Journal Of American Science 2013;9(7) Www .
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgThe Effect of Cold Application on Pain and Anxiety during Chest Tube Removal1Raiza Abdoullah Al –Otaibi. 2Fatma M Mokabel and 3Yasser AL-Ghuneimy12Demonstrator Fundamental of Nursing Department-Medical / Surgical Nursing- College of NursingAssociate Professor Fundamental of Nursing Department -Medical / Surgical and Critical Care Nursing- College ofNursing3Associate Professor Surgical Department-Thoracic Surgery- College of Medicine University of Dammamfatmamokabel@yahoo.co.ukAbstract: Many cardiothoracic patients indicate an insertion of a chest tube, in either emergency or nonemergencysituation with eventual removal after cardiothoracic surgery, trauma, and other condition. Patients always describechest tube removal as a painful event and report that the pain is poorly managed. Little evidence-based research hasguided health team in attempts to alleviate such pain. The aim of this study was to examine the effect of coldapplication on pain intensity and anxiety during chest tube removal. Material and method: Single - blindedrandomized experimental design was used. The study was conducted at the cardiothoracic, surgical ward andintensive care unit at King Fahd Hospital of the University, Al-Khobar. Forty patients who had a chest tube aftercardio-thoracic surgery was randomly assigned into two groups. The study group received ice therapy 20 minutesbefore CTR, whereas control group without cold application. One tool was used it covered three part: 1)Demographic data , tube and surgical information’s , 2) Visual Analogue Scale for measuring pain intensity and3)Hamilton Anxiety Scale for measuring Anxiety Level. Results: revealed that the correlation between pre anxietyand pain before and during chest tube removal was insignificant correlated, while it was significantly correlated afterremoval with p .05, and the main pain during chest tube removal for the cold application group were 2.00 whichmean mild pain sensation and 7.95 for the control group which mean severe pain sensation. Conclusion andRecommendation: The ice packs application able to reduce the intensity of pain and anxiety level associated withchest tube removal. Therefore it was recommended to be used during chest tube removal. Additional research isneeded to investigate this effect.[Raiza Abdoullah Al-Otaibi.; Fatma M Mokabel, and Yasser AL-Ghuneimy. The Effect of Cold Application onPain and Anxiety during Chest Tube Removal. J Am Sci 2013;9(7):13-23]. (ISSN: 1545-1003).http://www.jofamericanscience.org. 2Key Words: Pain, Anxiety and Chest tuberoutinely assess the tube function, and document howmuch drainage is coming from tube on the specificsheet (Broscious SK 2010).Chest tubes are categorized as pleural ormediastinal based on the tube tip location. Themediastinal chest tube are usually placed at theconclusion of cardiac operations or other proceduresperformed through a median sternotomy incision,while pleural drainage are perform after non- cardiacoperations through a thoroctomy incision (Carson etal.,2010). The management of pain is consider themain concern for all hospitalized patients, manyeffort was done to improve the competency of themanagement of pain, it would be best if we couldreduce pain from the start (Charnock Y). Theexperience of pain is a multidimensionalphenomenon. Pain is perceptual process influencedby a host of factors and characterized by unique, yetpredictable response. A multidimensional model ofprocedural pain provided a conceptual framework forstudy of analgesic intervention for patientsundergoing painful procedure such as chest tuberemoval. Studies show that patients who undergo1. IntroductionChest drains are inserted in a wide range ofsituations (after cardiothoracic surgery, trauma, postoperative complication, and other medical condition)to drain air and fluid from lung. Thoracic injury isdirectly responsible for 25% trauma deaths andcontributes to the demise of another 25%. Mostmortality attributable to chest trauma occurs in thefield, secondary to disruption of the great vessels,heart, or tracheobronchial tree. Of those who survivethe initial insult, only 15% will have injuries thatrequire operative intervention. In short, tubethoracostomy is often the only procedure initiallynecessary in chest trauma (Akrofi M et al 2007.).Many cardiothoracic patients indicate aninsertion of a chest tube, in either emergency ornonemergency situation with eventual removal(Biteman, K et al 2009). These chest tubes areinserted during the postoperative period to drainaccumulate of air, blood, and fluid from the chestcavity (Bostancı K 2008). By preventing theseaccumulations, severe complications can be avoidedto the heart and the lung. Each chest tube should be13
