LAPORAN ANALISIS JURNAL

Comparison of the effectiveness of three different methods in decreasing pain

during venipuncture in children: ball squeezing, ballon inflating and
distraction cards

Oleh:

Kelompok 2

LAILATUL AZIZAH

201810420311022

FAKULTAS ILMU KESEHATAN PROGRAM STUDI S1 ILMU

KEPERAWATAN

UNIVERSITAS MUHAMMADIYAH MALANG 2020

HALAMAN PENGESAHAN

ANALISIS JURNAL

Oleh:

LAILATUL AZIZAH

201810420311022

Telah di ACC :
Hari :.....
Tanggal :....
dan dinyatakan layak oleh:

Fasilitator

Aini Alifatin, M.Kep

2
 KATA PENGANTAR

Dengan memanjatkan puji dan syukur kehadirat Allah SWT, sehingga

melalui rahmat-Nya lah penulis dapat menyelesaikan tugas laporan analisis jurnal
ini yang berjudul” Comparison of the effectiveness of three different methods in
decreasing pain during venipuncture in children: ball squeezing, ballon
inflating and distraction cards”. Jurnal ini diajukan untuk memenuhi tugas mata
kuliah pada blok Keperawatan Anak, selama penyusunan laporan jurnal ini,
penulis banyak mendapatkan dukungan dari berbagai pihak. Oleh karena itu,
penulis menyampaikan banyak ucapan terima kasih kepada semua pihak yang
telah membantu dan mendukung dalam penyelesaian analisis jurnal ini dan
terimakasih saya ucapkan kepada ibu Aini Alifatin, M.Kep selaku fasilitator dari
kelompok 2.

Pada laporan jurnal ini penulis menyadari bahwa masih banyak

kekurangan yang harus di perbaiki lagi. Semoga laporan jurnal ini bisa bermanfaat
bagi para pembacanya dan dapat mengembangkan pendidikan di dunia kesehatan
menjadi lebih baik.

Malang, Maret 2020

Penyusun

3
 DAFTAR ISI

HALAMAN PENGESAHAN......................................................................................i

KATA PENGANTAR..................................................................................................ii

DAFTAR ISI.................................................................................................................iii

BAB I............................................................................................................................1

1.1 LATAR BELAKANG............................................................................................1

1.2 TUJUAN ................................................................................................................2

BAB II ..........................................................................................................................3

BAB III ........................................................................................................................4

3.1 PROFIL PENELITIAN .........................................................................................4

3.2 DESKRIPSI PENELITIAN BERDASARKAN PICO ..........................................5

BAB IV ........................................................................................................................10

4.1 KESIMPULAN ......................................................................................................10

4.2 SARAN ..................................................................................................................10

DAFTAR PUSTAKA ..................................................................................................11

LAMPIRAN .................................................................................................................12

4
 BAB I PENDAHULUAN

1.1 Latar Belakang

Nyeri pertama kali dialami di masa kecil dan merupakan pengalaman
umum bagi anak-anak diseluruh dunia. Saat ini rasa sakit dianggap sebagai
‘tanda vital kelima’ untuk dipantau dalam perawatan medis dan professional
kesehatan dalam merawat pasien anak. [ CITATION Ayd16 \l 1033 ]

Nyeri merupakan pengalaman sensori yang dibawa oleh stimulus sebagai

akibat adanya kerusakan jaringan. Nyeri terdiri dari dua komponen yaitu nyeri
secara fisiologis dan psikologis. Komponen fisiologis merupakan proses
penerimaan impuls tersebut menuju saraf pusat. Sementara komponen
psikologis meliputi rekognisi sensasi, interpretasi rasa nyeri dan reaksi
terhadap hasil interpretasi nyeri tersebut. [ CITATION Kur17 \l 1033 ]

Metode pengobatan nyeri terdapat dua macam yaitu secara farmakologi

dan nonfarmakologi. Sesuai dengan jurnal ini maka penjelasan metode
pengobatan lebih ke nonfarmakologi. Pengobatan nonfarmakologi adalah
pengobatan atau terapi tanpa menggunakan obat-obatan, tetapi menggunakan
dukungan, distraksi dan lain-lain. [ CITATION Has19 \l 1033 ][ CITATION Ast17 \l
1033 ]

Tindakan sederhana untuk mengatasi nyeri pada anak adalah bernilai

namun sering dilupakan. Hal ini antara lain menjelaskan, menenangkan dan
menangani anak dengan lembut dan lingkungan tenang, teknik cognitive-
behavioral dalam mengendalikan nyeri (misalnya latihan pernafasan,
hypnosis). Teknik ini merupakan salah teknik nonfarmakologi dalam
menghilangkan rasa nyeri. Namun penggunaan teknik ini sangat sulit
dilakukan kepada anak, karena anak sangat sulit untuk mengikuti instruksi
yang diberikan oleh perawat. Salah satu cara agar anak dapat melakukan
relaksasi nafas dalam yaitu dengan melakukan kegiatan bermain. [ CITATION
Mac18 \l 1033 ]

Kegiatan bermain dapat mengalihkan ketegangan dan stress yang dialami

anak saat dilakukan pungsi vena, karena mengalihkan rasa nyerinya dengan
kegiatan bermain. Permainan yang dapat memberikan efek nafas dalam pada
anak tanpa diberikan instruksi oleh perawat yaitu meniup gelembung dengan
sedotan, meniup balin dan meniup baling-baling kertas. Hal ini dilakukan
sebagai pereda nyeri pada anak-anak. [ CITATION Mac18 \l 1033 ]

1
 Pada jurnal ini menggunakan tiga tindakan nonfarmakologi yang berbeda
yaitu, meremas bola, inflasi balon dan kartu pengalihan perhatian untuk
mengurangi rasa nyeri saat pengambilan darah pada anak. Selain itu juga
terdapat pendekatan keluarga sebagai kelompok control. [ CITATION Ayd16 \l
1033 ]

Penelitian ini menggunakan metode randomized controlled trial.

