A STUDY TO ASSESS THE EFFECTIVENESS OF DISTRACTOR ON

PAIN AMONG CHILDREN DURING SELECTED INVASIVE

PROCEDURES IN HOSPITALS AT KOLAR DISTRICT.

PROFORMA FOR REGISTRATION OF STUDENTS FOR DISSERTATION

KONINTY CHANDRAKALA LUCAS

A.E& C.S. PAVAN COLLEGE OF NURSING, KOLAR

0

6.0 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION

“Bitter are the tears of a child: sweeten them.

Deep are the thoughts of a child: quiet them.

Sharp is the grief of a child: take it from him.

Soft is the heart of a child: Do not harden it.”

PAMELA GLENCONNER

The word pain is derived from the latin word ‘poena’ which means

punishment, which in turn derived from the Sanskrit root ‘pu’ meaning puification.

The international association for the study of pain defines, “pain is an unpleasant

sensory and emotional experience associated with actual or potential tissue

damage, ar described in terms of such damage”. The international association for

the study of pain further states that, “pain is subjective. Each individual learns the

application of the word through experiences related to in early life.” This definition

emphasizes the individuality of each person’s pain response and the importance of

pain experiences, especially those in early life, in shaping that response. Thus, a

child experience during painful medical procedures likely plays a significant role

in shaping that individuals pain response to future events.24

Pain in children is often under treated. The reasons for the lack of adequate

pain control may include: myths about pain and pain management, fears held by

parents and health professional, and the lack of appropriate pain assessment. Myths

surrounding pain management may prevent the timely and appropriate treatment of

children. Nurses are in a unique position to improve the management of childrent

pain because children and parents will often tell them things they do not tell

physicians and they are often the professionals who have the most contact with an

ill child in and out of the hospital. Nursing intervention can alleviate some of the

fear and pain caused by painful procedures (Eland 1990)

1

Relief of pain is a basic need and right of all children. Management of pain

in the child must be individualized. Age, sex, birth order, cultural background,

parents, caregiver’s response and past experiences affects the child’s response. The

newborn baby, the infants, and the toddler are unable to localize and describe the

severity of pain.25

The nurse must be aware of the child’s response to pain through assessment

of behavioral responses and differentiation of crying. During the pre-school period,

the child acquires the ability to verbally describe the pain experience.

Dependending on the cause of the pain experience, non pharmacologic or

pharmacologic interventions or both may be utilized. The nurse should provide

explanation for what is happening to the school-age child. The nurse should

explore ‘adolescents’ coping pattern and encourage their use in helping this young

people deal with pain.26

A study was conducted on management of injection pain in children. The

groups were designated as: distraction, distraction with suggestion, suggestion and

control. The study supported the use of music distraction in the reduction of

injection pain in children.1

A study was conducted by using parents as distraction coaches during I.V

insertion. Parent –child dyads were ramdomized onto two groups experimental

and control group. The experimental group children showed decreased behavioral

distress over time than did the control group.2

A study was conducted by using virtual reality and Audio-visual eyeglass

system as adjunct analgesic techniques to reduce pain. The study revealed that both

virtual reality and Audio- visual distraction can be promising analgesic technique

that may be used safely and effectively for the reduction of pain and discomfort

during medical procedures.3

2

6.1 NEED FOR THE STUDY :-

The pain response is individual and is learned through social learning and

experience. Early pain experience may play a particularly important role in

shaping an individuals pain responses. In adequate relief of pain and distress

during childhood painful medical procedures may have long- term negative effects

on future pain tolerance and pain responses [Ann Emerg Medical 2005; 45:160-

171].

Many hospitalized children have to undergo painful procedures.

