|Year : 2020 | Volume
| Issue : 1 | Page : 34-38
An experimental study to determine the effectiveness of blunt pressure technique on pain response among patients receiving intramuscular injection
Dinesh Kumar Suganandam1, Jasmin Ruby Anand1, Amala Rajan1, Georgene Singh2, Bijesh Kumar Yadav3
1 College of Nursing, CMC, Vellore, Tamil Nadu, India
2 Department of Anesthesia, CMC, Vellore, Tamil Nadu, India
3 Department of Biostatistics, CMC, Vellore, Tamil Nadu, India
|Date of Submission||17-Jul-2019|
|Date of Acceptance||04-Jan-2020|
|Date of Web Publication||16-Apr-2020|
Mr. Dinesh Kumar Suganandam
College of Nursing, IDA Scudder Road, CMC, Vellore, Tamil Nadu, India
Source of Support: None, Conflict of Interest: None
Context: Pain is a universal phenomenon. It is considered to be the “fifth vital sign.” Pain originating from intramuscular (IM) injection should not be underestimated, because a painful injection might incite severe fear of injection, which may delay the patient seeking medical help. Aims: This study was intended to determine the effectiveness of blunt pressure technique on pain response among subjects receiving IM injection. Settings and Design: Using Quantitative approach, randomized controlled trial with posttest only design was undertaken for 6 a period of 6 weeks in a tertiary care centre. Materials and Methods: Patients receiving IM injection in the injection room were selected using consecutive sampling technique. The individuals were randomly allocated to control and experimental arm using computer generated random number table in the sealed envelope. Patients with infectious skin diseases, bleeding disorder, trauma and injury, cognitive impairment were excluded from the study. Control arm received injection using standard technique and experimental arm received injection using blunt pressure technique with the operation protocol. Numerical pain rating scale was used to collect the data. Statistical Analysis Used: Descriptive statistics was used to describe the data. Mann–Whitney U-test and Kruskal–Wallis test were used to infer the data. Results: The mean pain response in the standard technique was 3.15 ± 1.44 and in the blunt pressure technique was 1.01 ± 0.98. The difference in pain response was found to be statistically significant (P < 0.001). Conclusions: Blunt pressure technique is found to be effective in reducing the pain response. Nurses can embrace this innovative technique with scientific base to alleviate the procedural pain.
Keywords: Blunt pressure, intramuscular injection, pain, procedural pain
|How to cite this article:|
Suganandam DK, Anand JR, Rajan A, Singh G, Yadav BK. An experimental study to determine the effectiveness of blunt pressure technique on pain response among patients receiving intramuscular injection. Indian J Pain 2020;34:34-8
|How to cite this URL:|
Suganandam DK, Anand JR, Rajan A, Singh G, Yadav BK. An experimental study to determine the effectiveness of blunt pressure technique on pain response among patients receiving intramuscular injection. Indian J Pain [serial online] 2020 [cited 2020 May 29];34:34-8. Available from: http://www.indianjpain.org/text.asp?2020/34/1/34/282550
| Introduction|| |
Pain is a basic essential human experience. It acts as a warning mechanism to prevent harm to the organs of the body. Hence, it is protective in nature. Pain has always an emotional component attached to it. It is highly mandatory to address that in the context of holistic care. Pain has been called as an ageless universal phenomenon – an unpleasant multidimensional sensory experience that delivers wide variations in intensity, quality, duration, and persistence.
The phrase “pain as the fifth vital sign” was initially promoted by the American Pain Society to elevate awareness of pain treatment among healthcare professionals. The concept of “Right to be free from pain” has to be emphasized by the institutional administrators. Procedural pain is an important source of discomfort for clients in nursing care settings. Pain management during invasive procedure is a challenge for the direct care providers. Nurses are ethically and legally responsible for managing pain and reliving suffering. Effective pain management not only reduces physical discomfort, but also improves quality of life. Pain originating from IM injection should not be underestimated, because a painful injection might incite severe fear of injection, which may lead a patient to delay seeking medical help.
