Effect of imagery on children's pain and anxiety during cardiac catheterization

Anxiety reduction after pre-procedure meetings in patients with CHD

BACKGROUND

Cardiac catheterisations for CHD produce anxiety for patients and families. Current strategies to mitigate anxiety and explain complex anatomy include pre-procedure meetings and educational tools (cardiac diagrams, echocardiograms, imaging, and angiography). More recently, three-dimensionally printed patient-specific models can be added to the armamentarium. The purpose of this study was to evaluate the efficacy of pre-procedure meetings and of different educational tools to reduce patient and parent anxiety before a catheterisation.

METHODS

Prospective study of patients ≥18 and parents of patients <18 scheduled for clinically indicated catheterisations. Patients completed online surveys before and after meeting with the interventional cardiologist, who was blinded to study participation. Both the pre- and post-meeting surveys measured anxiety using the State-Trait Anxiety Inventory. In addition, the post-meeting survey evaluated the subjective value (from 1 to 4) of individual educational tools: physician discussion, cardiac diagrams, echocardiograms, prior imaging, angiograms and three-dimensionally printed cardiac models. Data were compared using paired t-tests.

RESULTS

Twenty-three patients consented to participate, 16 had complete data for evaluation. Mean State-Trait Anxiety Inventory scores were abnormally elevated at baseline and decreased into the normal range after the pre-procedure meeting (39.8 versus 31, p = 0.008). Physician discussion, angiograms, and three-dimensional models were reported to be most effective at increasing understanding and reducing anxiety.

CONCLUSION

In this pilot study, we have found that pre-catheterisation meetings produce a measurable decrease in patient and family anxiety before a procedure. Discussions of the procedure, angiograms, and three-dimensionally printed cardiac models were the most effective educational tools.

The Difficulties of Studying Children's Pain at Home

Children experience moderate to severe pain in the days after tonsillectomy surgery. This article describes the challenges of analyzing data from pain diaries 24 hours after ambulatory tonsillectomy surgery. Instructions were to record pain levels every 4 hours and the analgesic as given; however, the number of entries was inconsistent, making comparison of groups difficult. The use of analgesics can threaten the construct validity of cause and must be considered and controlled statistically. Opioids were converted to morphine equivalents and the nonopioids were held as a separate covariate. This article describes the steps taken to find an appropriate statistical means of dealing with inconsistent diary entries and analgesic use. Hierarchical linear modeling (HLM) provides a means to analyze unbalanced data and control for analgesics. Issues of control must be addressed in research that measures children's pain in the home. HLM can address issues of incomplete data in repeated-measures studies.

Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: A Prospective Cohort Study

BACKGROUND

Although circumcision for phimosis in children is a minor surgical procedure, it is followed by pain and carries the risk of increased postoperative anxiety. This study examined predictive factors of postoperative pain and anxiety in children undergoing circumcision.

METHODS

We conducted a prospective cohort study of children scheduled for elective circumcision. Circumcision was performed applying one of the following surgical techniques: sutureless prepuceplasty (SP), preputial plasty technique (PP), and conventional circumcision (CC). Demographics and base-line clinical characteristics were collected, and assessment of the level of preoperative anxiety was performed. Subsequently, a statistical model was designed in order to examine predictive factors of postoperative pain and postoperative anxiety. Assessment of postoperative pain was performed using the Faces Pain Scale (FPS). The Post Hospitalization Behavior Questionnaire study was used to assess negative behavioral manifestations.

RESULTS

A total of 301 children with a mean age of 7.56 ± 2.61 years were included in the study. Predictive factors of postoperative pain measured with the FPS included a) the type of surgical technique, b) the absence of siblings, and c) the presence of postoperative complications. Predictive factors of postoperative anxiety included a) the type of surgical technique, b) the level of education of mothers, c) the presence of preoperative anxiety, and d) a history of previous surgery.