Understanding the study of the pediatric pain experience has increased

exponentially during the part 2 decades. Besides the negative experience of pain

itself, growing evidence supports the occurrence of long- term negative effects

from inadequately treated pediatric pain, especially in infants. Significant short-

term adverse outcome have also been demonstrated, including hypoxemia, altered

metabolic stress responses, even mortality

The developing brains neuronal architecture may be permanently altered by

repeated noxious stimuli such as painful procedures. Children consistently name

the invasive procedures as the cause of the most painful experiences (Hester, 1993)

Challenges to the nurses who provide their care, co- operation of children

during painful invasive procedures is very important. Nurses are in a unique

position to improve the management of children’s pain because children and

parents will often tell them things they do not tell physician, and they are often the

professionals. Pain is often associated with fears, anxiety and stress. A number of

non- pharmacological techniques to reduce pain and distress with procedures such

as, techniques, distraction, Deep-breathing, Blowing, Suggestion, Superhero –

imagery.

3

Memory for the painful event is another factor influencing long-term

negative effects. Children even thou who display low distress, tend to have a

distorted negative recall of the pain they experienced with procedures. Recall is

further distorted if children were distressed at the procedure.

These fragmented traumatic memories easily become exaggerated memories

of the pain experienced, resulting in increased distress at subsequent procedures.

Thus, inadequate treatment of a child’s distress at an initial procedure produces a

negative ongoing cycle of distress at subsequent procedures. Altering there

distorted memories to more realistic ones through postevent suggestion and

feedback may break this cycle. The first step to adequate pain management is

adequate assessment. Assessment instruments used must be practical, reliable,

valid and appropriate for the Childs developmental stage.

Pain may be described as a feeling of hurt or strong discomfort and is the

body’s way of sending a message to the brain that an injury has occurred. The

unrelieved pain causes the body to release certain chemicals that may actually

delay healing. Inadequate prevention treatment of children’s pain and distress

responses to medical procedures may have long-term negative effects on their

future pain responses.

Distraction is a proven effective psychological intervention. Distraction is a

power relief intervention that children are accoustomed to using. Distraction can

be used as one of the strategies to gain co-operation of the child. Distraction is the

ability to focus attention on something other than pain and does not mean that the

pain is gone.24

4

A study was conducted, using nurse coaching and cartoon distraction: an

effective and practical intervention to reduce child, parent and nurse distress

during immunization. The intervention consisted of children viewing a popular

cartoon movie and being coached by nurses and parents to attend to the movie.

Therefore, nurses coaching of children to watch cartoon movies has great potential

for dissemination in pediatric setting.4

A study was conducted to evaluate the validity and reliability of FLACC

tool for assessing pain in children with CI (Cognitive impairment). The child

nurse observed and scored pain with the FLACC tool before and after analgesic

administration simultaneously, parents scored pain with a visual analog scale and

scores were obtained from children who were able to self – report pain. One–

hundred Forty observations were recorded from 79 children. FLACC scores

correlated with parent scores (P<0.001) and decreased after analgesics (P=0.001)

suggesting good validly. Correlations of total scores(r=0.5-0.8; p<0.001) and of

each category (r=0.3-0.8; p<0.001), as well as measures of exact agreement

(R=0.2-0.64), suggest good reliability. Test- retest reliabilility was supported by

excellent correlations (r=0.8-0.883; p<0.001) and categorical agreement (r=0.617-

0.935R=0.400 - 0.881; p<0.001). There data suggest that the FLACC tool may be

useful as an objective measure of past operative pain in children with CI. 5

As distraction is a promising, cost effective, non-pharmacological technique

in reducing pain and distress among children undergoing painful medical

procedures. The researcher in this study is, intented to use cartoon movies, an

audio visual aid as a distractor among children during painful invasive procedures.

6.2 REVIEW OF LITERATURE

Review of literature is a key step in research process. The review of

literature is defined as a broad, comprehensive in depth, systematic and criitical 5

review of scholarly publications, unpublished scholarly print materials, audio-

visual materials and personal communication.

Emphasis has been placed on pharmacologic procedural sedation and

analgesics, but environmental and non pharmacologic therapis contribute greately

to distress reduction.

Review of literature is organized under the following section.

SECTION - I STUDIES RELATED TO PAIN AND BEHAVIORAL DISTRESS DURING

PAINFUL PROCEDURES.

