0.187 ns
Laboratory investigation
INR
Low 4 8 6 12 0,490 0.783ns
Normal 39 78 38 76
High 7 14 6 12
PC
Low 6 12 8 16
0,332 0,564ns
Normal 44 88 42 84
PT
Normal 43 86 44 88
High 7 14 6 12 0,088 0,766ns
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Table (3): Comparison of the study and control groups regarding pain intensity
score.
Table (4): comparison of the study and control groups regarding bruising category
scale after 48 hours and 72 hours.
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Orginal Articl Mansoura Nursing
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Table (5): comparison of the study and control groups regarding ecchymosis
formation scale after 48 hours and 72 hours.
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Orginal Articl Mansoura Nursing Journal,Volum9,Issu1.
Discussion
Injection time, injection site,
injection dose, needle size, and use of cold
therapy are now factors impacting pain In terms of gender, more than two-thirds
and bruising caused by subcutaneous of the patients in both the study and
injection of anticoagulant injections. The control groups were male, according to the
use of cold compresses lowers tissue current study. This finding is in line with
temperature, blood flow, and cellular that of Zaki et al. (2020), who found that
metabolism. Cold compresses are a men made up more than two-thirds of the
nonpharmacological technique that study participants. This finding is
reduces catecholamine levels, increases congruent with Avsar & Kasikci (2019),
endorphin levels, and delays the who discovered that the majority of
transmission of pain signals to the central patients analyzed are male in their study
nervous system, all of which serve to "Assessing Four Different Methods of
lessen pain severity. Cold compresses also Subcutaneous Heparin Application in
constrict peripheral blood arteries, Inducing Bruising and Pain." This
lowering blood flow to tissues and conclusion contradicts Sendir,
reducing bruising and ecchymosis (Thijs Buyukyilmaz Celik, and Taskopru's (2015)
E, 2019). findings in a study titled "Comparison of 3
techniques for pain and bruise avoidance
Section (I): demographic following subcutaneous heparin
characteristics of the studied patients. administration," which indicated that more
than half of the participants investigated
In terms of age, the current study were women.
discovered that more than half of the study
patients were between the ages of 40 and Section( II): medical data of studied
50, with a mean age of 45.8 7.435, which patients :
was compared to Alabdalhai, Mokabel,
and Al-Ghuneimy, (2017) in their paper Moreover, two-thirds of the study and
entitled "Injection Site Pain and control groups had a normal BMI, with
Hematoma as a Result of Noraparin mean values of 23,400 2,952 and 24,156
(Kingdom of Saudi Arabia-Arabia) 2,731, respectively, in the current study.
Patients ranged in age from 47.5 to 20.7 Jareno-Collado et al. (2018) investigated
years. This finding was also similar to that "ecchymosis and/or hematoma formation
of Zaki et al. (2020), who evaluated "The following prophylactic treatment of
effect of cold compresses on patients enoxaparin in the abdomen or arms of
receiving subcutaneous enoxaparin." ", critically ill patients" and found that only
found that more than half of the about a quarter of the patients were obese.
participants in the study were under the This contradicts the findings of Palese et
age of 50, with a mean age of 45.43 18.18 al. (2019), who discovered that just about
years. Ahmadi, Ahmadi, Saadati, and half of the patients were obese.
Mehrpour (2016), conducted a study titled In terms of laboratory tests, the majority of
"Effect of prolonged subcutaneous heparin the study and control groups had normal
injection on pain severity and incidence of INR, PC, and PT levels. This finding is in
bruising" and found that more than two- line with that of Alabdalhai et al. (2017),
thirds of the cases were the case, who found that more than two-thirds of the
contradict this finding. Patients in the patients in their research had normal
study ranged in age from 50 to 69 years prothrombin timings. This study's findings
old. on INR are congruent with those of Zaki et
al. (2020), who found that more than
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