Membandingkan ketiga kelompok intervensi yang berbeda dalam megurangi
rasa nyeri pada saat pengambilan darah pada anak. [ CITATION Ayd16 \l 1033 ]

1.2 Tujuan Penulisan

Tujuan penulisan analisis jurnal ini adalah sebagai berikut:

1. Membandingkan efek ketiga metode yaitu meremas bola, inflasi balon dan
kartu distraksi untuk mengurangi rasa nyeri saat pengambilan darah pada
anak
2. Mengetahui metode yang efektif diantara ketiga metode yaitu meremas
bola, inflasi dan kartu distraksi untuk mengurangi rasa nyeri saat
pengambilan darah pada anak.

2
 BAB II JURNAL PENELITIAN

ORIGINAL ARTICLE

Comparison of the effectiveness of three different

methods in decreasing pain during venipuncture in
children: ball squeezing, balloon inflating and
distraction cards
Diler Aydin, Nejla Canbulat S,ahiner and Esra Karaca C,
iftc,i

Aims and objectives. This study aimed to

investigate three different distraction methods What does this paper contribute
(squeezing a soft ball, balloon inflation and to the wider global clinical
distraction cards) on pain and anxiety relief in community?
children during phlebotomy. • Internationally, pain relief
Background. Needle-requiring medical procedures during phlebotomy is an
such as venipuncture, phle- botomy and important nursing task. Health
care work- ers need effective
intramuscular injections are common and
pain relief methods that are
significant sources of pain for children, and these easily applica- ble and do not
cause anxiety, distress and fear. take much time. This was a
Design. This study was a prospective, randomised controlled trial. randomised con- trolled trial that
Methods. The sample consisted of children (n = assessed the effect of squeezing
120) who required blood tests. Data were a soft ball, balloon inflation and
distraction cards during
obtained through face-to-face interviews with the phlebotomy in chil- dren.
children, their par- ents and the observer before • Pain and anxiety relief was seen
and after the procedure. The children’s pain levels in all three distraction methods
were assessed and reported by the parents and during phlebotomy in children;
observers, and the children them- selves who self- however, no statistically signifi-
cant difference was observed.
reported using Wong–Baker FACES. The The lowest pain and anxiety
children’s anxiety levels were also assessed using levels were seen with the distrac-
the Children’s Fear Scale. tion cards and groups during
Results. One hundred and twenty children (mean age: 9·64 T 2·07 years)phlebotomy
were in children; no sta-
included. No difference was found between the tistically significant difference
was observed.
groups in the self-, parent- and observer-reported
• Most importantly, this study
procedural pain levels (p = 0·446, p = 0·467, p = contributes to the knowledge of
0·318 respec- tively). Furthermore, no significant the beneficial results of distrac-
differences were observed between the groups in tion methods.
procedural child anxiety levels according to
the parents and observer (p = 0·323, p = 0·144
respectively).

3
Conclusion. Pain and anxiety relief was seen in the
three methods used during phlebotomy; however,
no statistically significant difference was observed.
Relevance to clinical practice. This study
contributes to the literature on nonphar-
macologic pain relief methods during
phlebotomy in children.

Key words: children, nonpharmacological method,

pain relief, randomised con- trolled trial

Accepted for publication: 26 March 2016

Authors: Diler Aydin, PhD, RN, Assistant Correspondence: Diler Aydin, Assistant Professor,
Professor, Department of Pediatric Nursing, Faculty Department of Pediatric Nursing, Faculty of
of Health Sciences, Bandirma Onyedi Eylul Health Sciences, Bandirma Onyedi Eylul
University, Bandirma; Nejla Canbulat S,ahiner, University, 10200 Bandirma/Balikesir, Turkey.
PhD, RN, Associate Professor, Department of Telephone:
Pediatric Nursing, School of Health, Karamanoglu
Mehmetbey University, Karaman; Esra Karaca +90 266 718 64 00.
C, iftc,i, PhD, RN, Assistant Professor,
Department of Pediatric Nurs- ing, Faculty of E-mail: dileraydin@gmail.com
Health Sciences, Zirve University, Gaziantep,
Turkey

