Jenniejosej

A STUDY TO ASSESS THE EFFECTIVENESS OF CARTOON
ANIMATION SHOW DURING VENIPUNCTURE IN
REDUCING PAIN AMONG TODDLERS IN
THE SELECTED HOSPITAL AT
KANYAKUMARI DISTRICT
DISSERTATION SUBMITTED TO
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI
IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE
AWARD OF DEGREE OF MASTER OF
SCIENCE IN NURSING
OCTOBER- 2015
2013-2015
Certified that this is the bonafide work of

JENNIE JOSE. J
II year M.Sc Nursing 2013-2015
Global College of Nursing, Edavilagam,
Nattalam, Marthandam,
Kanyakumari District -629195
COLLEGE SEAL
SIGNATURE:--------------------------
Prof. Mrs. JOSEPHINE GINIGO, M.Sc.(N)
Principal,Global college of Nursing,
Edavilagam, Nattalam.
Marthandam, Kanyakumari District-629195, Tamil Nadu.

SCIENCE IN NURSING
OCTOBER- 2015
2013-2015
PROFESSOR IN NURSING RESEARCH

Prof.Mrs. Josephine Ginigo, M.Sc(N) ----------------------------------
Principal,
Global College of Nursing,
Edavilagam, Nattalam,
Marthandam ,Kanyakumari District .
CLINICAL SPECIALITY EXPERT

Mrs. Vimala. M.Sc(N),Asst.Professor, --------------------------------------
Child Health Nursing,
Global College of Nursing,
Edavilagam, Nattalam,
Marthandam ,Kanyakumari District .
SCIENCE IN NURSING
OCTOBER- 2015
REDUCING PAIN PERCEPTION AMONG
TODDLERS IN THE SELECTED HOSPITAL
AT KANYAKUMARI DISTRICT
2013-2015
Internal Examiner External

Examiner
Date: Date:
SCIENCE IN NURSING
OCTOBER- 2015
CERTIFICATE
7KLV LV WR FHUWLI\ WKDW WKH GLVVHUWDWLRQ HQWLWOHG ³$ 6WXG\ WR DVVHVV WKH
effectiveness of cartoon animation show during venipuncture in reducing pain
SHUFHSWLRQDPRQJWKHWRGGOHUVLQWKHVHOHFWHGKRVSLWDODW.DQ\DNXPDUL'LVWULFW´LVD
bonafide work done by Miss. Jennie Jose.J, II Year M.Sc Nursing, Global College of
Nursing, Nattalam in partial fulfilment of the University rules and regulations for the
award of M.Sc. (N) degree under my guidance and supervision during the academic
year October 2013-2015.
Name and Signature of the guide : -----------------------------------------------

-
Mrs. VIMALA. M.Sc(N)
Assistant Professor in Nursing.
Date:
Name and Signature of the Head of Department : -----------------------------------
Mrs. VIJILA BERLIN, M.Sc(N)
Associate Professor in Nursing.
Date:
Acknowledgement
ACKNOWLEDGEMENT
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.HHSJRLQJJRGDOZD\VZLWK\RX´
First and Foremost I thank and Praise the almighty god for giving all the
wisdom, knowledge, strength and guidance to complete this study successfully.
I express my gratitude to the Chairman Dr. Sam G Jeba Joselin and the
Secretary Mrs. Sakhila Santhakumari, MA.,M.Phil, the managing Trustee of
Global college of nursing for having given me this opportunity to undergo Post
Graduate programme in this esteemed institution, that has passed a way for me to
conduct this study.
I consider myself fortunate to have been piloted by Prof. Mrs. Josephine
Ginigo, M.Sc(N), Principal, Global College of Nursing whose guidance and
support enabled me to do the work successfully . I shall always be thankful for her
constant encouragement, valuable in-depth discussions and suggestions throughout
the study and has made it a successful one.
I am privileged to express my hearty thanks to Mrs. Helen Mary,
M.Sc(N),Vice Principal, Global College of nursing, for her constant impression and
motivation to proceed with the study.
I extent my gratitude to Mrs. Vimala, M.Sc(N), Asst.Prof. of Child Health
Nursing, Global College of Nursing who has guided me as a good mentor and for
her valuable suggestions, motivation and guidance throughout this dissertation work.
I extent my gratitude to Mrs. Vijila Berlin, M.Sc(N), Associate Professor
HOD of Child Health Nursing, Global College of Nursing who has guided me as
a good mentor and for her valuable suggestions, motivation and guidance throughout
this dissertation work.
I express my sincere thanks to Mrs.Jeyanthi, M.Sc(N)., Department of
mental health nursing and my class co-ordinator for her support ,guidance and
encouragement to complete this dissertation successfully.
My deep sense of gratitude is expressed to Dr. Sashya, M.B.B.S, D.C.H
Pediatrician, and all the study subjects for their co-operation without whom the
study could not have been completed successfully.
I am very much obligated to Mr.P.Anto, M.Sc, M.Ed, M.Phil, PGDBS,
Biostatistician, Global college of nursing , for his guidance in the statistical analysis
of data in this study.
I am grateful to Print Land for having patiently deciphered the manuscripts
into a legible piece of work.
My immense thanks to Mrs.Sindhu Librarian of Global College of
Nursing and the library of The Tamilnadu Dr.MGR Medical University Chennai,
for having assessed me to procure the required literature review for conducting this
study.
Words are beyond expression for meticulous effort of my parents and my
brother for their encouragement towards the completion of study.
I am thankful to all my classmates and friends who directly and indirectly
contributed towards the completion of my project.
JENNIE JOSE.J
TABLE OF CONTENTS
CHAPTER CONTENTS PAGE NO
I INTRODUCTION 1-3
Need for the study 4-5
Statement of the Problem 5
Objectives 5
Hypothesis 5-6
Operational definitions 6
Assumption 7
Delimitations of the study 7
Conceptual Framework 7-10
II REVIEW OF LITERATURE
¿ Studies related to venipuncture or any

11-16
painful procedures to toddlers
¿ Studies related to non pharmacological

16-20
measures to relieve pain among toddlers
¿ Studies related to the effectiveness of

cartoon animation show during
venipuncture in reducing pain perception 20-24
among toddlers
III METHODOLOGY
Research approach 26
Research design 26
Setting of the study 27

CHAPTER CONTENTS PAGE NO
Population of the study 27
Sample 27
Sampling Technique 27
Criteria for selection of sampling
x Inclusion criteria 28
x Exclusive criteria 28
Description of the tools 28-29
Validity of the Tool 29
Reliability of the Tool 30
Ethical consideration 30
Pilot study 30-31
Data collection procedure 31
Plan for data Analysis 31-32
IV DATA ANALYSIS AND 33-53