SECTION - II STUDIES RELATED TO NON-PHARMACOLOGICAL INTERVENTIONS

DURING PAINFUL PROCEDURES.

SECTION - III STUDIES RELATED TO DISTRACTION DURING PAINFUL

PROCEDURES.

SECTION - IV STUDIES RELATED TO FLACC SCALE.

Section - I

STUDIES RELATED TO PAIN AND BEHAVIORAL DISTRESS DURING PAINFUL PROCEDURES.

A study was conducted on pain reduction during pediatric immunizations.

The pain associated with immunizations is a source of anxiety and distress for the

children receiving the immunization, their parents, and the providers who must

administer them. A number of studies suggest that the ventrogluteal area is the

most appropriate for all age. Longer needles are usually associated with lees pain

and less local reaction. During the injection, parental demeanor clearly affects the

child’s pain behaviors. Excessive parental reassurance, criticism, or apology

seems to increase distress, where humor and distraction tend to decrease distress.

Immunizations are stressful for many children; until new approaches are

developed, systematic use of available technique can significantly reduce the

burden of distress associated with these procedures.6

6

A study was conducted on 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 standard 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.7

A study was conducted, to reveal, the effect of music versus non- music on

behavioral signs of distress and self- report of pain in pediatric injection patients.

Music has been examined as a potential distraction during pediatric medical

procedures. Subsequent analysis indicated that children who received more

injection tended to benefit more from the music intervention, in terms of their

perceived pain.8

A study was conducted, that allowing 1or both parents to be present during

invasive procedures reduces the anxiety that parents experience while their child is

in the pediatric intensive care unit; to evaluate if the parents presence helpful to the

child and parent; and to determine whether this presence was harmful to the nurses

or physicians. A 12-bed pediatric intensive care unit in upstate New York. The

study population consisted of the parents of 16 children undergoing 1or more

procedures; Allowing parental presence during procedures decreases procedure-

related anxiety.9

7

A study was conducted to investigate the effectiveness of a distraction

technique in reducing a child’s perceived pain and behavioral distress during an

acute pain experience. During venipuncture, the central subjects receives standard

preparation,. Which consisted of being comforted by physical touch and soft

voices, while experimental subjects were encouraged to use a kaleidoscope as a

distraction technique. Results confirmed that the experimental group perceived

less pain and demonstrated less behavioral distress than the control group.10

The study was conducted to reveal, that acute painful medical procedures

frequently engender anxiety reactions in children and sensitize them to future

medical interventions. Techniques that reduce pain and anxiety, including

behavioral distraction (e.g bubbles and pop-up books), kinesthetic methods ( e.g

hypnosis). These pain reductions techniques are synergistic with analgesics and

long term benefits for pediatric patients.11

Section-II

STUDIES RELATED TO NON-PHARMACOLOGIC INTERVENTIONS DURING PAINFUL PROCEDURES

A study was conducted using Guided imagery and distraction therapy and

distraction Therapy in paediatric hospice care available evidence indicates deficits

in the pain management of children with analgesic drugs used licensed boundaries,

in situations where their pharmacokinetics are untested. A care series is used to

demonstrate the effectiveness of more holistic techniques such as guided imagery

and distraction therapy in reducing the pain experienced by children in the hospice

setting. Using there techniques it may be possible to reduce the amount of

analgesia or the frequency of administration.12

A study was conducted to reveal, the analgesic effect of passive or active

distraction during venipuncture in children. 69 children aged 7-12 years

undergoing venipuncture were randomly divided in to three groups: a control

8

group © without any distraction procedure, a group (M) in which mothers

preformed active distraction and TV group (TV ) in which passive distraction (a

TV Cartoon) was used. TVwatching was more effective than active distraction or

to the distracting power of television.13

A study revealed, non-pharmacologic intervention such as distraction, as

powerful adjuncts in reducing pain and anxiety in children with both acute and

chronic painful conditions. The use of distraction techniques is effective in

reducing situational anxiety, pain intensity and pain distress (as perceived by the

parents). This technique improve the quality of management of procedural pain in

a pediatric setting.14

A study revealed that, pediatric nurses are often present with children who

are in discomfort or pain, and are essential to successful management of this pain.