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.13321

4
Introduction
The International Association for the Study of Pain (IASP)
described pain as an unpleasant sensory and emotional state
and behaviour that originates from any region of the body,
depends on existing or possible tissue damage, or can be
identified with this damage, and is affected by past experi-
ences of the individual (IASP 1994, Gupta et al. 2014, Abd
El-Gawad & Elsayed 2015). Pain is first experienced in
childhood and is a common experience for children in all
societies around the world (Sadeghi et al. 2013, Uman
et al. 2013, Canbulat et al. 2014). Today, pain is consid-
ered the ‘fifth vital sign’ to monitor in medical care, and
health professionals should monitor and manage it when
caring for paediatric patients (Cohen et al. 2008, Sadeghi
et al. 2013, Mutlu & Balcı 2015).
Background
Procedures with injectors constitute a substantial part of
early exposure to pain (Uman et al. 2013, Canbulat et al.
2014). Painful medical procedures such as phlebotomy,
injections, and vaccinations are frequent medical interven-
tions in children admitted to a hospital. These procedures
are sensed as frightening interventions by children (Pillai
Riddell et al. 2011, Uman et al. 2013, Canbulat et al.
2014, Inal & Canbulat 2015, Schreiber et al. 2016). There-
fore, use of effective methods in pain relief is very impor-
tant during injection procedures in children.
To this end, the American Academy of Pediatrics
(AAP) and American Pain Society (APS) recommend min-
imising and relieving pain and stress in minor procedures
such as establishing vascular access (American Academy
of Pediatrics – American Pain Society (AAP-APS) 2001).
Therefore, pharmacologic and nonpharmacologic methods
are adopted for reducing pain during medical procedures
(Pillai Riddell et al. 2011, Inal & Canbulat 2015). When
used appropriately, nonpharmacologic methods can be
effective in dulling procedural pain. Nonpharmacologic
methods used in children can be categorised in three
main groups: supportive methods, cognitive/behavioural
methods and physical methods (Uman et al. 2013, Wohl-
heiter & Dahlquist 2013, Mutlu & Balcı 2015, Ali et al.
2016). Supportive methods comprise techniques, such as
watching a video, reading a book, family’s presence
alongside the child during painful procedure; physical
methods include touching, giving position, massage, skin
stimulation, hot and cold pack application (Uman et al.
2013, Inal & Canbulat 2015). In contrast, cognitive/be-
havioural methods are based on the premise that pain
has a perceptual and behavioural dimension and are com-
posed of relaxation and distraction methods (Uman et al.
2006, 2008, 2013, Sadeghi et al. 2013, Inal & Canbulat
2015, Mutlu & Balcı 2015).
There are two main types of distraction techniques:
active and passive (Wohlheiter & Dahlquist 2013, Mutlu
& Balcı 2015). Active distraction methods involve active
forms of distraction; children are encouraged to be involved
in an action during the painful procedure. Some of the most
frequently used active distraction techniques in clinical set-
tings include interactive toys, guided imagery and relax-
ation, controlled breathing, electronic games, virtual reality
(VR), balloon inflation and squeezing a soft ball (Sadeghi
et al. 2013, Mutlu & Balcı 2015).
Distraction is a commonly used method by parents and
health care professionals to help reduce pain and anxiety
during painful procedures (Srouji et al. 2010, Koller &
Goldman 2012). The use of distraction cards has recently
been shown to be beneficial in pain control during phle-
botomy (Inal & Kelleci 2012, Canbulat et al. 2014, Sahiner
& Bal 2015). Additionally, it has been shown that distract-
ing a child by inflating a balloon is also beneficial for deal-
ing with pain during phlebotomy (Gupta et al. 2006,
Mutlu & Balcı 2015, Sahiner & Bal 2015). Although in
small numbers, there are studies in the literature that
showed the effectiveness of squeezing a soft ball in decreas-
ing pain during procedures performed by nurses (Sadeghi
et al. 2013).
No randomised controlled studies have revealed
superior- ity of ball squeezing or balloon inflation over
each other in reducing procedural pain or their effects
when used together. In light of this information, this study
aimed to compare the effect of distraction by using
distraction cards (Flippits; MMJ Labs LLC, Atlanta, GA,
USA), ball squeez- ing and balloon inflation to reduce
procedural pain and anxiety in children during
phlebotomy.
Study hypotheses
Hypothesis 1. Having a child squeeze a ball with the
opposite hand during phlebotomy reduces pain and anx-
iety experienced by the child.
Hypothesis 2. Having a child inflate a balloon during
phlebotomy reduces pain and anxiety experienced by the
child.
Hypothesis 3. Use of distraction cards during phle-
botomy reduces pain and anxiety experienced by child.
Hypothesis 4. Ball squeezing, balloon inflation and dis-
traction cards used together during phlebotomy does not
affect pain and anxiety in children.
Methods
Design
This study was conducted at the phlebotomy station of the
Bandirma State Hospital, Turkey between 1 October 2015–
20 January 2016. It was designed as a prospective ran-
domised clinical trial that evaluated and compared the
effects of squeezing a soft ball, balloon inflation and use of
distraction cards on procedural pain and anxiety levels of
children during phlebotomy.
participants. Children were randomised into four groups:
the ball squeezing group (n = 30), balloon inflation group
(n = 30), distraction card group (n = 30) and the control
group (n = 30) (Fig. 1). Numbers from 1–120 were ran-
domly distributed by a computer program to the four
groups with no number repetition to determine which child
would be in which group. All data were obtained through
face-to-face interviews with the children, their parents and
the observer after the procedure. The phlebotomy process
took an average of three minutes (min: one, max: five
minutes).