INTERPRETATION
V DISCUSSION 54-56
VI SUMMARY, CONCLUSIONS, 57-62

IMPLICATIONS AND
RECOMMENDATIONS
BIBIOLOGRAPHY 63-67
APPENDICES i-vi
LIST OF TABLES
TABLE CONTENTS PAGE NO

NO
1. Frequency and Percentage distribution of the 34-35

samples according to the selected demographic
variables in the experimental group and control
group
Frequency and percentage distribution of post test 49
2. level of pain in the experimental group and control

group
3. Comparison of post test level of pain between 51

the experimental and control group
4. Association of post test level of pain in the control 53

group, with demographic variables
LIST OF FIGURES
FIGURE TITLES PAGE NO

NO
1.1 Conceptual framework- &DOOLVWD5R\¶V 10

Adaptation Model (1999)
3.1 Schematic Representation of research 25

methodology
4.1 Bar diagram showing frequency percentage 38

distribution of age in months in the
experimental and control Groups
4.2 Bar diagram showing Frequency Percentage 39

distribution of gender in the experimental and
control groups

distribution of order of birth in the
experimental and control groups

distribution of number of siblings in the
experimental and control groups

distribution of type of family in the
experimental and control group
Bar diagram showing Frequency Percentage 43

distribution of education of father in the
4.6
4.7 Bar diagram showing Frequency distribution 44

of education of mother in the experimental and
control group
FIGURE TITLES PAGE NO
NO
distribution of occupation of father in the

distribution of occupation of mother in the

distribution of previous experience of
venipuncture in the experimental and control
group

distribution of site of venipuncture
5 Bar diagram showing Frequency Percentage 50

distribution of post test level of pain in the
6 Bar diagram showing comparison of post test 52

level of pain between the experimental and
control groups
LIST OF APPENDICES
APPE TITLES PAGE

NDIX NO
NO
Letter seeking and Granting Permission to conduct research
1. study i-ii
Tool for Data Collection

2.
Section A: Demographic Variables iii-iv
Section B: FLACC scale v
vi
Section C: Intervention
ABS RA
ABSTRACT
The present study is aimed to assess the effectiveness of cartoon animation
show during venipuncture in reducing pain perception among toddlers in the
selected hospital at Kanyakumari district .
The objectives of the study are,
x To assess the level of pain perceived by the toddlers during
venipuncture after cartoon animation show in group A and without
cartoon animation show in group B.
x To assess the effect of cartoon animation show in reducing pain
during venipuncture by comparing the pain scores among both
groups.
x To determine the association of pain perceived by the toddlers in the
control group with their selected demographic variables such as age in
months, gender, order of birth, number of siblings, type of family,
education of father, education of mother, occupation of father,
occupation of mother, previous experience of venipuncture, site of
venipuncture
7KHLQYHVWLJDWRUDGRSWHG&DOOLVWD5R\¶VDGDSWDWLRQWKHRU\ Ds the
conceptual framework for the study. Quasi experimental post test only design with
control group was used and the formal consent was obtained from Jeyaharan
memorial hospital and the investigator selected 60 samples using purposive sampling
technique and who are fulfilling the inclusive criteria were selected as a samples
both in experimental and control group. Measurement of pain experienced by the

toddler was assessed with the help of FLACC scale (face, legs, activity,
consolability, cry).
Descriptive and inferential statistics were used to analyze the data.
Analysis of demographic variables was done in terms of frequency and percentage
distribution. Comparison of post test level of pain between the experimental and the
controO JURXSV ZDV DQDO\VHG E\ µW¶ WHVW :KLFK LV DQ LQIHUHQWLDO VWDWLVWLFDO DQDO\VLV
Association of post test level of pain in the control group with demographic variables
was analysed by using chi-square test. The findings concluded that Out of 30
samples in the experimental group majority 15 (50%) had moderate pain,15(50%)
had severe pain and in control group majority 27(90%)had severe pain, 3(10%) had
moderate pain.
In the experimental group, the post test level of mean pain score was 6.5 with
S.D 19.5 and in the control group the post test mean score was 8.16 with S.D 34.168.
7KH PHDQ GLIIHUHQFH VFRUH ZDV 7KH FDOFXODWHG µW¶ YDOXH RI ZDV
statistically significant at P<0.001 level indicating that there was significant
difference in the post test level of pain between the experimental and control
group.Hence the cartoon animation show was responsive in reducing the
venipuncture pain among toddlers.