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgchest tube removal experience moderate to severepain with or without intervention (Cline ME et al2006). This pain result from the chest endothelialtissue which is adhere to the tube tip and at the timeof removal the pulling force will shear this adhesioncausing severe pain. Several studies indicated that thepatients always described chest tube removal (CTR)as a painful and frightening experience and the painis poorly managed, so the patient’s will had anegative emotion. Pain associated with chest tuberemoval is no exception. Studies show that patientswho undergo chest tube removal experiencemoderate to severe pain with or without intervention(Curry, D. M et al 2006 and Owen S & Gould D2007).Studies have revealed that a more intense painlevel occurs during the first 2 days following cardiacsurgery. Patients described their pain after coronaryartery bypass graft surgery with terms such as sore,aching, tender, tiring and annoying more often onpostoperative days 2 and 3. Pain decreasedsignificantly from postoperative day 2 to day 3 andpain was significantly lower by day 7. (Allibone L2007 and Moore E E 2002). There was no nationalstandards have been set for managing this pain andthe anxiety level which is associated with chest tuberemoval. Little evidence-based research has guidedclinicians in attempts to alleviate such pain (Curry, D.M et al 2006).Anxiety and discomfort are unpleasant feelingcan be result from the pain associated with chest tuberemoval. Anxiety is an emotion characterized byheightened autonomic system activity, especiallyactivation of the sympathetic nervous system which"increased heart rate, blood pressure, respiration, andmuscle tone", subjective experience of anxiety is notnecessarily accompanied by particular behavioralindicator are often present (De Jesus PV et al.2009and Berthol et et al.2011,).The nurse plays important role for painmanagement by administer of analgesic which is themost common intervention usually used in a differentsituations for pain management. Although analgesicagents are consider commonly as the mostintervention used for relieving pain during chest tuberemoval. The use of cold application can be apotential solution for the pain management duringchest tube removal, has been proved that theapplication of cold is effective for pain relieving inpatients after surgery than other sedative medication,(Demir Y and Khorshid L 2010) by using iceapplication this will help in decreasing givinganalgesic for patients after procedure and is alsofortified by the theory that nerve conduction velocitydecreased and pain tolerance increased.It is aneffective alternative or adjacent and it has beenaccepted for decades as an effective nonpharmacologic intervention for pain. It’s simple andinexpensive therapy and is commonly used as a nonpharmacologic method for relieving pain. Studieshave shown that application of cold can result in paincontrol and can increase the threshold of pain (EtochSW et al.,2005 and Deneuville M,2002). Therefore,the use of pharmacologic agents should be advisedas well as a combination of non-pharmacologicinterventions during and after a painful proceduresuch as chest tube removal, to managing this pain andthe anxiety level.Aim of the StudyThe present research was conducted to examinethe effect of cold application on pain intensity andanxiety levels during Chest Tube Removal.Hypothesis:1. Patients with cold application will havesignificantly less pain intensity associated withCTR than those in the control group.2. Patients with cold application will havesignificantly less anxiety level during CTR thanthose in the control group.2. Method and ProceduresSetting:The study was conducted at the CardiothoracicSurgical Ward and Intensive Care Unit at King FahdHospital of the University. Al-Khobar -Kingdom ofSaudi ArabiaDesign:A single-blinded randomized experimentaldesign was used in this study.Sample:Forty patients hospitalized in the CardiothoracicSurgical Ward and Intensive Care Unit (ICU) andwho had a chest tube for duration at least 24 hoursafter cardiac-thoracic surgery. Patients were assignedto two groups:Group I: (Study group) Applied cold application withsoft icepack gel which comprised 20 patients.Group II: (Control group): placebo group withoutapplication with ice bag which comprised 20patientsInclusive criteria:1. 18 years old or older.2. Oriented to place and time.3. Able to report pain.4. Have one or two mediastinal chest tubes orpleural tube.5. Patients with normal vital signs.Exclusive criteria: Patients with:1. Mechanical ventilation support.2. Communication problems.14