CONCLUSIONS

Although our study was not without its limitations, it expands current knowledge by adding new predictive factors of postoperative pain and postoperative anxiety. Clearly, further randomized controlled studies are needed to confirm its results.

Perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures: a quantitative systematic review

AIMS

To examine the relationship between perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures and the differences in children's perioperative anxiety and postoperative pain among subgroups of demographics.

BACKGROUND

While anxiety and pain are regarded as two common problems experienced by children and adolescents perioperatively and the relationship between them has been reported in previous studies, there has been no review paper examining this phenomenon.

DESIGN

A quantitative systematic review.

DATA SOURCES

Nine electronic databases were searched for studies published in English from the inception date of the databases to December 2010, using various combinations of search terms of 'adolescents', 'anxiety', 'child', 'pain', 'surgery' and 'correlation/relationship'.

REVIEW METHODS

Using the Joanna Briggs Institute's comprehensive systematic review strategies, relevant studies were independently appraised and extracted by two reviewers using the standardized critical appraisal instruments and data extraction tool from Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument.

RESULTS

Ten studies were included in this review from 943 studies initially retrieved. Children and adolescents who had higher level of perioperative anxiety experienced a higher level of postoperative pain. Inconclusive evidence was found regarding differences of perioperative anxiety and postoperative pain between demographic subgroups of gender, age and past surgical experience.

CONCLUSION

Results of this review inform healthcare providers of the role perioperative anxiety plays on children's and adolescents' postoperative pain and indicate the need to use interventions to reduce perioperative anxiety and, therefore, optimize their postoperative pain management during the perioperative period.

The life threatened child and the life enhancing clown: towards a model of therapeutic clowning

In the last decade, there has been a rapid growth in the presence of clowns in hospitals, particularly in pediatric settings. The proliferation of clowns in health care settings has resulted in varying levels of professionalism and accountability. For this reason, there is a need to examine various forms of clowning, in particular therapeutic clowning in pediatric settings. The purpose of this article is to address what therapeutic clowning is and to describe the extent to which it can provide a complementary form of health care. In an attempt to apply theory to practice, the article will draw upon the experiences of a therapeutic clown within a pediatric setting while providing a historical and theoretical account of how clowns came to be in hospitals. Toward this end, a proposed model of therapeutic clowning will be offered which can be adapted for a variety of settings where children require specialized forms of play in order to enhance their coping, development and adjustment to life changes. Finally, current research on clowning in children's hospitals will be reviewed including a summary of findings from surveys administered at the Hospital for Sick Children.

Exploring influencing factors of postoperative pain in school-age children undergoing elective surgery

PURPOSE

The purpose of this study was to examine the influencing factors of postoperative pain among children undergoing elective surgery.

DESIGN AND METHODS

A survey was conducted in 2011 with a convenience sample of 66 children, 6 to 14 years old, in a tertiary hospital in Singapore.

RESULTS

Children experienced moderate preoperative anxiety and postoperative pain. Gender, preoperative anxiety, and negative emotional behaviors were significant influencing factors for postoperative pain. Boys reported less postoperative pain than girls.

PRACTICE IMPLICATIONS

Effective strategies for assessing and managing children's preoperative anxiety are needed to achieve an optimal postoperative pain management outcome.

Distraction techniques for children undergoing procedures: a critical review of pediatric research

Pediatric patients are often subjected to procedures that can cause pain and anxiety. Although pharmacologic interventions can be used, distraction is a simple and effective technique that directs children's attention away from noxious stimuli. However, there is a multitude of techniques and technologies associated with distraction. Given the range of distraction techniques, the purpose of this article was to provide a critical assessment of the evidence-based literature that can inform clinical practice and future research. Recommendations include greater attention to child preferences and temperament as a means of optimizing outcomes and heightening awareness around child participation in health care decision making.