CHAPTER -I
INTRODUCTION
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Deep are the thoughts of a child: quiet them.
Sharp is the grief of a child: take it from him.
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PAMELA
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only to cope with current demands but also to prepare with many unexpected events
they will face in their tomorrows. Adults serve as advocates for children and it is the
duty of every adult citizen to keep up this unit of pride safely for the benefit of the
country. So we should be sensitive to the feelings, and need of children to build a
better tomorrow. For this reason children are considered as the pride of a nation.
Unfortunately children face various crisis in their life, especially during the
early years of their life. Often illness and hospitalization are the first crisis that
children face. Stressors of hospitalization include separation, loss of control, bodily
injuries and the major one is pain.
The worG SDLQ LV GHULYHG IURP WKH ODWLQ ZRUG µSRHQD¶ ZKLFK means
punishment, which is GHULYHGIURPWKH6DQVNULWURRWµSX¶PHDQLQJSXULILFDWLRQ7KH
LQWHUQDWLRQDODVVRFLDWLRQIRUWKHVWXG\RISDLQGHILQHV³SDLQLVDQXQSOHDVDQWVHQVRU\
and emotional experience associated with actual or potential tissue damage, are
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SDLQIXUWKHUVWDWHVWKDWSDLQLVVXEMHFWLYH³(DFKLQGLYLGXDOOHDUQVWKHDSSOLFDWLRQRI
the word through experiences UHODWHGWRLQHDUO\OLIH´7KLVGHILQLWLRQHPSKDVL]HVWKH
LQGLYLGXDOLW\RIHDFKSHUVRQ¶VSDLQUHVSRQVHDQGWKHLPSRUWDQFHRISDLQH[SHULHQFHV
especially those in early life, in shaping that response. Thus, a child experiences
1
during painful medical procedures likely plays a significant role in shaping that
individuals pain response to future events.
Pain continues to be the most complex and challenging sensory emotions in the
life of children. It is defined as a universal unpleasant, subjective, sensory and
emotional human experience. Because of its strong sensation; it activates the
sympathetic nervous system to alter the quality of life in children such as sleep,
mobility, nutrition, thought, emotional wellbeing, and creativity
Pain is the fifth vital signs. A pain scale measures a SDWLHQW¶VSDLQ intensity
or other features. Pain scales are based on self-report, observational (behavioural), or
physiological data. Pain scales are available for neonates, infants, toddlers,
adolescents, adults, seniors, and persons whose communication is impaired. The
appropriate observational pain scale for toddler is FLACC scale. (Face Legs Arms
Cry Consolability Scale)
Needle puncturing is painful to all children but how they response to that
depends on their developmental ages and their previous experiences. During
venipuncture the nurse can provide various diversionary activities before, during and
after procedure.
Behaviours that are commonly used to identify presence of pain are facial
expression, vocalization, posture, movement. Crying is widely accepted as a method
of communicating pain. Cry pattern, facial expression and body movements are
behaviour indication of children.
The distraction appears to offer significant promise in the control of pain.
Conscious attention is necessary to experience pain. Distraction helps the child to
focus attention on something other than the pain. Distraction technique that are more
2
likely to be effective because, they provoke curiosity in child to use their auditory,
visual, tactile and kinesthetic sense when maneuvering them and thus distraction
effectively minimizes the distress associated with painful event . The distracting
techniques like cartoon animation show, party blowers and music help the child to
NHHSDZD\IURPWKLQNLQJRIWKHLUSDLQ'LVWUDFWLRQWHFKQLTXHVVHHNWRIRFXVDFKLOG¶V
attention on interesting or challenging tasks to avert the attention from venipuncture.
Distraction is a non-pharmacological intervention that diverts attention from a
QR[LRXVVWLPXOXVWKURXJKSDVVLYHO\UHGLUHFWLQJWKHVXEMHFW¶VDWWHQWLRQRUE\DFWLYHO\
involving the subject in the performance of diversion task. Distraction involves
FDSWXULQJ FKLOG¶V DWWHQWLRQ DQG IRFXVLQJ DZD\ IURP WKH VWUHssful situation and
towards something more pleasant. It takes little training to learn, is easy to
administer, and requires few materials and something familiar to most individuals. It
is particularly useful for younger children. Examples of distracters used with children
are picture books, talking with the child, music, party blowers, kaleidoscope, prop up
book, blowing bubbles, looking for hidden objects in the room, counting out loud,
hand-held computer games, imagining fun, cartoon shows and exciting things or
quiet and relaxing scenes.
Distraction techniques used with the toddler age group are mostly passive.
Cognitive strategies used to reduce pain perception in children are either visual or
auditory interventions. Visual aids can include pictures, cartoons, mobile phones, and
mirrors. Auditory aids include music, lullabies sung by parents or healthcare
professionals.
3
Need for the study
The pain response in individual and is learned through social learning and
experience. Early pain experience may play a particularly important role in shaping
an individuals pain responses. Inadequate relief of pain during childhood
venipuncture may have long- term negative effects on future pain tolerance and pain
responses [Ann Emerg Medical 2005; 45:160-171].
Injections of any type can hurt. Children remember pain, and may avoid
future medical care because of painful experiences in a hospital or clinic. Untreated
pain suffered early in life can have profound and long-lasting effects on social and
physical development, and can cause permanent changes in the nervous system that
will affect future pain experience and development. Craig states that the intensity of
pain behaviour during invasive procedures decreases with the age of the child that is,
younger children responds to painful procedures with more distress than older
children.
Pain is a subjective experience, and infants and children respond to pain with
behavioural reactions that depend upon age and cognitive processes. According to
the International Association for the Study oI 3DLQ ³3DLQ LV DQ XQSOHDVDQW VHQVRU\
and emotional experience associated with actual or potential tissue damage.
Relief of pain is a basic need and right of all children. Management of pain in
the child must be individualised. Age, sex, birth order, cultural background, parents,
FDUHJLYHU¶VUHVSRQVHDQGSDVWH[SHULHQFHVDIIHFWVWKHFKLOG¶VUHVSRQVH7KHQHZERUQ
baby, the infant, and the toddler are unable to localise and describe the severity of
SDLQ7KHQXUVHPXVWEHDZDUHRIWKHFKLOG¶VUHVSRQVHWRSDin through the assessment
of behavioural responses and differentiation of crying.
4
As distraction is a promising, cost effective, non-pharmacological technique
in reducing pain among school age children undergoing venipuncture. The
researcher in this study is, intended to use cartoon animation show, an audio visual
aid as a distractor among children during venipuncture .
Statement of the Problem
A study to assess the effectiveness of cartoon animation show during
venipuncture in reducing pain perception among toddlers in selected hospital at
Kanyakumari district.
Objectives
1. To assess the pain perceived by the toddlers during venipuncture in both
experimental and control group.
2. To assess the effectiveness of cartoon animation show in reducing pain
during venipuncture by comparing the pain scores among both groups.
3. To determine the association of pain perceived by the toddlers in the control
group with their selected demographic variables such as age in months,
gender, order of birth, number of siblings, type of family, education of father,
education of mother, occupation of father, occupation of mother, previous
experience of venipuncture, site of venipuncture
Hypotheses
H1 ± There is a significant difference in the pain perceived by the toddlers during
venipuncture among experimental and control groups.
H2 ± There is a significant association between the pain perceived by the toddlers
during venipuncture in control group and their selected demographic variables
5
such as age, sex, order of birth, number of siblings, type of family, education of
father, education of mother, occupation of father, occupation of mother, previous
experience of venipuncture, site of venipuncture.
Operational definitions:
x Effectiveness:
In this study, it refers to the positive outcome of cartoon animation show in
reduction of pain perception during venepuncture, as measured by FLACC scale
(Face, leg, activity, cry, consolability)
x Cartoon animation show:
In this study, it refers to a motion picture or television film consisting of a
photographed series of drawings, objects or computer graphics that stimulate motion
by recording very slight, continuous changes in the images, frame by frame shown to
the child from the start of venipuncture until it gets over.
x Reducing pain perception:
In this study, it refers to bringing down the pain score to low level due to
cartoon animation show during venipuncture as measured by FLACC pain rating
scale.
x Venipuncture:
Introducing a sterile polyethylene tube along with stillet into the vein for a
purpose of blood drawing or to infusing fluids.
x Toddlers:
In this study, it refers to those boys and girls between the age of 1-3 years
admitted in the selected hospital at kanyakumari district.
6
Assumptions
1. All the toddlers may perceive severe pain during venipuncture.
2. Cartoon animation show may reduce the pain perception among toddlers
during venipuncture.
3. Reduction of pain perception may enhance the toddlers to cooperate with
venipuncture procedures.
Delimitations
This study is delimited to only:
- one hospital
- toddlers requiring venipuncture
- 60 samples
- 4 weeks for data collection
Conceptual framework
The conceptual framework provides a certain frame reference for clinical,
education and research. It gives direction to research for relevant question,
phenomenon and points out solution to practical problem.
Conceptual framework refers to interrelated concepts or abstractions that are
assembled together in some rational scheme by virtue of their relevance of a common
theme (Polit and Hunger-1999).
7KHRUHWLFDO PRGHO IRU WKLV VWXG\ ZDV GHULYHG IURP &DOOLVWD 5R\¶V DGDSWDWLRQ
model (1999). According to 5R\¶V DGDSWDWLRQ PRGHO WKH JRDO RI QXUVLQJ LV WR
facilitate adaptation between the person and the environment through the
management of stimuli.
7
The unique focus of the model is the input of the focal, contextual and
residual stimuli activity through the regulator and coagnator coping mechanism to
produce behavioural responses in the four interrelated adaptation models, self
concepts, role function, inter dependence and physiological purposes.
Systems:
Are a set of organized components related to form a whole body, Roy
considers the recipient of care to be an open adaptive system.
Input:
,Q 5R\¶V V\VWHP LQSXW LV LGHQWLILHG DV VWLPXOL ZKLFK FDQ FRPH IURP WKH
environment or within the person. A focal stimuli was starting venipuncture. Input
stLPXODWHV FKLOG¶V UHVSRQVH WR VWLPXOL. A contextual stimuli was the order of birth,
type of family, education of parents, occupation of parents, number of siblings,
previous experience of venepuncture. A residual stimuli are age, gender.
Throughput:
Throughput refers to makes use of persons processes and effectors. Processes
refers to level of pain in toddlers during venipuncture. Effectors refers to showing
cartoon animation show to reduce venipuncture pain.
Output:
2XWSXW LV WKH RXWFRPH RI WKH V\VWHP ,Q 5R\¶V DGDSWDWLRQ V\VWHP RXWSXW LV
categorized as adaptive responses that promote a toddlers integrity or ineffective
responses. These responses provides feedback to the system. So in this study the
samples who were in experimental group had a reduction in the level of pain in
toddlers.
8
Paradigms:
Human Being:
She emphasized human are individuals possesses unique potential and strives
towards self direction and needy stimulation whatever the individual does ,it
represents his or her best judgment at the movement .self awareness and self
acceptance are essential to individuals. Sense of integrity and self worth these
circumstances require respect from the nurse.
Health:
She does not defiQH KHDOWK VKH VXSSRUWV WKH :RUOG KHDOWK RUJDQL]DWLRQ¶V
definition of health.
Environment:
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which is a complex of extraneous factors and circumstances that are present in every
nursing situation. Framework includes objects such as policies , setting, atmosphere,
humans and happenings.
Nursing:
Nursing is a clinical discipline, is a practice discipline designed to
procedure explicit desired results. The art of nursing is goal oriented activity
requiring the application of knowledge and skills towards meeting a need for help
experienced by a patient .Nursing is a helping process that extends to restore the
SDWLHQW¶VDELOLW\WRFRSHZLWKGHPDQGVLPSOLFLWLQWKHVLWXDWLRQ
9
Figure 1&DOOLVWD5R\¶V$GDSWation Model(1999)
Input Throughput Output
FOCAL STIMULI
Post test Reduction of
Starting venipuncture EXPERIMENTAL Venipuncture was Effective
pain
GROUP assessed by FLACC scale
CONTEXTUAL STIMULI perception
(face, legs, activity,
Showing during
x Order of birth consolability, cry)
cartoon venipuncture
x Number of siblings Feedback
animation FLACC Interpretation:
x Type of family
0= Relaxed and No
x Education of father
comfortable
x Education of mother change
1-3= Mild discomfort
x Occupation of father 4-6= Moderate
x Occupation of discomfort
mother CONTROL
7-10= Severe discomfort
x Previous experience GROUP
of venipuncture
Hospital
x Site of venipuncture No
routine
change
RESIDUAL STIMULI
x Age
x Gender
10
CHAPTER II
REVIEW OF LITERATURE
A review of literature is an eventual aspect of scientific study .It involves the
systematic identification location, setting and summary of the written materials
that certain information on a research problem. It broadens the view of the
investigator regarding the problem under investigation, helps in focusing on the
issues especially concerning the study.
This chapter deals with the information collected in relation to the present study
through published and unpublished materials which provided the foundation to
carryout this study.
The literatures have been organized as follows,
¾ Studies related to venipuncture or any painful procedures to toddlers
¾ Studies related to non pharmacological measures to relieve pain among
toddlers
¾ Studies related to effectiveness cartoon animation show during venipuncture
in reducing pain perception among toddlers.
Studies related to venipuncture or any painful procedures to toddlers :
Fran Lang Porter, Cynthia M. Welf et. al (1996) conducted a
survey regarding pain management in newborns. The purposes of the study was to
examine the beliefs and self described behavior of physicians and nurses
regarding the management of procedural pain in newborns. A survey was
distributed to 467 clinicians (nurses and physicians) working in learn level II and
four level III nurseries in a large metropolitan area. respondents were asked to rate
the painfulness of 12 common bedside nursery procedures and low often
11
pharmacologic and non pharmacologic measures are currently used and should be
used for those procedures. The results indicated that surveys were completed by
374 clinicians (80%response rate) physicians and nurses believe infants feel as much
pain as adults and that of the 12 listed procedures are moderately very painful.
Neither pharmacologic nor comfort measures are believed to be used frequently.
Even for the most painful procedures. Physicians and nurses believe both
pharmacologic and comfort measures should be used more frequently than do
physicians. The study concluded in despite their beliefs that infants experience
VLJQLILFDQW SURFHGXUH UHODWHG SDLQ FOLQLFLDQV EHOLHYH SDLQ PDQDJHPHQW IRU LQIDQW¶V
remains below optimal levels. Barriers to more consistent and effective pain
management need to be identified.
Powers KS, Rubenstein.JS.(1999)., conducted a comparative study to
evaluate if the parents presence helpful to the child and parent, 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; The study concluded that allowing
parental presence during procedures decreases procedure-related anxiety.
Sinno H.P Simons et.al.(2003) conducted a prospective study of
procedural pain and analgesia in neonates . The objective of the study was to
assess the frequency of use of analgesics in invasive procedure in neonates and the
associated pain. 150 neonates were selected and recorded all painful procedures
12
including the number of attempts required, and analgesic therapy used during the
first 14 days of NICU admission. The result showed that the highest exposure to
painful procedures occurred during the first day of admission, many
procedures were estimated to be painful. The primitive analgesic therapy was
provided to fewer than 35% of neonates per day, while 39.7% of the neonates did not
receive any analgesic therapy in the NICU. The study concluded that the NICU
procedures are painful, but only third of the appropriate analgesics treatment for
the painful procedures is limited. Systematic approaches are required to reduce
the occurance of pain and to improve the analgesic treatment of repetitive pain in
neonates.
Anil Agarwal et al., (2005) conducted a study to evaluate of the Valsalva
manuever on pain during venous cannulation among children. In this study 75
samples were randomly assigned to 3 groups respectively. Group I was control group
without intervention, group II was instructed to blow into sphygmomanometer tubing
and raise the mercury column upto 30 mm of hg for 20 seconds and group III was
instructed to press a rubber ball. After 20 seconds peripheral venous cannulation was
performed. Venous cannulation pain was graded by a 4 point scale. Results showed a
significant reduction in the incidence of pain in group II (72%), whereas other two
groups experienced 100% pain. Researcher concluded that, the Valsalva maneuver
performed at that time of venous cannulation greatly decreases venipuncture pain.
Gupta et al., (2005) carried out a prospective, randomized controlled study
to evaluate the efficacy of balloon inflation on venous cannulation pain among
children by devandra. The study was conducted among 75 children aged 6-12 years
who were randomly divided into three equal groups. Group I was control group with
13
no intervention, groupII was provided with distraction like pressing a ball and group
III with balloon inflation. Visual analogue scale was used to assess the venipuncture
pain and there was a significant reduction observed in group II and group III, when
compared with group I. visual analogue score in group III was decreased when
compared with group II (p<0.05>). The incidence of pain during venipuncture in
group I and group II was 100% and which was reduced to 56% in group III
(p=<0.05). The study concluded that, inflation of balloon during venipuncture
reduced both the incidence and severity of venipuncture pain among children.
Farion et al., (2006) conducted a randomized control study to determine the
effect of vapocoolant spray on pain during intravenous cannulation by among 80
children between 6-12 years. The children received either vapocoolant spray or
placebo before cannulation. Children rated their pain using a 100-mm colour visual
analogue scale. Parents (p=0.04), nurses (p=0.01) and child life specialists (p<0.01)
FRQVLGHUHGWKHFKLOGUHQ¶VSDLQWREHUHGXFHGZLWKWKHXVHRIYDSRFRRODQWVSUD\7KXV
vapocoolant spray quickly and effectively reduces pain due to intravenous
cannulation in children and improved the success rate of cannulation.
Lassetter JH.(2006)., conducted an experimental study 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
14
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 and it
decreases the pain.
Sofia Bisogni, Chiara Dini, et,al.(2009) conducted a comparitive study of
pain during vemipuncture for chronic and non-chronic disease children in karnataka.
The study included 230 children in total: 82 of them suffered from chronic diseases
and had already experienced venipuncture at least once, while the remaining 148
children had no previous experience of venipuncture. The children with chronic
diseases reported more pain (median pain score of 8 on the Wong or numeric scales,)
and showed more signs of behavioral distress (median score of 27 on the OSBD)
than non-chronic children (median pain score of 2 on the Wong/numeric scales,
pԜ =Ԝ 0.00001; median OSBD score 5, pԜ =Ԝ 0.00001).It concluded that pain is more
in chronic disease children than in non-chronic disease children.
Harrison et al., (2011) conducted a randomized controlled study to assess the
efficacy of sweet tasting solutions or substances for reducing needle related
procedural pain in children beyond one year age. A sweet tasting solution or
substance was given to 330 children between 1 to 16 years of age randomly in
experimental group. Control conditions includedwater, non- sweet tasting substances,
pacifier, distraction, no treatment, positioning or breastfeeding. Results for the
toddlers or preschool children show that in the sucrose group in one study had
significantly lower cry duration and behavioural pain scores, compared with the no
15
intervention group in the other study. For school aged children, chewing sweet gum
either before, or during the procedure, did not significantly reduce pain scores.
Studies related to non pharmacological measures to relieve pain among
toddlers:
Wendy B, Kristen D, Nancy Peterson, Tamara (2001) conducted an
experimental study to evaluate the effect of an intervention to reduce procedural pain
and distress for children with HIV infection undergoing routine venipuncture at
virginia. Following a baseline venipuncture, children were exposed to an intervention
including preparation, relaxation, distraction, parent involvement and eutectic
mixture of local anesthetics) and followed for three additional venipuncture
procedures. After each procedure, child distress was rated on procedure behaviour
checklist, pain was rated on using FACES scale. Results is significant reduction in
child distress and pain were found. Author concluded that interventions appear
effective at reducing pain, distress and parent anxiety for children with HIV.
Evelyn Cohen Reis, Erika Kraus Roth et al. (2003) conducted a study to
assess the effectiveness, feasibility and parental acceptance of a simple combination
pain reduction intervention for infants receiving multiple immunization injections.
The infants receiving their second month immunizations, consisting of 4 injections
were selected as a sample. There were 116 infants participated. Subjects were
randomly assigned to the intervention or control group for administration of 4
injections. The intervention group received sucrose and oral administration of tactile
stimulation and were held by their parents during immunization. The control group
did not receive these interventions. The median first cry duration was 19.0 seconds
16
for the intervention group compared with 57.5 seconds for the control group. Nurse
rated ease of vaccine administration was equivalent for both treatment groups. They
concluded that combining surge, oral administration of tactile stimulation, and
parental holding was associated with significantly reduced crying in infants receiving
multiple immunization injections.
Bellieni c v et.al. (2006) conducted an experimental study to reveal, the
analgesic effect of passive or active distraction during venipuncture in children in
texas hospital. Samples of 69 children aged 7-12 years undergoing venipuncture
were randomly divided in to three groups: a control group without any distraction
procedure, a group in which mothers preformed active distraction and TV group (TV
) in which passive distraction (a TV Cartoon) was used. Purposive sampling
technique is used. FACES scale is used to assess the pain level. The study concluded
that TV watching was more effective than active distraction or to the distracting
power of television.
Mohavedi et al., (2006) conducted a study to examine the effect of local
refrigeration prior to venipuncture on pain related responses among school age
children. 80 children aged 6-12 years were selected by purposive sampling. In
experimental group the injection site was refrigerated for three minutes using an ice
bag before venipuncture and in control group venipuncture was performed according
to routine procedure. Physiological responses, behavioural responses and subjective
responses were assessed in both groups. Results showed no significant difference
between two groups for physiological responses, whereas behavioural responses
(p=0.0011) and subjective responses (p=0.0097) showed that, the test group had