Measurements
Setting and sample
The study population comprised children aged between 7–
12 years who presented to the children’s phlebotomy room
of Bandirma State Hospital. The study sample constituted
120 randomly selected children who met the selection crite-
ria. Inclusion criteria were being aged 7–12 years and
requiring blood tests. Children were excluded if they were
neuro-developmentally delayed; had verbal difficulties, or
hearing or visual impairments; used analgesics within the
last six hours; or if they had a history of syncope due to
blood sampling.
A power analysis was performed to determine a sample
size capable of detecting a reduction of about 10% in the
phlebotomy response (e.g. anxiety, pain) that would be seen
with a frequency of 90% with a confidence level of 95%;
the sample was determined to require at least 120
The study data were obtained using the ‘Child and Family
Information Form’, ‘Wong–Baker FACES (WB-FACES)
Pain Rating Scale’, ‘Children’s Fear Scale (CFS)’, soft ball,
balloons and distraction cards (Flippits; MMJ Labs LLC).
Child and Family Information Form
This form consisted of questions that contained socio-
demographic characteristics of the child and previous phle-
botomy history.
Distraction cards
The distraction cards (Flippits1, MMJ Labs, Atlanta, GE,
USA) consisted of 5 9 8 cm2 visual cards with various pic-
tures and shapes. The children were given the opportunity
to examine the cards, and then the researcher asked the

Enrollment Offered to participate (n = 200) Did not agree to participate (n = 0)

Volunteers assessed for Eligibility (n = 120)

Randomization (n = 120)

Group 1 Group 2 Allocation Group 3 Group 4

Ball Squeezing group (n = 30)
Balloon inflation group (n = 30)Distraction cards group (n = 30) Control group (n = 30)
 AnalyzedAnalysisAnalyzedAnalysisAnalyzedAnalysisAnalyzed (n = 30)(n = 30)(n = 30)(n = 30)
ExcludedExcludedExcludedExcluded
analysisanalysisanalysisanalysis

Figure 1 Diagram showing the flow of

participants.
children about what they could see on the cards. Distrac-
tion with the cards began immediately prior to phlebotomy
and continued until the procedure had been completed. An
expert fluent in Turkish and English translated the instru-
ment because the children were not native English
speakers.
Two volunteer nurses with a minimum of five years’ experi-
ence in paediatric patient care and phlebotomy injections
were trained for and assisted in the conduct of the study.
The nurses had no conflict of interest. A paediatrician made
the clinical decision for phlebotomy. Patient demographics
were collected using the self-report forms, and these

Soft ball

The soft ball used in the study was roughly 10 cm in diam-

eter and could return to its original form when squeezed.
Before use, the children in ball-squeezing group were given
a ball and asked to squeeze it with their hand on which no
application was being conducted. The children are asked to
squeeze and loosen the ball during application.

Balloon inflation

After their latex allergy condition was tested, the children

were asked for their choice of balloon colour. They were
asked to inflate the balloon once to assess the suitability of
balloon inflation. They were given balloons after
venipunc- ture started and asked to inflate it during the
application.

Control group
The children in this group were allowed to keep their
family nearby. The routine blood taking procedure was
conducted.

Wong–Baker FACES (WB-FACES) Pain Rating Scale

Pain levels were assessed using self-reports, in addition to

parent and observer reports, with the Wong–Baker FACES
(WB-FACES) pain rating scale. The WB-FACES scale is a
0–10 scale. Six illustrated faces on the cards show a range
of emotions from a smiling face (0 very happy/no pain) to
a crying face (10 ‘hurts worst’).

Children’s Fear Scale

The CFS was used to evaluate the children’s level of anxi-

ety. CFS is a 0–4 scale, showing five cartoon faces that
range from a neutral expression (0 = no anxiety) to a
frightened face (4 = severe anxiety). Preprocedural and pro-
cedural pain, and anxiety were evaluated for all children by
the parents and the researchers.

Data collection
included medical history, recent analgesic use and body mass
index (BMI). Prior to randomisation, the researcher read a
standardised description of the pain and anxiety tools to the
parents and children, both of whom acknowl- edged that they
understood how to complete the measure- ment tasks. The first
nurse, who functioned as an observer, evaluated the
preprocedural and procedural anxiety, and pain for each child
using the 0–4 CFS scale for anxiety and the 0–10 WB-FACES
scale for pain. The second nurse con- ducted the phlebotomy
procedure for all children. The chil- dren’s anxiety levels were
subsequently reviewed by the parents and observers. A total of
120 children were ran- domised using a computer-generated
table of random num- bers into four groups of 30. After the
group assignment, the children and their parents went to the
phlebotomy unit for the procedure. Venipuncture sessions were
held between 8:00–12:00 AM and 12:00–16:00 PM and
performed using a 5-ml injector and a 22-G needle. The same
nurse con- ducted the distraction cards for all children. All
parents stayed with their children in the injection unit. The
distrac- tion cards were used continuously prior to and during
the phlebotomy. The balloon was inflated during the venipunc-
ture procedure in the balloon inflation group. Before needle
insertion, the children in the intervention group were instructed
to hold and squeeze a rubber ball in the hand opposite to the
needle insertion, press on the ball, and focus on it, and to
continue doing so during the procedure. The children’s pain
levels were assessed post procedure using the same method
as used with the anxiety levels.