Journal of American Science 2013;9(7)http://www.jofamericanscience.org3. Any psychiatric disease/ Mental disabilities orwith perception problems.Tool:One tool was used in this study: AnObservational Record Form covered three partsnamely: demographic data, pain intensity and anxietylevel.First Part:Demographic information was collected fromthe patients' medical records regarding: gender, age,surgical procedure, length of surgery, type of chesttube, number of days chest tube was inserted, chesttube insertion indication, body temperature, heartrate, systolic, and diastolic blood pressure.Second Part:The Visual Analogue Scale (Cline ME )A visualanalog scale is an instrument used to measure theintensity of pain.Third Part:Hamilton Anxiety Scale. ( Hamilton M). It wasone of the first rating scales developed to measure theseverity of anxiety level, The scale consists of 14items, each item was scored on a scale of 0 (notpresent) to 4 (severe), with a total score range of 0–56, where 17 indicates mild severity, 18–24 mild tomoderate severity and 25–30 moderate to severe.Methods: The research was approved from the EthicalCommittee of the University. Informed consent of all patients was obtained. A pilot study was carried out on 5 adult from thepreviously mentioned setting according to thechosen criteria and will not be included in thetotal sample. Patients in control and study groups wereprepared to chest tube removal by administered1g perfalgan to the patient 60 minutes before theremoval time.they felt with the chest tube in place on the VASof the area where the soft icepack gel will beapplied (1st measurement).- The researcher was placed a single layer of sterilegauze pad around the area of insertion to skin ofthe chest tube and place an icepack on top of it.The researcher terminate the ice application whenthe skin temperature reached 13 C,and measuredthe patient Anxiety level 10 minute before chesttube removal. (2nd measurement).- Fifteen minutes after the chest tube removal,researcher measured the pain as well as anxietylevel (3rd measurement).The control group:The same steps as study group except applyingthe cold application in the second measurement.Data AnalysisData were entered into the SPSS statisticalsoftware package from each patient’s data collectionfiles. Repeated measures analysis of variance (RMANOVA) was used to investigate the effects of coldapplication on the changes in pain intensity andanxiety level at 3 times: before, immediately after,and 20 minutes after the chest tube was removed.One-way ANOVAs were used to test differencesamong groups.3. Result:Table (1) illustrated that forty chest tubeswere inserted to patient s in group I and group II(Group I: 20 patients using ice pack during chest tuberemoval, while Group II:20 patients without using ice-pack during chest tube removal). This table showsthat (15.0%) of patients were female and (85.0%)were male in group I.In group II (30.0%) were femaleand (70.0%) were male. The mean age was 45.25 18.116 in group I and 39.15 14.637 in group II. Itcan be seen that The mean duration of chest tube was5.35 5.761 in group I and 4.95 1.669 in group II.The table also shows that there was no statisticalsignificant different in relation to sex with (p .256),age (p .249) and duration of chest tube days (p .7).The study group- The researcher asked the patients to mark the painTable 1: Patients characteristics:CharacteristicsFemaleSexMaleAge / yearsDuration of chest tube / daysSignificant level at P 0.05Mean (SD)Mean (SD)Group I (n 20)No (%)315.0%1785.0%45.25 (18.116)5.35 (5.761)15GroupsGroup II (n 20)No (%)630.0%1470.0%39.15 (14.637)4.95 (1.669)P-Value0.2560.2490.7
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgFigure (1) shows the length of surgical procedure. Fifty two percent of patients were ranged from more than3hr to less than 6hr.While 22% of patients were ranged from1 to 2hr length of surgical procedure followed by 20%more of patients were more than 6 hours.Figure 1: Length of surgical procedureFigure 2: Chest Tube Insertion Indications16(Hemothorax)drain uma) drainbloodlung sion(AfterCardiacSurgery) drainChest Tube Insertion Indication
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgFigure (2): Presents the distribution of the studysample in relation to chest tube insertion indications.It can be seen that thirty percent of the study samplehad chest tube after cardiac surgery, 17.5% hadpleural effusion and 15% had tumor. While it was anequal in percent 10% of pneumothorax and lungabscess indicated and the rest of the study sample hadchest trauma, haemothorax, pulmonary fibrosis andpericardial effusion.Figure 3: Types Chest TubeFigure (3) shows the type of chest tubeinsertion. The majority of chest tube were pleural62.5%, followed by retrocardial 22.5% and then 15%had retrosternal.A: CABG Mitral valve replacementB: Rigid bronchoscopy VATS drainageC: Thoracotomy pleurectomy lobectomy bullectomyD: Chest tube insertionE: Pericardial window removal of blood clot from pericardial cavityF: Open lung biopsy pleural biopsy Thoracoscopic biopsyG: OthersFigure 4: Types of surgical procedure17