lower score in behavioural and subjective responses compared to the control group.
17
The researcher concluded that the use of local refrigeration prior to venipuncture can
be considered as an easy and effective intervention for reducing pain related to
venipuncture.
Ali Fakhr, Shahnaz, Bijan Kelkhaee, et, al., (2006) conducted a quasi
experimental study to determine the effect of local refrigerator prior to venipuncture
on pain- related responses in school age children. The samples were 80 children 6-
12 years of age selected by purposive sampling after being referred to the pediatric
emergency ward. Two groups were chosen for the study : the test and control groups,
in order to test the effect of local coldness in reducing the pain of venipuncture. The
results of this study suggest that the use of local refrigeration prior to venipuncture
can be considered an easy and effective intervention of reducing venipuncture-
related pain.
Andrea Windich, Isabella, Debra, et, al., (2007) conducted a study to
evaluate the effect of self-selected distracters (ie bubles, music table, handled video
games) on pain, fear and distress in 50 children and adolescents with cancer ages 5 to
18, with port access or venipuncture. Using an intervention- comparison group
design. Results show that self- reported pain and fear were significantly different
between groups. Intervention participants demonstrated significantly less fear and
distress. The authors conclude that distraction has the potential to reduce fear and
distress during port access and venipuncture.
Shavit et al., (2009) conducted a single- blind randomized controlled study to
examine the efficacy and safety of a new topical anethetic containing a disinfection
ingredient (lidodin cream) in reducing pain associated with venipuncture by
comparing it with the proven eutectic mixture od lidocaine 2.5% and prilocaine 2.5%
18
(EMLA cream). The visual analog scale was used for pain assessment. 20 patients
were selected with mean patient age was 6-13 years for the lidodin group and 12-14
years for the EMLA group (p=0.347). Patient VAS scores and nurse VAS scores of
the lidodin group were not statistically different than those of the EMLA group
(p=0.57 and 0.93, respectively). This pilot study demonstrated that lidodin and
EMLA seem to be equally safe and effective topical anesthetics for venipuncture.
Lori Huff et at., (2009) conducted a descriptive quantitative study to
LQYHVWLJDWHZKHWKHUWKH DSSOLFDWLRQRIKHDW SODFHGWR DFKLOG¶V SRWHQWLDOLQWUDYHQRXV
site after the application of EMLA cream decreases vasoconstriction, thereby
promoting atraumatic care in the hospitalized children. A convenient sample of 30
hospitalized Caucasian children of 8 to 12 years of age were participated. Vascular
ultrasound directly measured the vein prior to and 1 hour after EMLA cream
application, as well as 2 minutes after heat application. Mean vein measurements
were 0.243 cm prior to EMLA cream, 0.205 cm after EMLA cream applied for 1
hour and 0.253 cm after 2 minutes of heat. There was a significant increase in vein
visualization from pre- application of heat to post application of heat with a success
rate of 80% with the first time attempt of IV insertion. Therefore application of heat
counteracts the adverse effect of vasoconstriction that occurs with EMLA cream
application, potentially increasing peripheral venous cannulation success rates.
Navjot Kiran, Sukhjit Kaur, RK Marwaha (2013) conducted a quasi
experimental study to assess the effectiveness of ice pack application at the site prior
to venipuncture on intensity of pain. Samples of 100 subjects were selected by
purposive sampling. Randomization was done by lottery method. 50 subjects each in
experimental group and control group were assigned. Ice pack (ice cube covered by
19
flannel cloth over 5 cm area around the site of venipuncture) was applied at the site
prior to venipuncture for 3 minutes. Pain was assessed in both the groups by using
FLACC behaviour pain assessment scale. Pain score was compared in both the
group. Results shows statistically significant reduction in pain during venipuncture in
experiment group. Hence null hypothesis was rejected. It was concluded that ice
pack application significantly decreases pain during venipuncture in 3-7 years old
children. It is safe, easy, cheap and effective method to reduce pain among children.
Studies related to effectiveness cartoon animation show during venipuncture in
reducing pain perception among toddlers:
Lobo (2007) conducted a quasi- experimental study was conducted on
children of 1-3 years of age who were undergoing venepuncture at selected hospitals
at Mangalore. A study comprised of 60 school agers selected by convenience
sampling method- 30 in experimental, 30 in control group. Animated cartoon was
shown along with the routine care of experimental group and routine care was given
to control group. Then the post venepuncture pain was assessed .The tool included
was baseline proforma- Wong Baker Faces pain scale. The results revealed that
significantly(p<0.05) less pain felt by the children who viewed cartoon during
venepuncture than those children who did not receive it. The findings also revealed
that there was no significant association between the level of pain and demographic
variables. It was concluded that cartoon distraction is effective distraction for the
children undergoing venepuncture.
Sorokhaibam Nandarani Devi .et.al., (2009) conducted a study to find the
effectiveness of cartoon animation show on pain perception reduction among school
20
agers during venepuncture in selected hospital at Mangalore. Post test only with
control group was adopted. The sample for study would comprised of 60 toddlers (30
control group and 30 experimental group). Results showed that the significant level
of pain reduction in experimental group than in control group.
Devi SN .(2010) conducted a quasi experimental study was conducted to assess
the effectiveness of cartoon movies on pain reduction among schoolers during
cannulation in selected hospitals at Mangalore. The sample comprised of 60
schoolers (30 in experimental and 30 in control group) between the ages of 6-12
years. The sample was selected using purposive sampling technique. During
cannulation the cartoon movie was provided to schoolers in the experimental group
by using laptop where as schoolers in control group were not given the intervention.
Mean pain levels rated by modified CHEOPS were 3.13±1.50 and 7.37±2.32 for the
experimental and control group, respectively. ThH FDOFXODWHG µW¶ YDOXH LV
greater than the table value 2.00 (t=2.00, p<0.05)and the result revealed that there
was significant difference between pain score of experimental group and control
group. Hence, the cartoon movie was effective to reduce pain among schoolers
during cannulation.
James J, Ghai S, Rao KLN, Sharma N (2010) conducted a quasi
experimental study was conducted in PGIMER, Chandigarh, on 50 children of three
to six years age who were undergoing venipuncture to see the effectiveness of
"Animated Cartoons" as a distraction strategy to reduce the perception of pain.
During the first venipuncture children were assessed at pre, during and post
venipuncture for perception of pain with routine care only and during the second
21
venipuncture with routine care and animated cartoon. The tools used for the study
included a baseline proforma and FLACC (Face, Legs, Activity, Cry and
Consolability) behaviour pain scale. The mean pain score was significantly less, i.e.,
almost half with animated cartoon (2.26±2.18) as compared to routine care
(4.76±2.08) at pre-venipuncture. Similarly, the mean pain score during venipuncture
was significantly less with animated cartoon (6.24±2.09) as compared to routine care
(8.06±1.70). During post-venipuncture also the mean pain score was significantly
less, i.e., almost half with animated cartoon (2.94±1.71) as compared to routine care
(5.94±1.61). The results revealed that there was significantly (p<0.001) less pain
related behavioural responses with the use of animated cartoons as a distraction
strategy at pre-, during and post-venipuncture. It was concluded that animated
cartoon is an effective distraction strategy to reduce pain among the children
undergoing venipuncture. Thus animated cartoons can be used for effective handling
of behavioural responses in children during invasive procedures.
Annamaria Bagnasco., (2012) conducted a study to find the effect of
distraction techniques in children during venipuncture: an Italian experience. Sample
included 203 patients aged 2 and 15 years. During venipuncture a video was shown
to the patient. Pain and parent collaboration was measured using validated scale.
Significant differences were observed between the mean score of pain in patients
undergoing venipuncture with audiovisual distracting technique (2.53+/-1.76) and
the mean score obtained in those undergoing venipuncture without this technique
(5.22+/-2.53). In the group with audio- video distractors, the mean level of
cooperation was 0.38 (SD= 0.63) compared to 0.20(SD= 0.54) in the control group.
In relation to the presence of parents, no significant differences were found in the
22
mean pain scores, whereas the mean scores of cooperation were significantly
different. Audio visual distraction effectively improved pain management and
IDYRXUHGFKLOGUHQ¶VFRRSHUDWLRQGXULQJYHQLSXQFWXUH
Harsh varshan gupta, amanlo kaur, et, al., (2014) conducted a quasi-
experimental study of comparison between the analgesic effect of two techniques on
the level of pain perception during venipuncture in children upto 7 years of age.
Purposive sampling technique was used to select 70 children admitted in pediatric
ward of Guru Singh Medical Hospital, Farikot, 35 children in each group viz. group
1 (child held by family member during venipuncture) and group 2 (child held by
family member along with an animation distraction during venipuncture) and video
clippings were made for each subject in both groups. Standardized FLACC pain
scale was used to assess the level of pain during venipuncture be seeing video clips
of procedure in both groups. Findings revealed that the mean pain score of group 1
was 3.86 and that of group 2 was 2.43. Findings revealed that in group 1 majority
31(88.57%) got severe pain and none remained relaxed during venipuncture whereas
in group 2 majority 10(28.58%) got moderate pain, 9(25.71%) remained relaxed and
only 7(20%) got severe pain. The comparison of mean pain score of both groups was
checked statistically by computing independent t test and the value of t comes out to
be 7.199 with p- value 0.000*** which was found to be highly significant. The study
concluded that when during painful procedures like venipuncture if children are
given any non- pharmacological intervention like cartoon distraction along with their
family member it helps in managing the pain. In other words, it distracts/ diverts the
FKLOG¶V DWWHQWLRQ IURP SDLQ DQG UHVXOWV LQ EHWWHU FRRSHUDWLRQ RI FKLOG GXULQJ
procedure.
23
Baljit Kaur, Jyoti Sarin, Yogesh Kumar (2014) conducted a quasi
experimental study was undertaken on children of 4 to 12 years age who were
undergoing intravenous injections to determine the effectiveness of cartoon
distraction as a strategy to reduce pain perception and distress.the study comprised of
30 children selected through purposive sampling method. In this the assessment of
pain and distress done in morning without cartoon distraction and in evening with
cartoon distraction at initiation, at five minutes and at termination of administration
of intravenous injection on FACES pain scale. The results revealed that there is
significantly less pain and distress in children with cartoon distraction at initition, at
five minutes and at termination of administration of intravenous injection. It was
concluded that cartoon distraction is an effective distraction strategy to reduce pain
and distress among children during intravenous injection.
24
CHAPTER - III
METHODOLOGY
Figure.2 Schematic Representation of research methodology
Research Design
Quasi experimental, post test only design with control group
Target population
All the toddlers admitted at Jeyaharan Memorial hospital
Accessible population
The toddlers who were selected for the study
Sampling Technique
Purposive sampling technique
The toddlers who are going to get venipuncture
Experimental group 30 (cartoon animation Control group 30(cartoon animation