Data analysis
All statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS Inc., Chicago, IL, USA)
version 21.0 for Windows. Baseline characteristics among the
groups, and all parametric data were analysed using the Chi-
square test. Parametric data such as the level of pain in
children was compared with one-way analysis of
variance. Statistical significance was set at p < 0·05, a Bon-
ferroni test was performed as a post hoc analysis.

Ethical consideration
The study was approved by the ethics committee of Balike- sir
University Balikesir Medical Faculty, Balikesir, Turkey (ethics
approval number 2015/55, September 30th, 2015, Balikesir,
Turkey). The aims and method of study were explained to the
children and their parents. They were also notified that they
could leave the study at any time without having to explain
their reasons.
Results respectively). Although pain was determined at a lower
level in the distraction card group, it was not statistically
significant (p > 0·05). Although this situation was not sta-
tistically significant, it is clinically significant.
Comparison of the groups
One hundred and twenty [61 (30·5%) girls and 59 (29·5%)
boys] were included in this study. The mean age of the chil-
Comparison of the groups in terms of
dren was 9·64 T 2·07 years (range, 7–12 years). The chil-
dren were randomised into the distraction cards (n = 30),
anxiety levels
ball squeezing (n = 30), balloon inflation (n = 30) and con-
Research groups’ procedural anxiety levels are presented in
trol (n = 30) groups. The characteristics of children are pre-
Table 3. No significant difference was found between the
sented in Table 1. Age, sex, body mass index (BMI) and
children’s procedural anxiety levels reported by the parent
preprocedural anxiety levels of children were similar among
and observer groups (p = 0·323, p = 0·144 respectively).
the four groups. There were no significant differences
Although the parent- and observer-reported anxiety levels
among the preprocedural anxiety levels of the study groups
were low in the distraction card group, they were not found
in terms of self-, parent- and observer-reported (p = 0·076,
statistically significant (p > 0·05). Although this situation
p = 0·147, and p = 0·107 respectively).
was not statistically significant, it is clinically significant.

Comparison of the groups in terms of Discussion

pain levels
Pain level evaluations of research groups are presented in
Table 2. Based on this table, no intergroup difference was
found between self-, parent- and observer-reported proce-
dural pain levels (p = 0·446, p = 0·467, p = 0·318
The American Society for Pain Management Nursing rec-
ommends that optimal pain control before and during pain-
ful procedures needs to be provided (Czarnecki et al.
2011). In recent years, nonpharmacological and distraction
methods in particular are frequently used in pain

Table 1 Baseline characteristics and preprocedural anxiety scores of the study groups
Distraction card Ball squeezing Balloon group Control group
group (n = 30) group (n = 30) (n = 30) (n = 30) v2 p

Sex
Female 15 (50) 15 (50) 16 (53) 15 (50) 0·935 0·100
Male 15 (50) 15 (50) 14 (47) 15 (50)

Distraction card Ball squeezing Balloon group Control group

group (n = 30) group (n = 30) (n = 30)
(n = 30) F p

Age 9·33 T 1·8 9·67 T 2·15 9·67 T 2·35 9·90 T 2·02 0·372 0·773
BMI 17·63 T 4·71 16·59 T 2·52 16·91 T 3·36 18·23 T 4·65 1·061 0·369
Preprocedural anxiety levels
Self-reported 0·60 T 1·10 1·46 T 1·61 1·30 T 1·48 1·33 T 1·32 2·346 0·076
Parent-reported 0·86 T 1·19 1·66 T 1·58 1·40 T 1·49 1·53 T 1·38 1·822 0·147
Observer-reported 0·90 T 1·09 1·66 T 1·56 1·40 T 1·32 1·66 T 1·47 2·074 0·107

Data are represented as number (percentage) or mean T standard deviation, where appropriate.
BMI, Body Mass Index.

Table 2 Comparison of procedural pain scores of the study groups

Procedural pain scores Distraction card Ball squeezing Balloon group Control group
according to WB-FACES group (n = 30) group (n = 30) (n = 30) (n = 30) F p

Self-reported 1·86 T 2·28 1·93 T 3·03 2·80 T 3·69 2·86 T 3·30 0·896 0·446
Parent-reported 1·73 T 2·50 2·86 T 3·51 2·53 T 3·31 2·80 T 2·90 0·854 0·467
Observer-reported 1·40 T 1·90 2·53 T 3·23 2·26 T 2·95 2·60 T 2·83 1·186 0·318

Data are represented as mean T standard deviation. WB-FACES, Wong–Baker FACES.