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgFigure (4) presents the percentage of surgical procedures. It was noticed that quarter of the study sample werecoronary artery bypass graft and Mitral valve replacement (25%), followed by Rigid bronchoscopy and VideoAssisted Thoracoscopic Surgery (VATS),drainage (20%). Whereas 17.5 % of patients had Thoracotomy,pleurectomy, lobectomy and bullectomy, and 15% had chest tube insertion. Regarding the length of surgery amongpatients in both groups, the result of this table showed that (25%) were less than 30 min, followed by 22.5% rangedfrom 1to 2 hours, 20% of patients had a surgery for more than 6 hours and 17.5% ranged from 2 to 3 hours.Table 2: The effect of pain on demographic characteristics before, during and after chest tube removalCharacteristics FactorsPainbefore Painduring Pain after .699.490Surgical Procedure3.042.007-.195.847-.842.406Length Of Surgery1.316.1983.378.0073.860.003Type Of Chest Tube2.326.027.581.5651.380.178Chest Tube Insertion Indication3.563.001-.220.8281.381.177Number of Days Chest Tube Was 0PSignificant level at P 0.05Table 2 presents the effect of pain ondemographic characteristics before, during and afterchest tube removal. It can be seen that the pain beforechest tube removal were highly significant withsurgical procedure, type of chest tube and chest tubeinsertion indications with p .007, p .027 and p .001 respectively. The table also shows that theoverall effect of pain before chest tube removal wassignificant with p .035. As regards to pain duringchest tube removal, it can be seen that there was onlystatistical significant correlation between pain andlength of surgery with p .007. On the other hand, theoverall effect was insignificant with p .433. It canbe seen that length of surgery was the only significantfactor affect pain after chest tube removal with p .003 and the overall effect of pain was insignificantp 0.190.Table 3 : Pain Intensity Scores over time:Study groupsMean SDPain (Before Removal)Group I5.40 1.569Group II4.10 1.683Pain (During Removal)Group I2.00 1.026Group II7.95Pain (After Removal)Group I.50.761Group II2.301.838Significant level at P 0.05t2.527P0.016*14.1750.000*4.0460.000*Table (3) illustrates the pain intensity between the two groups before, during, and after chest tube removal. Themeans of pain intensity scores before chest tube removal were 5.40 1.569 for group I, while 4.10 1.683 for groupII. Pain during chest tube removal for group I were 2.00 1.026 which mean mild pain sensation and 7.95 1.572which mean severe pain sensation for group II. The mean of pain intensity score after chest tube removal were.50 .761 for group I, while 2.30 1.838 for l group II. Moreover, there were statistical significant different between thetwo groups at different times was (p 0.016) before chest tube removal, (p 0.000) during chest tube removal, and (p 0.000) after the chest tube removal.18
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgTable 4: Hamilton Anxiety Rating Scale (HAM-A) Comparing study versus Control group before and after chesttube removalGroup IGroup IIPParametersM SDM SDPre1.80 .6161.75 .444.770Anxious moodPost0.35 .5870.75 .444.020*Pre1.80 .6961.70 .470.597TensionPost.30 .4700.45 .510.34Pre0.65 .8750.80 .894.849FearsPost.30 .4700.65 .587.044*Pre2.25 .7162.30 .923.337InsomniaPost1.40 .6812.15 .933.006*Pre0.45 1.2340.60 .821.653Difficulties in concentration & memoryPost.25 .6390.60 .754.122Pre1.30 .8011.05 .999.388Depressed moodPost.50 .5130.80 .696.129Pre1.90 .4471.75 .444.294General somatic symptoms MuscularPost.60 .8210.85 .366.221Pre0.60 .5030.35 .489.119SensoryPost0.10 .3080.40 .503.029*Pre1.60 .5981.650 .587.791Cardiovascular symptomsPost0.65 .6710.95 .510.12Pre1.70 .6571.95 .224.115Respiratory symptomsPost0.55 .6861.10 .447.005*Pre1.70 .6571.60 .503.592Gastro-intestinal symptomsPost.75 .7161 .30 .470.007*Pre.80 .768.40 .503.059Genito-urinary symptomsPost.10 .308.40 .503.029*Pre2.00 .0001.95 .9224.324Other autonomic symptomsPost0.65 .6711.20 .523.006*Pre1.95 .6861.80 .768.519Behavior during interviewPost0.20 .4100.65 .587.008*Table 4: Presents the level of anxiety of thestudy sample before and after chest tube removal.Comparing the group I versus group II. It can be seenthat the mean scale was significantly correlated withanxious mood (p .020), fears (p .044), insomnia (p .006), sensory parameter (p .029), respiratorysymptoms (p .005), gastro-intestinal symptoms (p .007), genito-urinary symptoms (p .029),autonomic symptoms (p .006), and behavior duringinterview (p .008).Table (5) shows that mean pain decreasedconsiderably from 4.75 before chest tube removaland 4.98 during removal to 1.40 after removal. Thecorrelation between pre anxiety and pain before chesttube removal and during chest tube removal wasinsignificant, while it was positively significant afterremoval with p .05. It can also be seen that thecorrelation between post anxiety and pain beforeremoval and during removal and after removal wasinsignificant.19