show during venipuncture was given) show was not given)
Post test done using FLACC Scale Post test done using FLACC Scale
Data analysis (Descriptive and inferential statistics was given by tables and figures)
Interpretation of findings
25
RESEARCH METHODOLOGY
Methodology is the systematic theoretical analysis of the methods applied to
a field of a study. The chapter deals with research design, settings, population,
sample, sampling technique, data collection and plan for data analysis.
Research approach:
It involves the description of the plan to investigate the phenomenon under
study in a structured, unstructured or a combination of the two methods.
The present study used to determine the effect of cartoon animation show
among toddlers undergoing venipuncture. Hence a Quantitative approach is used in
this study.
Research design:
A research design is a plan of how, when, and where data are to be
collected and analyzed.
The research design adopted for this study is Quasi experimental, Post test
only design with control group.
The design of the study is depicted below:
Experimental group (E) X O1
Control group (C) _ O2
O1 - Observation of pain during venipuncture in the experimental group.
O2 - Observation of pain during venipuncture in control group.
X - Intervention by showing cartoon animation show in the experimental group.
26
Research Setting :
The study setting is the location in which the research is conducted it could be
natural,partially controlled or highly controlled.
The study was conducted in Jeyaharan Memorial Hospital, Nagercoil in
Kanyakumari district.
Population :
,W UHIHUV WR ³The entire set of individual or objects having some common
characteristics selected for a research study´
The target population was comprised of Whole toddlers admitted in the
Jeyaharan Memorial Hospital, Nagercoil in Kanyakumari district.
Sample size :
It refers to, ³The 6XEVHWRIWKHSRSXODWLRQWKDWLVVHOHFWHGIRUDVWXG\´
The sample for the study considered of 60 toddlers undergoing venepuncture in
Jeyaharan Memorial Hospital at Kanyakumari district.
Sampling technique:
,WUHIHUVWR³7KHSURFHVVRIVHOHFWLng a portion of the population to represent
WKHHQWLUHSRSXODWLRQ´
The investigator has selected the sample by Purposive Sampling technique for
this study, as she has intentionally selected the toddlers who were going to get
venipuncture in Jeyaharan Memorial Hospital at Kanyakumari district.
Criteria for selection of sampling:
List of the characteristics essential for inclusion or exclusion of samples from
the target population
27
Inclusion criteria:
- 1-3 years children undergoing venipuncture
- Those who are willing to participate
- Both male and female.
Exclusion criteria:
- Toddlers with sensory deprivation
- Toddlers who are not willing to participate in the study
- Toddlers who are already on IV infusion
- Mentally challenged toddlers
- Toddlers whose mothers are not willing to conduct the show
- Immediate postoperative toddlers who are on sedation and yet to get IV
infusion.
Method of developing the tool:
The tool was developed after an extensive review of literature, internet search
and experts opinion. It helped the investigator to select most suitable FLACC scale.
Discription of the tool:
This study tool consisted of 2 sections, section A and section B.
Section : A : Demographic Profile
This dealt with demographic data of the toddlers. The included items such as
age, gender, order of birth, Number of siblings ,type of family, education of father,
education of mother, occupation of father, occupation of mother, previous experience
of venipuncture, site of venipuncture.
28
Section : B
This dealt with measurement of pain experienced by the toddler with the help
of FLACC (Face, leg, activity, consolability, cry) developed by S Merkel in 1997.
The FLACC pain scale consists of five categories for which different scoring is
given.
The five categories are;
x Face
x Legs
x Activity
x Cry
x Consolability
At the end of pain assessment, pain level was graded based on the following scores;
0 - Relaxed and Comfortable
1-3 - Mild discomfort.
4-6 - Moderate pain.
7 ± 10 - Severe pain.
Content Validity:
&RQWHQWYDOLGLW\GHILQHGDV³7KHGHJUHHWRZKLFKWKHLWHPVLQDQLQVWUXPHQW
adequately represent the universe of content for the concept being measured´
(Denise F. Polit,2011)
The content validity was not necessitated since the investigator has used a
standardized FLACC pain Scale developed by S Merkal in 1997 in order to assess
the pain experienced by toddlers.
29
Reliability of the tool:
5HOLDELOLW\ LV GHILQHG DV ³7KH GHJUHH RI FRQVLVWHQF\ RU GHSHQGDELOLW\ ZLWK
ZKLFKDQLQVWUXPHQWPHDVXUHVDQDWWULEXWH´ 'HQLVH)3ROLW
The tool was standardized FLACC (face, leg, activity, cry, consolability) pain
rating scale developed by S Merkal in 1997 in order to assess the pain experienced
by toddlers.
Method of Data collection:
Ethical consideration:
x The study was conducted after the approval of dissertation committee at
global college of nursing.
x Formal written permission was obtained from the medical director of
Jeyaharan Memorial Hospital, Nagercoil.
x An informed verbal consent was obtained individually from parents of
toddlers who participated in the study.
x Confidentiality was assured to parents throughout the study.
x Parents were informed that their toddlers participation were voluntary based
and had the freedom to drop out from the study as when they liked to do so.
Pilot study
Pilot study was conducted in Jeyaharan Memorial Hospital, Nagercoil, after
receiving a formal approval from Administrative Officer, Jeyaharan Memorial
Hospital, Nagercoil. The pilot study was conducted in Jeyaharan Memorial Hospital,
Nagercoil among 6 toddlers 3 were in study group and 3 were in control group who
were selected. Then assessment was done with the help of FLACC pain scale for
control group. Then intervention was given by showing cartoon animation to the
30
experimental group and pain was assessed with the help of FLACC scale. Analysis
of the data was done by using descriptive and inferential statistics. The tool was
reliable and tool scoring was found feasible and practicable. No changes were made
and researcher proceeded for main study.
Procedure for data collection
The researcher got permission from Principal, and research ethical committee
of Global College of Nursing. A formal permission was obtained from the
Administrative Officer of Jeyaharan Memorial Hospital, Nagercoil. The institutional
ethics review board approved the protocol.
Data collection period was between 1-9-2014-30-9-2014 morning and
evening. 60 toddlers who are getting venipuncture were selected by purposive
sampling technique.
Rapport was established with the toddlers and brief introduction about the
study was given. Consent was obtained from each childs mother. Pain score was
assessed for both control and experimental group. The pain score assessment was
done by FLACC pain rating scale. The data were collected approximately 4-5 study
subjects per day.
Plan for data analysis
The data were analyzed by using descriptive and inferential statistics.
¾ Descriptive statistics
Frequency and percentage distribution were used to analyze the
demographic data.
31
¾ Inferential statistics
UnpDLUHG µW¶ WHVW ZDV XVHG WR DVVHVV WKH HIIHFWLYHQHss of reduction of pain
during venipuncture. Chi-square test was used to find out the association of the
clinical variables and pain among toddlers.
Summary
This chapter consisted of research design, variables in the study, study
setting, population, sampling technique, sample size, criteria for selection of sample,
development and description of tool, content validity, pilot study, data collection
procedure and plan for data analysis.
32
CHAPTER- IV
DATA ANALYSIS AND INTERPRETATION