Table 3 Comparison of procedural anxiety scores of the study groups
Procedural anxiety Distraction card Ball squeezing
scores group (n = 30) group (n = 30)
Parent-reported 0·66 T 0·88 0·96 T 1·12
Observer-reported 0·56 T 0·77 0·90 T 1·06
Data are represented as mean T standard deviation.
management during medical procedures such as phle-
botomy (Uman et al. 2013).
There is strong evidence that distraction is effective in
reducing pain and distress that children experience during
needle procedures (Uman et al. 2013). Numerous studies
have reported the effectiveness of a variety of distraction
methods used by parents and health care professionals to
relieve medical procedure-related pain and anxiety, and
have been found effective (Inal & Kelleci 2012, Sadeghi
et al. 2013, Abd El-Gawad & Elsayed 2015, Karakaya &
Gozen 2015, Meiri et al. 2016, Mutlu & Balcı 2015). Dis-
traction is a cost-effective technique for pain management
in children (Bagnasco et al. 2012, Inal & Canbulat 2015)
and numerous types of distraction techniques for decreasing
pain during phlebotomy have been reported (Bellieni et al.
2006, Uman et al. 2006, Klassen et al. 2008, Kirby et al.
2010, Akdas et al. 2014, Gupta et al. 2014, Abd El-Gawad
& Elsayed 2015, Karakaya & Gozen 2015, Meiri et al.
2016, Mutlu & Balcı 2015, Moadad et al. 2016). Distrac-
tion interventions can be effective, easily accessible, inex-
pensive and safe. In our study, we evaluated the efficiency
of ball squeezing, balloon inflation and distraction cards,
which are among the distraction techniques.
Recently, Inal and Kelleci (2012), Canbulat et al. (2014),
and Sahiner and Bal (2015) demonstrated that distraction
cards (Flippits) were very effective in reducing procedural
pain and anxiety in children during phlebotomy. In our
study, similar to study results in the literature, we found
that pain and anxiety levels of the test groups (ball squeez-
ing, balloon inflation and distraction cards), distraction
cards in particular, were substantially lower than the control
group; however, no statistically significant difference was
detected. It is specified in various studies in the literature
that balloon inflation during medical procedures reduces
pain, anxiety and aggressive behaviours (Gupta et al. 2006,
Mutlu & Balcı 2015). Gupta et al. (2006) determined that
school children in the intervention groups (balloon inflation
and distraction) experienced less pain than children in their
control group during intravenous access procedures. Mutlu
and Balcı (2015) found that balloon inflation was effective
in reducing pain during venous blood drawing in children.
Sahiner and Bal (2015) found that balloon inflation
Balloon group Control group
(n = 30) (n = 30) F p
1·10 T 1·18 1·20 T 1·42 1·174 0·323
1·03 T 1·18 1·23 T 1·40 1·841 0·144
significantly lowered procedural anxiety scores, thus
provid- ing an effective technique during painful medical
proce- dures. Different from the studies of Gupta et al.
(2006), Mutlu and Balcı (2015) and Sahiner and Bal (2015),
in our study, although pain and anxiety levels in with balloon
inflation were lower than in the control group, no statistical
significance was found. Even though the results of our study
are different from those in the literature, balloon inflation is
among the more interesting methods for school-age children
(Uman et al. 2006, 2008). There are a limited number of
studies in which ball squeezing has been used. Sadeghi et al.
(2013) found that ball squeezing was a distraction technique
that could reduce children’s pain during IV cannulation.
Unlike Sadeghi et al. (2013) study, in our study’s results,
pain and anxiety levels with ball squeezing were determined
to be lower than the control group, however, no statistical
significance was found. Although there are limited data
about ball squeezing, it is a recommendable method because
it is easy to use, it is considered entertaining for children,
and it is interesting.
Conclusions
Distraction through squeezing a soft ball, balloon inflation
and distraction cards during phlebotomy reduced pain and
anxiety levels, but the results were not statistically signifi-
cantly different. The effects of ball squeezing, balloon infla-
tion and distraction cards observed during short-term
painful procedures, such as phlebotomy and vascular
access, should be supported through further evidence-based
studies with different age groups and different cultural
groups.
Relevance to clinical practice
In addition, nurses should be aware of the harmful effects
of procedural pain and anxiety in children, use of distrac-
tion methods and have knowledge about different nonphar-
macological methods that may reduce their impact. This
study contributes to the literature on nonpharmacological
pain relief methods. This study should be replicated in more
settings to see if the findings are similar.
Acknowledgements
The authors thank the children and their parents who
agreed to participate in this study for their effort and con-
tribution.
Contributions
Study design: DA, NCS, EKC; data collection and analysis:
DA, NCS; manuscript preparation: DA, NCS, EKC.
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 BAB III PEMBAHASAN

3.1 Profil Penelitian

Judul Penelitian : Comparison of the effectiveness of three
different methods in decreasing pain
during venipuncture in children: ball
 squeezing, ballon inflating and
distraction cards

Pengarang/ Author/s : Diler Aydin, Nejla Canbulat Sahiner and

Esra Karaca Ciftci

Sumber/ source : JCN (Journal of Clinical Nursing), doi:

10.1111/jocn.13321

Kata kunci/ keyword : children, nonpharmacological method,

pain relief, randomized controlled trial

Abstrak :

Background: Needle-requiring medical procedures such as venipuncture,

phlebotomy and intramuscular injections are common and
significant sources of pain for children, and these cause
anxiety, distress and fear

Methods : The sample consisted of children (n = 120) who required blood

tests. Data were obtained through face-to-face interviews
with the children, their parents and the observer before and
after the procedure. The children’s pain levels were assessed
and reported by the parents and observers, and the children
themselves who self-reported using Wong–Baker FACES.
The children’s anxiety levels were also assessed using the
Children’s Fear Scale.

Results : One hundred and twenty children (mean age: 964 207 years)
were included. No difference was found between the groups
in the self-, parent- and observer-reported procedural pain
levels (p = 0446, p = 0467, p = 0318 respectively).
Furthermore, no significant differences were observed
between the groups in procedural child anxiety levels
 according to the parents and observer (p = 0323, p = 0144
respectively)

Conclusion: Pain and anxiety relief was seen in the three methods used
during phlebotomy; however, no statistically significant
difference was observed. Relevance to clinical practice. This
study contributes to the literature on nonpharmacologic pain
relief methods during phlebotomy in children.