As a patient advocate, the nurse takes all possible means to alleviate the patient's pain and suffering. She continues to advocate for the patient through any other means if the patient's pain needs are inadequately addressed. There are four main considerations regarding injections: the route, site, techniques, and equipment. Here the researcher is interested in introducing a new “Blunt Pressure Technique” to reduce the pain perception.
There are various techniques which were employed in reducing the pain related to intramuscular (IM) injection based on the Gate Control Theory. Blunt pressure application prior to injection significantly reduces pain. Romanò and Cecca from Italy and Yeganekhah et al. from Iran conducted the same study using blunt pressure technique during injection procedure and found to be significantly reducing pain.
The blunt pressure technique refers to the method of administering an injection through a small opening in the round plastic disc with multiple blunt plastic pins which is pressed over the patient's skin. This blunt plastic pins will exert a pressure over the skin. According to the Gate Control Theory, the pain perception will be diminished via interference by the other physical stimulation.
As nurses play a crucial role in the delivery of health care, they need to embrace novel and innovative techniques to provide effective and best possible treatment to their patients. By keeping this mind, the researcher wanted to utilize the innovative multiple blunt pressure technique in the IM injection to minimize the pain experience of patients. The study was intended to determine the effectiveness of blunt pressure technique on pain response among patients receiving IM injection and also to identify the difference in pain response of the individuals with demographic and clinical variables. Formulated hypotheses were:
- H1: There is a significant difference in pain response of patients receiving IM injection using standard technique and blunt pressure technique
- H2: There is a significant difference in the pain response of patients based on patient's demographic and clinical variables.
| Materials and Methods|| |
The study was performed after getting approval from Institutional Review Board. The study was also enrolled in the Clinical Trials Registry of India (CTRI/2016/09/007266). A written informed consent was obtained from all the individuals after informing them about the details of the study. Adequate privacy was provided during the injection procedure. Confidentiality of the information was achieved by maintaining anonymity of the individuals and assigning sample numbers so that the responses of the individuals could not be traced. The data were stored in a password protected system.
Study setting and design
Using quantitative approach, a randomized controlled trial with posttest only design was undertaken for this study over a period of 6 weeks in a tertiary care center.
Selection and description of participants
Samples were recruited in the injection room of a tertiary care center of South India. Individuals with the age group of 16–65 years, willing to participate in the study were included. Individuals with pain, injury, bleeding disorder, dermatological problems were excluded. Sample size was calculated for the primary outcome. The individuals were selected using consecutive sampling technique and randomly allocated using computer generated random numbers and allocation concealment by sealed envelope. Data were collected using demographic profile, Numerical Rating Scale for Pain (Numerical Rating scale is a 10 cm scale with 0 at one end and 10 at other end). The demographic profile consist of age, gender, literacy, occupation, number of injection in the past 3 months, height and weight, the drugs used, site of injection, and volume of the drug used.
In the control arm, registered nurses performed IM injection procedure using the standard technique as given by clinical nursing procedure manual of the institution. Among the experimental arm, the investigator performed IM injection using blunt pressure technique. Following the disinfection of skin, round plastic disc with multiple blunt pins [Figure 1] was placed over the subject skin and held in place using forefinger and middle finger. The disinfected cotton swab was kept near the middle finger. Gentle two finger pressure was applied over the disc for 5 s. Injection was given through the middle hole created in the disc at 90° angle. The ring finger and small finger were placed over the disc. Hub of the needle was held using forefinger and thumb. The syringe was gradually withdrawn to check whether the placement is in right place. The drug was slowly injected at the rate of 10 s/cc. After the completion of injection, the hub of the needle was held and the syringe was withdrawn. The cotton ball was pressed at the injected site. The pressure over the disc and injection site was held for 1 min following the injection. Device was removed after 1 min. The individual was allowed to massage the site. Post assessment of pain was carried out.
Data was analyzed using SPSS software (IBM, New York, USA). Descriptive and inferential statistics were used to describe and infer the data. The level of significance was kept as 0.05 for testing the hypothesis. Since the values are not normally distributed, nonparametric equivalents were used. Mann–Whitney U-test was used to identify the mean difference of pain between control and experimental arm. Kruskal–Wallis Test was used to identify the difference in pain response of individuals with their demographic and clinical variables.