Selected non pharmacologic techniques are effective in reducing children’s

discomfort and pain and thus have value in nursing practice.15

A study conducted to assess the effect of an active distraction technique on

pain in pre- school children receiving diphtheria, pertussis and tetanus

immunization children were taught to blow out air repeatedly during the injection,

as if they were blowing bubbles. Children who were taught to blow out air during

their shots had significantly fewer pain behaviors and reported less pain. A simple

distraction technique can be effective in helping children cope with pain of

immunization.16

A study was conducted to reveal, that preparation of the child for a painful

procedure is an intervention that requires the provision of sensory-procedural

information and coping skills. These coping skills such as relexation, distraction

9

or imagery can be used by the child to reduce both quantitative and qualitative

aspects of the pain experience.17

Section-III

STUDIES RELATED TO DISTRACTION DURING PAINFUL PROCEDURES.

A study was conducted to test the efficacy and suitability of virtual reality

(VR) as a pain distraction for pediatric intravenous (I.V) placement. Twenty

children (12boys, 8girls) requiring I.V placement for a magnetic resonance

imaging / computer tomography (MRI/CT) scan were randomly assigned to two

condition,

1. VR distraction using street luge (SDT), presented via a head- mounted

Display or

2. Standard of care (Topical anesthetic) with no distraction.

Virtual reality pain distraction was positively endorsed by all reporters and

is a promising tool for decreasing pain, and anxiety in children undergoing acute

medical interventions.18

A study was conducted to reveal that, a distraction intervention reduce the

distress of preschool children undergoing repeated chemotherapy injections. The

results suggest that a developmentally appropriate, multisensory, variable –

distracting activity that requires active cognitive processing and active motor

responses may be a cost –effective alternative to more time – intensive parent –

training programs for preschool- age children.19

A study was conducted to assess whether the use of a protocol for assessing,

preparing and distracting children during procedures such as cannulation would

decrease levels of pain and distress reported by children, parents and nurses. Pain

10

thermometers and ‘scary faces’were used as tools to assess pain and anxiety levels

of 82 children. Nurses have a responsibility to reduce children’s pain and anxiety

as much as possible and distraction is one way of doing this.20

A study was conducted to examine nurse- directed distraction for reducing

infant immunization distress. Ninety infants and their parents were randomly

assigned to a distraction condition (i.e. nurses used stimuli to divert infant’s

attention) or a typical care condition. Results indicated that infants engaged in

distraction and that distraction reduced their behavioral distress.21

A study was conducted to compare the effect of two forms of distraction on

injection pain of preschool children. A quasi experimental study of 105 children

(53 girls and 52 boys) age 4 to6 years needing DPT immunizations. Study

children were randomly assigned to receive one of three treatments with their DPT

injection: touch, bubble-blowing, or standard care. Both the forms of distraction

touch and bubble- blowing significantly reduce pain perception.22

Conducted the study, to evaluate the effect of self- selected distractors (i.e.

bubbles, I Spy: super challenges book, music table, virtual reality glasses, or

handheld video games) on pain, fear and distress in 50 children and adolescents

with cancer, ages 5 to 18, with part access or venipuncture. Using an intervention

comparison group design, participants were ramdomized to the comparison group

(n=28) to receive standard care or intervention group (n=22) to receive distraction

plus standard care. The authors conclude that distraction has the potential to reduce

fear and distress during port access and venipuncture.23

Section-IV

STUDIES RELATED TO FLACC SCALE.