Tanggal Publikasi: 26 Maret 2016

3.2 Deskripsi Penelitian Berdasarkan PICO

Tujuan Untuk mengetahui dan membandingkan efek tiga metode distraksi
Penelitian yang berbeda dengan meremas bola lunak, inflasi balon dan kartu
distraksi untuk menghilangkan rasa sakit dan kecemasan pada anak-
anak selama proses venipuncture.

Desain A Randomized Controlled Trial

Penelitian

Problem Ketakutan rasa nyeri pada anak-anak di wilayah Turki selama proses
pengambilan darah dengan prosedur medis atau suntikan sehingga
menghambat proses venipuncture.

Population Anak berusia 7-12 tahun yang datang ke ruang flebotomi anak di
Rumah Sakit Negeri Bandirma Turki. Terdiri dari (n=120 anak) yang
dipilih secara acak dan memenuhi kriteria seleksi.
Dari 120 anak dibagi menjadi empat kelompok secara acak yaitu
kelompok meremas bola (n=30), kelompok inflasi balon (n=30),
kelompok kartu pengalihan perhatian (n=30) dan kelompok kontrol
(n=30)
1. Kriteria inklusi: berusia 7-12 tahun dan membutuhkan tes darah.
2. Kriteria Eksklusi: Anak-anak dikeluarkan jika memiliki
perkembangan yang tidak baik, kesulitan verbal, gangguan
 pendengaran atau penglihatan, penggunaan analgesic dalam 6 jam
terakhir atau jika memiliki riwayat sinkop.

Intervensi Selama penelitian ini diawali dengan mengisi Formulir Informasi

Anak dan Keluarga, setelah itu dilanjutkan dengan melakukan tiga
metode perlakuan antara lain meremas bola, meniup balon dan kartu
pengalihan perhatian. Tindakan selanjutnya adalah mengisi Wong
Baker FACES (WB-FACES)/ skala penilaian nyeri dan skala
kecemasan anak-anak (CFS).

1. Formulir Informasi Anak dan Keluarga

Formulir terdiri dari pertanyaan yang berisi karakteristik
sosiodemografi anak dan riwayat flebotomi sebelumnya.
2. Kartu Pengalihan Perhatian
Kartu ini berukuran 5x8 cm2, kartu visual dengan berbagai
gambar dan bentuk.
a) Sesi venipuncture dilakukan antara jam 08.00-12.00 dan
00.00-16.00 PM.
b) Anak-anak diberi kesempatan untuk melihat kartu-kartu itu
dan kemudian peneliti bertanya pada anak-anak tentang apa
yang mereka lihat pada kartu itu.
c) Kartu pengalihan perhatian dimulai sebelum proses
venipuncture dan berlanjut sampai prosedur selesai.
Venipuncture dilakukan dengan menggunakan injector 5
ml dan jarum 22-G
3. Meremas bola
Bola yang digunakan berdiameter 10 cm dan bisa kembali ke
bentuk aslinya ketika diperas.
1. Sesi venipuncture dilakukan antara jam 08.00-12.00 dan
00.00-16.00 PM.
2. Venipuncture dilakukan dengan menggunakan injektor 0,5
ml dan jarum 22-G.
3. Anak-anak dalam kelompok ini diberikan bola dan diminta
 untuk menahan dan memerasnya dengan tangan mereka
selama proses venipuncture.
4. Meniup Balon (Inflasi Balon)
1. Melakukan pengujian alergi lateks, anak-anak diminta
untuk memilih warna balon .
2. Mereka diminta mengembangkan balon sekali untuk
menilai kesesuaian inflasi balon.
3. Mereka diberi balon setelah venipuncture dimulai dan
diminta untuk mengembangkan selama tindakan
berlangsung.
4. Tindakan venipuncture berlangsung jam 08.00-12.00 dan
00.00-16.00 PM dengan menggunakan injektor 5 ml dan
jarum 22-G
5. Kelompok kontrol
Anak-anak diizinkan bersama keluarga didekatnya. Prosedur
pengambilan darah rutin dilakukan dengan menggunakan
injektor 5 ml dan jarum 22-G.
6. WB-FACES skala penilaian nyeri
Tingkat nyeri dinilai dengan menggunakan laporan diri,
laporan pengamat (perawat 1 mengevakuasi kecemasan dan
tingkat nyeri setiap anak dan perawat 2 melakukan
phlebotomy) dan laporan orang tua dengan skala peringkat
nyeri WB-FACES. Skalanya 1-10. Enam wajah diilustrasikan
pada kartu yang menunjukkan serangkaian emosi mulai dari
wajah tersenyum (0, bahagia) hingga menangis (10 paling
buruk). Penilaian ini dilakukan pada semua anak.
7. Skala ketakutan anak-anak
CFS digunakan untuk mengevaluasi tingkat kecemasan anak.
CFS dinilai 0-4, menunjukkan lima wajah pada kartu yang
berkisar dari ekspresi netral (0=tidak ada kecemasan) hingga
wajah yang ketakutan (4 kecemasan parah). Penilaian skala ini
dilakukan pada semua anak.
Compare Pada jurnal ini terdapat perbandingan:
1. kelompok intervensi dilakukan tindakan metode meremas bola,
meniup balon dan kartu pengalihan perhatian untuk
mengurangi rasa nyeri dan kecemasan.
2. kelompok kontrol langsung diberikan tindakan venipuncture
dengan injektor 5 ml dan jarum 22-G tanpa metode apapun,
hanya didampingi dengan keluarganya saja.