Guided imagery for non-musculoskeletal pain: a systematic review of randomized clinical trials

CONTEXT

Our previous review of the literature concluded that there is encouraging evidence that guided imagery alleviates musculoskeletal pain, but the value of guided imagery in the management of non-musculoskeletal pain remains uncertain.

OBJECTIVES

The objective of this systematic review was to assess the effectiveness of guided imagery as a treatment option for non-musculoskeletal pain.

METHODS

Six databases were searched from their inception to February 2011. Randomized clinical trials were considered if they investigated guided imagery in human patients with any type of non-musculoskeletal pain in any anatomical location and assessed pain as a primary outcome measure. Trials of motor imagery and hypnosis were excluded. The selection of studies, data extraction, and validation were performed independently by two reviewers.

RESULTS

Fifteen randomized clinical trials met the inclusion criteria. Their methodological quality was generally poor. Eleven trials found that guided imagery led to a significant reduction of non-musculoskeletal pain. Four studies found no change in non-musculoskeletal pain with guided imagery in comparison with progressive relaxation, standard care, or no treatment.

CONCLUSION

The evidence that guided imagery alleviates non-musculoskeletal pain is encouraging but remains inconclusive.

Anxiety and pain in children undergoing elective surgical procedures: a systematic review

BACKGROUND

Anxiety and pain are two significant problems experienced by children undergoing elective surgical procedures, which may lead to suboptimal postoperative outcomes. Previous studies have shown a correlation between perioperative anxiety and pain in children.

OBJECTIVES

This review aimed to present the best available evidence on the correlation between perioperative anxiety and pain in children undergoing elective surgical procedures, and to determine the relationship between children's demographics, their anxiety and pain level in the perioperative period.

INCLUSION CRITERIA

Participants were children aged between five to 18 years old who were scheduled for an elective surgical procedure in the hospital setting.No specific intervention was of interest. So long as the primary studies examined correlation of children's anxiety and pain in the perioperative period, they were considered for inclusion.This review focused on children's preoperative level of anxiety; children's postoperative level of anxiety; children's postoperative pain intensity; and/or children's postoperative behavioural changes.This review included quantitative research studies, such as randomised-controlled trials, cohort studies, and descriptive studies which addressed the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures.

SEARCH STRATEGY

A three-step search strategy was utilised in this review. The following databases were searched for articles published in English from the inception date of databases to December 2010: CINAHL, PubMed, Scopus, PsycINFO, Mednar, Trip Database, ProQuest Dissertations and Theses, Scirus ETD and Web of Science.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed independently by two reviewers for methodological quality prior to inclusion in the review using standardised critical appraisal tools from Joanna Briggs Institute. There were no disagreements between the two reviewers, so the third reviewer was not required.

DATA EXTRACTION

Data were extracted using the standardised data extraction tools: the Joanna Briggs Institute Meta-Analysis Statistics Assessment and Review Instrument (JBI-MAStARI) for randomised-controlled trials, cohort studies, and descriptive/case series.

DATA SYNTHESIS

Since the ten included studies used various study designs and outcome measures for the levels of anxiety and pain, this made meta-analysis impossible and therefore the findings were summarised and presented in narrative form.

RESULTS

This review included two randomised-controlled trials, two cohort studies, five observational descriptive studies and one descriptive survey study. Eight studies revealed that children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. Pearson correlation coefficients of these eight studies were reported in the findings, with coefficients ranging between r = 0.29 (p < 0.05) to r = 0.57 (p < 0.001). There is no conclusive evidence supporting the relationships of children's demographics characteristics (i.e. gender, age and past surgical experience) and their perioperative anxiety and pain.

CONCLUSION

Children who had higher levels of pre- and post-operative anxiety experienced a higher level of post-operative pain. The review results inform healthcare providers of the role perioperative anxiety plays on paediatric postoperative pain.This evidence serves to generate implications for clinical practice and future studies in order to better manage children's perioperative anxiety and eventually improve their postoperative pain management. However, this review revealed insufficient evidence supporting the correlation between children's demographic data, namely gender, age and past surgical experience and their perioperative anxiety and pain.