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgTable 5: Correlation between pain and anxiety in relation to chest tube removalAnxiety LevelPain BeforePain duringPain afterremovalremovalremovalMean S.D.4.75 1.744.98 3.281.40 1.66CorrelationPREwith anxiety.133, p .05.183, p .05.0364, p .05CorrelationPOSTwith anxiety.185, p .05.181, p .05.185, p .05Significant level at P 0.05inter-costal nerve fibers into which the chest tubepasses leading to active and superficial CTR pain(Friesner, Stacy A et al 2006).On the other hand, (McCaffery M) presentedthat a policy of short drainage after cardiac surgeryshould be recommended and a significant decrease induration of chest tube drainage was found in the newprotocol group.Chest drains could be removed earlierbecause air leaks occurred less frequently ( Etoch SWet al 2005). Also, changing the threshold of dailyfluid drainage for the removal of chest tubes hascontributed to the decline in chest tube duration (Halvorson GA 2009).The present results areconsistent with the previous finding whichrepresented that there was statistical significantcorrelation between the experimental and controlgroups in relation to chest tube duration while(P 0.07).There was another interested study by(Friesner A 2006), who supported our study whorepresents comparison between control and studygroups as regards to pain intensity measurementscore through the 1st,2nd and 3rd day post-operative.No significant different was found in both group infirst day (P 0.273),there was a significant decreasedin study group versus control group in the second day(P 0.028)and show highly significant decrease instudy group versus control group in the second day(P 0.028)and show highly significant decrease instudy group on the third day (P 0.05).In the present study, it was observed that thevisual analogue score obtained 10 minutes beforechest tube removal was similar in the two groups(with cold application and without application),whereas the visual analogue score obtainedimmediately after chest tube removal were higherthan other score obtained for other time points. TheVAS scores obtained 15 minutes after CTR in coldapplication group produced the most improvement inpain and was the most effective in relieving the pain4. Discussion:The effect of ice application have beendemonstrated in many research. Ice reduced tissuetemperature and blood flow, pain and metabolism.(Kuzu N et al 2001) reported that cold applicationseemed to be more effectively in limiting swellingand decreasing pain in the short term (immediatelyafter application 1 week post surgery). However,thelong –term effects of ice application and the effect onthe tissue repair are not known. Several studies reportthat application of cold reduces postoperative painand the need for opioid analgesics and also showedthat when ice was applied before subcutaneousheparin injections, the subjects perceived pain wassignificantly reduced compared with subjects whodid not receive cold therapy (Joshi VS et al 2006 andGagliese L& Katz J 2006 and Mueller, XM et al2008).In the present study, it was observed that thevisual analogue score obtained 10 minutes beforechest tube removal was similar in the two groups(with cold application and without application),whereas the visual analogue score obtainedimmediately after chest tube removal were mild ingroup I and was higher than other score obtained forother time points in group II. The VAS scoresobtained 15 minutes after CTR in cold applicationgroup produced the most improvement in pain andwas the most effective in relieving the painassociation with CTR. Also, perceived pain was themost intense during CTR (VAS 2) in group II. Thisresult is in agreement with other studies tests theeffect of non-pharmacological interventions ondecreasing patients pains during chest tube removal,nor use of a quick relaxation technique, nor whilenoise or music was effective in decreasing painintensity below moderate level of pain. The CTRprocedure is a painful stimulant for parietal pleura,pectoral muscle and other type of fibers, including20
Journal of American Science ion with CTR. Also, perceived pain was themost intense during CTR (VAS 2), a result is inagreement with other studies tests the effect of nonpharmacological interventions on decreasing patientspains during chest tube removal, nor use of a quickrelation technique, nor while noise or music waseffective in decreasing pain intensity below moderatelevel of pain. The CTR procedure is a painfulstimulant for parietal pleura,pectoral muscle andother type of fibers, including intercostal nerve fibersinto which the chest tube passes leading to active andsuperficial CTR pain.) (Joshi VS et al 2007 andHariedy N et al 2011)The present results showed that the applicationof cold is effective in reducing pain intensityassociated with CTR.Pain is known to be subjectiveexperience with a dynamic interplay of sensory,perceptional and cognitive system.This result wassupported by the study done by (Ferrell B 2005) whonotice that pain is multidimensional subjectiveexperience that involves the interaction of sensory,perceptual,and