11

A study was conducted to test the validity of the FLACC behavioral pain

assessment scale for use with children. FLACC scores were assigned by one of the

nurse investigators, and a self-report of pain using the FACES scale was

concurrent validity was supported by the correlation between FLACC scores and

the children’s self-reported CAS scores during the procedure (r=0.59, P<0.05).

construct validity was demonstrated by the increase in median FLACC score to 1

during the procedure compared with 0 before and after the procedure (P<0.001).

interrater reliability during the procedure was supported by adequate kappa

statistics for all irems and for the total FLACC scores (k=0.85, P< 0.001). The

study support the use of FLACC as a valid and reliable tool for assessing

procedural pain in children aged 5-16 years.27

A study was conducted to evaluated the validity and reliability of the revised

and individualized face legs activity cry and consolability (FLACC) behavioral

pain assessment tool in children with CI. Eighty observations were recorded in 52

children aged 4-19 years. Twenty-one parents added individualized pain behaviors

to the revised FLACC. Interrater reliability was supported by excellent intraclass

correlation coefficients (ICC, ranging from 0.76 to 0.90) and adequated kappa

statistics (0.44-0.57). Criterion validity was supported by the correlations between

FLACC, parent and child scores (rho= 0.65-0.87; P< 0.001). Construct validity

was demonstrated by the decrease in FLACC scores following analgesic

administration (6.1 +/- 2.6 vs 1.9 +/- 2.7; P< 0.001). The study support the

reliability and validity of the FLACC as a measure of pain in children with CI.28

6.3 PROBLEM STATEMENT

A Study to assess the effectiveness of distractor on pain among children

during selected invasive procedures in hospitals at kolar district.

6.4 OBJECTIVES OF THE STUDY

12

1. To assess the effectiveness of pain distractor in reducing pain during

invasive procedure among children 4-7 years of age in experimental group.

2. To compare the effectiveness of pain distractor in reducing pain during

invasive procedure among children 4-7 years of age in experimental group and

control group.

3. To find association between pain level of children in experimental group

with their selected demographic variables.

6.5 OPERATIONAL DEFINITION

Assess: - To find the effectiveness of the distractor on pain among children.

Effectiveness: - It refers to the ability of distractor by cartoon movies

(Audio-visual aid) in reducing the pain as evidenced by the

scores obtained on the FLACC Scale.

Distractor: - It is the audio- visual aid, which displays the cartoon movies

On a monitor for diverting the child’s attention from painful

Invasive procedures.

Pain: - It is a feeling of hart experienced by the children during the invasive

Procedure or strong discomfort and is the body’s way of sending a

message to the brain that an injury has occurred. It is measured in

this study by using FLACC Scale during the procedure.

Children: - Refers to those between ages 4-7 years admitted in the selected

hospitals at kolar district.

Selected invasive procedures: - Refers to venipuncture for I.V insertion,

Venipunture for blood sampling, intra-

Muscular injection.

6.6 HYPOTHESIS : - 13

H1:- There is a significant difference between the pain levels among

Children in experimental and control group.

6.7 VARIABLES :-

DEPENDENT VARIABLE: - Levels of pain

INDEPENDENT VARIABLE: - Distractor

ATTRIBUTED VARIABLE: - Age, sex ,education, socio-economic

Status, types of invasive procedures,

previous hospitalization, previous

exposure to painful procedures, rank

order in the family and duration of the

invasive procedure.

6.8 DELIMITATION : -

This study is delimited to

1. Invasive procedures such as venipuncture, I.M injections.

2. Children between 4-7 years.

3. Selected hospitals at kolar district.

7. 0 MATERIAL AND METHOD : -

7.1 SOURCES OF DATA : -

Children from 4-7 years under going selected in vasive Produces in selected

hospitals at kolar district. 14

7.2.1 RESEARCH DESIGN :-

The experimental design, (post test only control group design) two groups

were selected for the purpose of comparision, one group had intervention (with

distraction) and other group has No intervention (without distraction).

7.2.2 SETTING OF THE STUDY –

The study will be conducted in the pediatric wards of S.N.R. hospital and

Chowdeshwar hospital at kolar District.

7.2.3 POPULATION

Children between the age of 4-7 years and undergoing invasive procedures

in the pediatric wards of selected hospitals at kolar district.