The sample size was calculated based on the pilot study findings. The mean pain response was found to be 3.60 ± 1.45 and 1.66 ± 1.39 in control and experimental arm, respectively.
- SD in the first group: 1.4
- SD in the second group: 1.4
- Mean difference between the samples: 2 (Found in the study) 0.9 (assumption)
- Significance level: 5
- Power: 90
- Estimated Sample Size: 51 individuals in each arm [Figure 2].
| Results|| |
The researcher found that 63.7% of the individuals were male in the study. The individuals belonged to the age group of 31–50 years were 47.1%. Fifty one percentage of the participated individuals were graduates and nearly half of the individuals were unemployed (45.1%). Based on the occupation, 27.5% were professionals. Among the number of injections in the past 3 months, 68.6% have not had past injection in the 3 months. Obese individuals were 35.3%, overweight individuals were 28.4%, normal and underweight individuals were 27.5% and 8.8%, respectively. Drugs received by the individuals were vitamin (39.2%), vaccine (35.5%), antibiotic (14.7%), hormones (10.8%). Most of the individuals (65.7%) received injection in the gluteal site. More of than half of the individuals (54.9%) received 0.1–1 ml of injection, 24.5% received 1.1–2 ml of injection, 20.6% received 2.1–5 ml of injection.
The mean pain score among individuals who received IM injection using standard technique and blunt pressure technique is 3.15 ± 1.44 and 1.01 ± 0.98, respectively. It was evident that the individuals who received injection using blunt pressure had less pain compared to others.
[Table 1] shows that there was an evidence of statistically significant difference in the mean pain response of the individuals receiving IM injection using standard technique and blunt pressure technique (P < 0.001) with the 95% confidence interval of 1.65 and 2.62. The mean difference in the pain response was 2.14. It is evident that the blunt pressure technique was effective in pain reduction among individuals receiving IM injection.
|Table 1: Comparison of pain response among individuals receiving intramuscular injection using standard technique and blunt pressure technique (n=102)|
Click here to view
[Table 2] reveals that female individuals had more pain (3.50 ± 1.31) compared to male individuals (2.93 ± 1.50). Young age group were found to have more pain than elders (4.12 ± 1.12). It was noted that unemployed individuals were having more pain (4.15 ± 1.26). This could be due to the majority of unemployed individuals were female, and it was already evident that they had more pain. Antibiotic injections were perceived as painful (3.83 ± 1.47) followed by hormone injections. The more the volume of drug injected (2–5 ml) the severe the pain perceived (3.66 ± 1.22).
|Table 2: Difference in pain response among individuals receiving intramuscular injection using standard technique based on demographic and clinical variable (n=51)|
Click here to view
[Table 3] infers almost similar findings of pain response during blunt pressure technique with regard to the demographic and clinical variable. Even in the individuals who received the injection using blunt pressure technique, antibiotic injections were painful (2.00 ± 1.11) and the larger volume of injection (2–5 ml) was found to have more pain compared to others (1.58 ± 1.16).
|Table 3: Difference in pain response among individuals receiving intramuscular injection using blunt pressure technique based on demographic and clinical variable (n=51)|
Click here to view
| Discussion|| |
The mean pain score was 3.15 ± 1.44 and 1.01 ± 0.98 among the individuals who received IM injection using standard technique and blunt pressure technique respectively. The mean difference in the pain response was 2.14, and there was an evidence of statistical significance (P < 0.001). The current findings were in line with the findings of the study done by Romanò and Cecca, where the pain score in the placebo group was 5.16 ± 1.37 and 1.90 ± 1.27 in the treated group. The difference in the pain response between the groups was found to be statistically significant (P < 0.0001). This finding was also supported by Yeganekhah et al. and Nasiry et al. Hence, it is evident that the usage of blunt pressure technique using the oval disc helped in reducing the pain during IM injection. Thus, H1 is accepted based on the current study findings.