IMPLICATIONS FOR PRACTICE

Children's perioperative anxiety should be routinely assessed prior to procedures in the clinical setting. This review also recommends that interventions be developed and implemented so as to reduce pain and anxiety for children during the perioperative period.

IMPLICATIONS FOR RESEARCH

Future studies are needed to examine the effectiveness of different interventions in reducing children's perioperative anxiety and pain, and to examine the relationship between anxiety and pain in other settings and countries. Future research should also be directed towards developing a reliable, shorter and practical anxiety assessment tool.

Normative salivary cortisol values and responsivity in children

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of children's physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial

Young children are generally restrained in supine position for IV starts, a position that creates fear but is presumed necessary. This study randomly assigned children of ages 9 months to 4 years (N = 118) to being held upright by a parent or lying flat on an exam table for their IV procedure. Distress scores as rated by the Procedure Behavior Rating Scale were significantly lower in the upright positioning group (p = .000); parents were more satisfied with the upright position, and the upright position did not significantly alter the number of IV attempts needed. The upright position appears to be an effective way to decrease IV distress in young children.

A pilot study of distraction for adolescents during allergy testing

PURPOSE

This pilot study describes pain and anxiety associated with allergy testing; tests distraction, specifically self-selected distraction; and examines the relationship between pain, anxiety, and engagement with distraction.

DESIGN AND METHODS

An experimental design was used with a convenience sample of 32 adolescents from an allergist's office randomly assigned to three groups. Pain was measured by the adolescent pediatric pain tool (APPT) and FACES scale.

RESULTS

No differences in pain ratings were found among the groups. Less pain was associated with lower anxiety and greater engagement with distraction. Greater engagement with distraction occurred with less anxiety.

PRACTICE IMPLICATIONS

Knowledge about allergy testing pain, anxiety, and engagement with distraction can assist nurses in preparing adolescents for this procedure.

The effectiveness of complementary therapies on the pain experience of hospitalized children

Pain is a complex phenomenon for children, and the concepts of hospitalization and pain are often linked in the minds of children. Despite best-practice guidelines and standards related to pain management, many hospitalized children continue to have unrelieved pain. This suggests that analgesics alone do not sufficiently relieve their discomfort. Complementary therapies may have an important role in holistic pediatric pain management. This review of literature evaluates available evidence related to the use and effectiveness of complementary therapies on the pain experience of children in hospital settings. Thirteen recent research articles relative to this topic were located and included in this review. A variety of complementary therapies, including relaxation, distraction, hypnosis, art therapies, and imagery, are included. Results of the research are mixed, and further investigation is required.

Playing in the park: what school-age children tell us about imagery

The purpose of this exploratory study was to describe children's use of imagery before and after ambulatory surgery (AS). The study sample was a subset of 75 children (7-12 years) who were randomly assigned to the treatment group (n = 38) from five AS settings in a larger study on the effectiveness of imagery after surgery. They listened to an audiotape of imagery before surgery, after surgery, and after discharge from AS. Imagery use was evaluated with the Imagery Assessment Questionnaire and a home diary. Imagery tapes were used significantly more times at home after surgery than before surgery. There were no significant changes in the children's Imagery Assessment Questionnaire scores at any time point. Children most often imagined going to the park when they used the tape.

A conceptual model of factors influencing children's responses to a painful procedure when parents are distraction coaches

The purpose of this article is to present a model of factors that may influence a child's response to a painful procedure when parents are distraction coaches during the procedure. Nonpharmacological interventions, in particular, distraction, and parents as coaches for their children during procedures are discussed. A conceptual model is presented that illustrates the multiple factors and their possible relationships. A selected review of studies is provided that supports the inclusion of these factors in the model. The model and literature review focus on three major areas: characteristics of the child, characteristics of the parent, and procedural variables. The model presented is currently being tested in a large multisite study on the use of distraction during intravenous line insertion.