Outcome Kelompok pada tingkat nyeri

Tidak ada perbedaan antara kelompok yang ditemukan yaitu:

1. laporan diri p= 0,046 menunjukkan hasil signifikan

2. orang tua p=0,467 menunjukkan hasil ketidaksignifikan
3. dan tingkat nyeri prosedural pengamat p=0,318 menujukkan hasil
ketidaksignifikan.
Meskipun tingkat nyeri lebih rendah pada kelompok kartu
pengalihan perhatian tetapi secara statistic tidak signifikan
(p>0,05), sedangkan secara klinis signifikan.

Kelompok pada tingkat kecemasan

Tidak ada perbedaan yang signifikan di antara kecemasan pada

kelompok:

1. Orang tua memperoleh p=0,323 menunjukkan hasil tidak

signifikan
2. Pengamat memperoleh p=0,144 menujukkan hasil tidak
signifikan.
Meskipun tingkat kecemasan dilaporkan lebih rendah pada
 kelompok kartu pengalihan perhatian, tetapi secara statistic tidak
signifikan (p>0,05), namun secara klinis signifikan.

Jadi, hasilnya pada kelompok kartu pengalihan, memeras bola dan

meniup balon rasa nyeri dan kecemasan lebih rendah dibandingkan
kelompok kontrol. Berdasarkan ketiga metode tersebut juga dihasilkan
bahwa metode yang paling efektif adalah menggunakan kartu
pengalihan perhatian.

Kekuranga -
n

Kelebihan 1. Penelitian ini memberikan kontribusi terhadap literatur tentang

metode nyeri nonfarmakologi
2. Penelitian ini tidak menerima spesifik pendanaan

Manfaat a. Manfaat Praktisi

Penelitian Metode penelitian ini dapat dikembangkan sebagai pengobatan
nonfarmakologis untuk mengurangi rasa sakit dan kecemasan
pada anak selama pengambilan darah.
b. Manfaat Teoritis
Metode penelitian ini juga dapat dikembangkan atau diperkaya
sebagai pembelajaran dalam Ilmu Keperawatan Anak sebagai
cara terbaru dalam mengatasi rasa nyeri pada anak.
 BAB IV KESIMPULAN

4.1 Kesimpulan
Meremas bola, inflasi balon dan kartu pengalihan perhatian dapat
mengurangi rasa sakit dan cemas selama pengeluaran darah pada anak. Tetapi
secara statistika hasilnya tidak signifikan (p>0,05), sedangkan secara klinis sangat
signifikan.

4.2 Saran
Saran pada penelitian ini harus direplikasikan lebih banyak pengaturan
untuk melihat temuan yang serupa. Selain itu juga metode nonfarmakologi ini
juga bisa diterapkan secara umum untuk mengurangi efek nyeri saat pengambilan
darah pada anak.
 DAFTAR PUSTAKA

Astuti, T. I., & Khasanah, N. N. (2017). Teknik Ditraksi Guided Imagery sebagai
Alternatif Manajemen Nyeri pada Anak saat Pemasangan Infus. Jurnal Kesehatan
, Volume VIII, No 3, hlm 326-330.

Aydin, D., Sahiner, N. C., & Ciftci, E. K. (2016). Comparison of the effectiveness
of three different methods in decreasing pain during venipuncture in children: ball
squeezing, ballon inflating and distraction cards. Journal of Clinical Nursing
(JCN) , 1-8.

Hastanto, U. P., & Handayani, D. W. (2019). FARMAKOLOGI JILID III.

Yogyakarta: CV BUDI UTOMO.

Kurlinawati, E., & Astutik, P. (2017). Pengaruh Relaksasi Gangguan Jari

Terhadap Penurunan Nyeri Pada Pasien Post Section Caesarea Di Ruang Dilema
RSUD Kertosono. STRADA, Jurnal Ilmiah Kesehatan , 30-37.

Machsun, T., Alfiyanti, D., & Mariyam. (2018). EFEKTIFITAS TEKNIK

RELAKSASI NAPAS DALAM DENGAN BALING-BALING TERHADAP
PENURUNAN SKALA NYERI PUNGSI VENA PADA USIA PRASEKOLAH.
Jurnal Ilmu Keperawatan Anak , Vol. 1 No1, Hal 1-7.
 LAMPIRAN LEMBAR KONSULTASI

Judul Jurnal: Comparison of the effectiveness of three different methods in

decreasing pain during venipuncture in children: ball squeezing, ballon inflating
and distraction cards

No Hari/Tgl Kegiatan TTD

Fasilitator

1. Konsultasi Judul Jurnal

2. Konsultasi Laporan Analisis Jurnal

3. Revisi Laporan Analisis Jurnal

4.
Power Point Analisis Jurnal
Mengetahui,

Fasilitator Penyusun

Aini Alifatin, M.Kep Lailatul Azizah