The study aimed to identify the difference in pain response of patients receiving IM injection with the demographic and clinical variables. In the present study, the researcher found that there was an evidence of statistically significant difference in pain response of individuals receiving IM injection with respect to occupation of the individuals (P < 0.01). Unemployed individuals were 39.2%, and they expressed maximum pain compared to others (4.15 ± 1.26). This could be because majority of the unemployed individuals were female and it was already found that female had more pain compared to male individuals in both the group. There was an evidence of statistically significant difference in pain response of individuals received IM injection using blunt pressure technique based on the drug used (P = 0.004). The pain response of individuals who received antibiotic using blunt pressure technique was more (2.00 ± 1.11) compared with individuals who received other drugs. Even the individuals who received injection using standard technique also experienced more pain with antibiotic injections compared to other injections. Researcher could not get any relevant studies to support the findings. However, with the expertise opinion and patient feedback, it was found that antibiotic injections were painful compared to other drugs in both the arm. Since the study could not find difference in pain response among many other demographic and clinical variables studied, H2 is not supported. Statistically significant difference in pain response based on the demographic and clinical variable was not found. However, there were few findings which can be clinically significant and appraised in day-to-day practice. In the current study, female individuals found to have more pain compared to male individuals in both the arms. This finding is in line with the study conducted by Kusumadevi et al. where it was concluded that women experience more pain than men. Individuals who were young and whomever received gluteal injection and more volume of drug had more pain. This findings can be incorporated in the regular practice and addressed accordingly.
The procedure of IM injection using blunt pressure technique can be incorporated in the clinical nursing practice manual. This technique need not be restricted in the hospital setting but can be practiced even in the community setting where there is a scarcity of resource. Non pharmacological measures shouldn't be stopped only with the injection procedure but also should be explored for its usage in any other invasive procedure. In-service education can be planned for all the staff nurses to teach about the incorporation of blunt pressure technique in the IM injection procedure.
The researcher identified there is a great scarcity of literature regarding other factors which can influence pain such as viscosity of the drug, pH of the drug, and speed of injection, and it can be studied in the future research.
| Conclusions|| |
Future research can focus on identifying the effectiveness of blunt pressure technique on pain response among patients undergoing various invasive procedures, finding the effect of adjuvant therapy along with blunt pressure technique in pain response, and comparing the blunt pressure technique and any other technique which was mentioned in other studies.
The gap between the theory and practice should be minimized by incorporating various research findings in to the practice. Based on the finding, it was evident that the blunt pressure technique was found to be reducing pain among the patients receiving IM injection. This effort of identifying the effectiveness of blunt pressure technique in reducing the pain response among patients receiving IM injection may be a modest one, but this will enlighten the nurses to change the practice to provide the best possible comfortable care to the patients.
Financial support and sponsorship
This study was financially supported by Fluid Research Grant of Institutional Review Board of CMC, Vellore.
Conflicts of interest
There are no conflicts of interest.
| References|| |
DeLaune SC, Ladner PK. Fundamentals of Nursing: Standards and Practice. 3rd
ed. New York: Thomson Delmar; 2007.
Potter PA, Perry AG. Fundamentals of Nursing. 7th
ed. St. Louis: Mosby Elsevier; 2009.
Ozdemir L, Pιnarcι E, Akay BN, Akyol A. Effect of methylprednisolone injection speed on the perception of intramuscular injection pain. Pain Manag Nurs 2013;14:3-10.
Romanò CL, Cecca E. A new method to reduce pin-prick pain of intra-muscular and subcutaneous injections. Minerva Anestesiol 2005;71:609-15.
Yeganekhah MR, Abedini Z, Tehrani TD. Evaluation of an applied method in reducing the pain of intramuscular injection. Qom Univ Med Sci J 2011;7:1-6.
Melzack R, Wall PD. Pain mechanisms: A new theory. Science 1965;150:971-9.
Mitchell JR, Whitney FW. The effect of injection speed on the perception of intramuscular injection pain. A clinical update. AAOHN J 2001;49:286-92.
Nasiry H, Hesam M, Asayesh H, Rahmani Anaraki H, Shariati K, Bathai SA. The effect of manual pressure on intramuscular injection pain severity. J Urmia Nurs Midwifery Fac 2013;11:113-8.
Kusumadevi MS, Dayananda G, Veeraiah S, Elizabeth J, Kumudavathi MS. The perception of intramuscular injection pain in men vs. women. Biomed Res India 2011;22:107-10.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]