Parents' roles in using non-pharmacological methods in their child's postoperative pain alleviation

Increasingly nowadays, parents participate more fully in the care of their hospitalized children. The purpose of this study was to describe parents' utilization of selected non-pharmacological methods in relieving their hospitalized child's (aged 8-12 years) postoperative pain, and factors related to this function. Data were collected by a questionnaire survey completed by parents (n=192) with a child hospitalized on a paediatric surgical ward in the five university hospitals of Finland. The response rate was 90%. Results indicated that non-pharmacological methods, such as emotional support and helping with daily activities, were well utilized whereas cognitive-behavioural and physical methods were less frequently used strategies. Certain background factors specific to the parents and their hospitalized children were significantly related to the non-pharmacological methods used by the parents. The hospitalized child's gender, the time of the surgical procedure, and the parents' assessments of their child's pain intensity, were especially significantly related to many of these strategies. The findings of this study could be used in clinical practice to improve guidance provided to parents regarding interventions for children's pain relief.

Nurses' perceptions of parental guidance in pediatric surgical pain relief

The aim of this study was to describe nurses' perceptions of how they guide parents in the relief of their child's (aged 8-12 years) surgical pain in the hospital, and factors related to this function. The convenience sample consisted of 162 nurses working on the pediatric surgical wards of five university hospitals in Finland. The data was collected with a Likert-type instrument designed for this purpose. The results of this study indicated that nurses felt parents were mostly well informed about their child's surgical procedure, including both cognitive and sensory information, and about the non-pharmacological methods employable for relieving their child's pain. However, some deficiency was identified in the preparatory information, as well as in the cognitive-behavioral and physical methods. Factors related to the nurses' background, such as age, education, work experience and the nurse's own experiences with prior hospitalizations of their children, appeared to have some effects on their perceptions regarding parental guidance.

Nonpharmacological methods in relieving children's postoperative pain: a survey on hospital nurses in Finland

AIM OF THE STUDY

The aim of this study was to describe nurses' use of selected nonpharmacological methods in relieving 8-12-year-old children's postoperative pain in hospital.

METHODS

The convenience sample consisted of 162 nurses working on the paediatric surgical wards in the five Finnish university hospitals. An extensive questionnaire, including a five-point Likert-scale, on the nurses' use of selected nonpharmacological methods and demographic data was used as a method of data collection. The response rate was 99%. Descriptive statistics as well as nonparametric Kruskall-Wallis ANOVA and the chi-squared test were used as statistical methods.

RESULTS

The study indicates that emotional support, helping with daily activities and creating a comfortable environment were reported to be used routinely, whereas the cognitive-behavioural and physical methods included some less frequently used and less well known strategies. The results also show that attributes, such as the nurses' age, education, and work experience, the number of children the nurses had, the nurses' experiences of hospitalization of their children as well as the hospital and the place of work, were significantly related to the use of some nonpharmacological methods.

CONCLUSIONS

The nurses used versatile nonpharmacological methods in children's postoperative pain relief, although some defects could be observed. More research is needed on the methods used by nurses to relieve children's pain in different patient groups and the factors which hinder or promote nurses' use of pain alleviation methods in the clinical practice.

Taking the "ouch" out of injections for children. Using distraction to decrease pain

PURPOSE

This research compared the effect of two forms of distraction on injection pain in a convenience sample of preschool children.

DESIGN

A quasi-experimental study of 105 children (53 girls and 52 boys) ages 4 to 6 years needing DPT immunizations. Data were collected at three sites: two school-based immunization clinics and one public health center with a walk-in immunization program.

METHODS

Study children were randomly assigned to receive one of three treatments with their DTP injection: touch, bubble-blowing, or standard care. Prior to injection, a measure of medical fear was obtained (Child Medical Fear Scale) and pain was measured through use of the Oucher Scale.