According to Polit and Hungler (2005) analysis is the method of organizing,
sorting and scrutinizing data in such a way that research question can be answered.
This chapter deals with the analysis and interpretation of data collected from
60 toddlers (30 Experimental and 30 control group) on reducing pain to evaluate the
effectiveness of cartoon animation show during venipuncture among toddlers in the
selected hospital at Kanyakumari District.
The analysis and interpretation of data were based on data collection and the
results were computed by using descriptive (Mean, Frequency, Percentage
GLVWULEXWLRQ DQG 6WDQGDUG GHYLDWLRQ DQG LQIHUHQWLDO µW¶-test and chi-square test)
statistics and the results were interpreted in tables, figures and diagrams.
Statistical analysis used:
The findings of the study were grouped and analyzed under the following
sections.
Section A: The frequency and percentage distribution of the Post test level of
pain in the experimental and control groups was an descriptive
statistics.
Section B: The frequency and percentage distribution of post test level of pain in
the experimental and control group.
Section C: The comparison of post test level of pain between the experimental and
control JURXSV ZDV DQDO\VHG E\ µW¶WHVW :KLFK LV DQ LQIHUHQWLDO
statistical analysis.
Section D: The Association of post test level of pain in the control group with
demographic YDULDEOHVZDVDQDO\VHGE\XVLQJµFKL-VTXDUH¶WHVW.
33
SECTION :A
Table-1.2 Frequency Percentage distribution of demographic variables in