7.2.4 SAMPLE

Children between the age group of 4-7 years and undergoing invasive

procedures in S.N.R. hospital and Chowdeshwar hospital at kolar District.

7.2.5 SAMPLE SIZE

1. 100children undergoing invasive produces.

2. 50 children with distraction and 50 children with out distraction.

7.2.6 SAMPLING TECHNIQUE

15

Children were selected using purposive sampling technique and were

allotted to experimental and control group to determine which practice should be

used i.e with distractor or without distractor.

7.2.7 SAMPLING CRITERIA

INCLUSION CRITERIA : -

1. All the children who were scheduled for invasive procedure

aged between 4-7 years.

2. Conscious and mentally alert.

3. Children who were co- operative

EXCLUSION CRITERIA:-

1. Children who are critically ill.

2. Children with neurological deficit.

7.2.8 TOOLS

FIACC Scale

Tool consists of two sections.

A) Section-I

Demographic characteristics demographic data of the child: - age, sex,

previous hospitalization, previous exposure to painful procedures, types of

painful procedures, education, rank order in the family and duration of the

invasive procedures.

B) Section-II

Consist of standaralezid pain assessment scale i.e Revised FLACC Scale 16

Which includes facial expression, leg movement Each of the five categories (F)

Face; (L) legs; (A) Activity; (C) Cry; (C) Consolability is Scored from 0-2, Which

results in a total Score between zero and ten.29

7.2.9 METHOD OF DATA COLLECTION

A formal written permission was secured from the administrator of

hospitals, nursing superintendent of the selected hospitals and also from the

research committee of the Pavan College of Nursing. The nature of the study was

explained to parents and health personnel’s. In the sample selection procedure,

purposive sampling will be used to select the sample and will be allotted to

experimental and control group. In tool the data will be collected as follows,

A) Section-I: Interview method is used.

B) Section-II: Observational checklist is used.

7.3 DATA ANALYSIS AND INTERPRETATION

Descriptive inferential statistics will be used

1. Frequency.

2. Mean

3. Standard deviation.

4. Paired‘t’ test of pain scores during different procedures with and

Without Distraction.

5. Chi-square test

7.4 DOES THE STUDY REQUIRE ANY INVESTIGATION TO THE

CONDUCED ON ANIMALS . 17

Yes, the study requires investigation to be conducted on human beings.

7.5 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

CONCERNED AUTHORITIES .

Prior to the study, permission will be obtained form the concerned

authorities to conduct the study and also from research committee of pavan college

of Nursing kolar.

8.0 REFERENCES

1. Fowler – Kerry s, lander JR. “Management of Injection pain in children”

Pain 1987 Aug; 30 (2): 169-75.

2. Kleiber C, Craft- Rosenberg M. Harper DC. Parents as distraction coaches

during I.V insertion a randomized study. J Pain symptom manage. 2001

Oct; 22 (4): 851-61.

3. Andreas A.J Wismerijer M.A. AD, JJ.M Vingerhoets. PH.D. Virtual reality

and audio visual eyeglass systems as Adjunct analgesic techniques to reduce

Pain. [PubMed-indexed for MEDILINE]

18

4. Cohen LL, Blount RC, panoponlos G. Nurse coaching and cartoon

distraction an effective and practical intervention to reduce child, parent and

nurse distress during immunization. J Pediatric Psychol. 1997. June; 22(3):

355-70.

5. Malviya S. Voepel –levis T, Tait AR, Etal. Pain management in children

with and without cognitive impairment following spine fusion surgery.

P aediatr Anaesth 2001; 11:453-8. [Medline].

6. Schechter NL, Zempshy WT, Cohen LL, MC Grath PJ, Mc Murtry CM,

Bright NS pain reduction during pediatric immunizations. Paediatrics. 2007

May: 119(5): e1184-98.

7. Lassetter JH. “The effectiveness of complementary therapies on the pain

experiences of hospitalized children. J. Holist nurs. 2006 Sep; 24(3):196-

208.

8. Noguchi LK. The effect of music versus non music on behavioral signs of

distress and self- report of pain in pediatric injection patients . J M usic ther .