cognitive condition. On contrast of thestudy done by (Miller, C. R., & Weber, R. L 2008)who stated that the finding of his study don't supportthat pain intensity scores & pain distress scores werenot significantly different between the participantswho received ice and the one who received tap water.A 10 minutes application of ice resulted insubcutaneous tissue cooling and analgesia in severalstudies. While, (Puntillo k 2006 ) study consisted of74 cardiac surgery reported minimal pain intensityand distress associated with removal of their chesttubes after surgery. Specially their mean intensity anddistress score of 3.26 and 2.98 respectively fallwithin a 0 to 10 NRS range from 1 to 4, which isequivalent to mild pain. These low pain intensity andpain distress scores reported much better pain reliefthan reported in previous studies on chest tuberemoval,in which mean pain intensity scores rangedfrom moderate to severe or strong.In our systematic review, anxiety was found tobe an important predictor for postoperative pain,especially in gastrointestinal, and cardiothoracicsurgery. An anxious state has been advocated as afactor in lowering pain threshold, facilitatingoverestimation of pain intensity, and activation in theentorhinal cortex of the hippocampal formation(Milikan JS 2008).Psychological factors, such as fear and anxiety,are known to provoke the stress response, fear andanxiety are heightened when the occurrence ofpainful experience is un predictable. Long-termeffects of pain include insomnia, depression, andfatigue. Biteman K et al 2009, reported that thepsychological factors influencing pain include: earlyexperience, anxiety about the pain, depression,helplessness and locus of control. Anxiety may alsohave been increased by the information receivedabout the procedure. This results are consistent withthe finding of the present study,patients experiencedhigh anxiety levels before CTR.There wassignificantly difference in the patients among the twogroups. And the sensation to be expected duringremoval of the chest tube and significant correlationsbetween patients’ anxiety and their perception ofsensations during chest tube removal, althoughneither mean anxiety and sensation scores norcorrelation coefficients were reported between studyand control groups especially in relation with anxiousmood p 0.020, fears p 0.044, insomnia p 0.006,sensory alteration p 0.029, respiratory symptomsp 0.005, gastrointestinal p 0.007 symptoms, genitourinary symptoms p 0.029, autonomic symptomsp 0.006 and behavior during interview p 0.008. Instudy done by Mimnaugh et al 2009,who reportedthat patients experienced high anxiety levels beforeCTR and moderate anxiety levels immediately afterCTR. There was no statistical difference in thevariation of anxiety of patients among the threegroups.Conclusion and Recommendations:It can be concluded that the ice packsapplication able to reduce the intensity of pain due tochest tube removal but and the anxiety levels. Coldapplication can be used as a non-pharmacologicintervention and is recommended as a pain relieftechnique during CTR, related its simplicity andbeing inexpensive therapy. Nurses make importantdecisions regarding application of nonpharmacologictherapeutic interventions for pain management.Additional research is needed to investigate theeffects of cold application combined with differentpharmacologic and nonpharmacologic therapeutictechniques to discover a successful resolution for thischallenging problem.Recommendation:Based on the result of the present study, it can berecommended that reducing pain with chest tuberemoval by:1. Physician determines patient's readiness for CTRaccording to standard criteria.2. Nursepractitionerprovidespreparatoryinformation before a procedure to decrease levelof anxiety.3. Ice packs covered with gauze, and applied to thearea surrounding the chest tubes for 20 minutes.4. Nurse practitioner assist the physician bypositioning the patients and provide sterile areafor tube removal.The individual removing the chest tube (s) should21
Journal of American Science 2013;9(7)http://www.jofamericanscience.orgpresent at the time of removal of the ice, and all chesttubes were removed within 1 to 2 minutes ofdiscontinuation of the intervention.12. Demir Y, Khorshid L. (2010). The effect of coldapplication in combination with a standardanalgesic administration on pain and anxietyduring chest tube removal. Journal of theAmerican society of pain. 11 (3):186-96.13. DeneuvilleM.(2002).Morbidityofpercutaneous tube thoracostomy in traumapatients. Eur J Cardiothorac Surg.22:673-8.14. Etoch SW, Bar-Natan MF, Miller FB,Ric
1Demonstrator Fundamental of Nursing Department -Medical / Surgical Nursing College of Nursing 2Associate Professor Fundamental of Nursing Department -Medical / Surgical and Critical Care Nursing College of . (De Jesus PV et al.2009 and Berthol
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