DATA ANALYSIS

Planned comparisons within analysis of variance (ANOVA) tested the differences in pain scores by treatment. Factorial ANOVA was used to determine the influence of age or gender on treatment, and the effect of medical fear on pain was analyzed using correlational statistics and factorial ANOVA.

RESULTS

Both forms of distraction, touch and bubble-blowing, significantly reduced pain perception. There were no interaction effects of either age or gender. Fear was a significant covariate, but distraction was effective even when fear was not held constant.

CLINICAL IMPLICATIONS

Distraction appears to be an effective method for decreasing injection pain in young children. It is an easy, practical nursing intervention to help children cope with this common, painful experience.

Measuring imaging ability in children

INTRODUCTION

Guided imagery has been suggested as an intervention to help children cope with noxious symptoms associated with medical care. A measure of imaging ability, that is, the ability to generate vivid mental images and to experience those images as if they were real, could be helpful in identifying children most likely to succeed in relieving symptoms with guided imagery. The purpose of this study was to test psychometric properties of a new instrument, the Kids Imaging Ability Questionnaire (KIAQ).

METHOD

Three expert clinicians and researchers were asked to review the KIAQ to assess content validity. A convenience sample of 58 children were invited to complete the questionnaire twice to obtain data for tests of reliability and criterion-related validity.

RESULTS

Content validity, internal consistency (alpha =.75-.76), and test-retest reliability (r =.73) were acceptable. Criterion-related validity using the Singer Fantasy Proneness Interview as a standard was poor (rho =.31-.46).

DISCUSSION

Some psychometric properties were acceptable; however, continued research will be necessary to test validity of the questionnaire and demonstrate a relationship between KIAQ score and success with imagery. With continued research, pediatric nurses may use the KIAQ in practice to identify children most likely to benefit from guided imagery.

Parental preparation of children for routine physical examinations

Preparation of the child and parents/caretakers for health care events is expected to decrease a child's anxiety and uncooperative behaviors. The purpose of this study was to ascertain the methods of preparation (discussion, reading, play, other) and levels of discussion used by parents in readying their preschool and school-age children for six selected events during routine physical examinations. A phone survey was conducted to all parents of children, ages 2 to 12 years, who visited an academic nursing center or public school for a routine physical examination (n = 132). The events are "listen to heart," "look in ears," "take temperature," "feel the stomach," "look at the throat," and "give a shot." The most common method of preparation parents used was discussion that consisted largely of procedural information rather than a reciprocal dialogue with the child. Preschool children were told what the health care provider would do and what they should do during the physical examination more often than school-age children.

Psychologic preparation to decrease anxiety associated with cardiac catheterization

Undergoing a cardiac catheterization arouses anxiety of most patients. Coronary angiography plays an essential role in the diagnostic evaluation of the patient with suspected or known cardiac disease, and it is an important preoperative cardiac screening protocol for vascular surgery patients. Studies on psychologic preparation have concluded that preparatory techniques--specifically, sensory-perceptual informational and modeling--are beneficial in reducing patients' anxiety in various situations, including cardiac catheterization. The purpose of this study was to compare the preparatory informative (sensory and procedural data) and modeling strategies in reducing anxiety before cardiac catheterization. The research hypothesis that persons (n = 30) given a combination of sensory-perceptual informational preparation and modeling preparation would exhibit less anxiety than persons receiving one preparation alone was not supported. Although no significant difference existed between the postintervention anxiety scores for the 3 different treatment groups, a significant difference existed between the preintervention and postintervention anxiety scores overall. Therefore, this study validates the psychologic and nursing literature that states psychologic preparation is beneficial in reducing patients' anxiety before a stressful experience such as cardiac catheterization. The study findings also revealed an interesting trend for employing a modeling technique. This information contributes to nursing knowledge and may alter and make more effective the nature of standard psychologic preparation for patients undergoing any invasive procedure.