2006 spring; 43(1):16-38.

9. Powers KS, Rubenstein.JS. “Family presence during invasive procedures in

the pediatric intensive care unit: a prospective study. Arch pediatr adolesc

Med. 1999 Sep; 153(9): 955-8.

10.Vessey JA, Carlson KL, Mc gill J. “Use of distraction with children during

an acute pain experience. Nurses Res. 1994 Nov-Dec; 43 (6): 369-72.

11.Kuttner L. “Management of young children’s acute pain and anxiety during

invasive medical procedures. Pediatrician. 1989; 16(1-2); 39-44.

12.Russell C, Smart S. “Guided imagery and distraction therapy in paediatric

H ospice care ”. 2007 Mar: 19(2): 24-5.

19

13.Bellieni c v et.al. “Analgesic effect of watching TV during Venipuncture”.

Arch dis child. 2006 Dec; 91 (12) : 1015-7. E pub 2006 Aug 18.

14.Sinha M, christopher NC, Fenn R, Reeves L. “Evaluation of non-

pharmacologic methods of pain and anxiety management for laceration

repair in the pediatric emergency department”. Pediatrics. 2006 Sep; 118

(3): 1321; author reply 1321-2.

15.Pederson, Harbaugh BL. “Nurses use of non pharmacologic techniques with

hospitalized children. Issues compr pediatr N urs . 1995 Apr-Jun; 18(2):91-

109.

16.French GM, Painter EC, Coury DL. “Blowing away shot pain: a technique

for pain management during immunization. Pediatrics. 1994 mar; 93(3);

384-8.

17.Broome ME. “Preparation of children for painful procedures”.

Pediatrics N urs . 1990 Nov-Dec; 16(6): 537-41.

18.Gold JI, kim SH, Kant AJ, Joseph MH, Rizzo As. “Effectiveness of virtual

reality for pediatric pain distraction during I.V placement”. Cyber psychol

behave. 2006 Apr; 9(2): 207-12.

19.Dahlquist LM, Pendley JS, Landthrip DS, Jones CL, Struber CP.

“Distraction intervention for preschoolers undergoing intramuscular

injections and subcutaneous port access. Health psychol. 2002. Jan; 21(1):

94-9.

20.Sparkes L. Taking the “Ouch” out of injections for children. Using

distraction to decrease pain. MCN AM J Matern child nurs . 2001 Mar-Apr;

26(2): 72-8.

20

21.Wood C. Intoducing a protocol for procedural pain. Paediatr nurs. 2002

Dec; 14(10): 10.

22.Cohen L.L. “Reducing infant immuzation distress though distraction.

Health psychol. 2002 Mar; 21(2): 207-11.

23.Windich – Biermeier A, Sjoberg I, Dale JC, Eshelman D, Guzzetla CE.

“Effects of distraction on pain, fear, and distress during venous port access

and venipuncture in children and adolescents with cancer.

24. Kelly D. Young, MD, MS, pediatric procedural pain, Volume 45, Mo.2:

February 2005.

25. Dorothy Marlow K, “T extbook of padiatric nursing ” 2008 New Delhi.

Published by elsevier a division of reed elsevier India private limited.

26. Donna L Wong- sixth edition 2002. “E ssential of P adiatric nursing” . St

louis Musori Mosby publication.

27. Willis et.al, FLACC behavioral pain assessment scale: a comparison with

the child’s self-report. Pediatric nursing. May 1, 2003.

28. Maviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised

FLACC observational pain tool: improved reliability and validity for pain

assessment in children with cognitive impairment. [PubMed – indexed for

MEDLINE]

29.Malviya,S., Vopel- levis, T, Burke,C., Merkel, S, Tait, A.R.(2006) the

revised FLACC observational pain tool: improved reliability and validity of

pain ssessment in children with cognitive impairment, P ediatri anesthesia

16:258-265.

21

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

22

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12. REMARKS OF THE CHAIRMAN &

PRINCIPAL

12.1 SIGNATURE

23