the experimental group and control group
EXPERIMENTAL
DEMOGRAPHIC CONTROL GROUP
GROUP
VARIABLES
F % F %
1.Age in months
a) 12-18 7 23.33 8 26.6
b) 19-24 5 16.6 5 16.6
c) 25-30 8 26.6 10 33.3
d) 31-36 10 33.33 7 23.33
2.Gender
a) Male 12 40 13 43.3
b) Female 18 60 17 56.6
3.Order of birth
a) First 16 53.33 15 50
b) Second 10 33.33 10 33.3
c) Third and above 4 13.33 5 16.6
4.Number of siblings
a) Nil 16 53.33 15 50
b) One 10 33.33 10 33.3
c) Two or more 4 13.33 5 16.6
5.Type of family
a) Nuclear 14 46.66 13 43.3
b) Joint 10 33.33 8 26.6
c) Extended 6 20 9 30
6.Education of father
a) Illiterate 0 0 0 0
b) Primary 2 6.6 3 10
c) Secondary 5 16.6 5 16.6
d) Collegeate 23 76.6 22 73.3
e) Others- specify 0 0 0 0
7.Education of mother
a) Illiterate 0 0 0 0
b) Primary 3 10 5 16.6
c) Secondary 5 16.6 3 10
d) Collegeate 22 73.3 22 73.3
34
8.Occupation of father
a) Unemployed 0 0 0 0
b) Coolie 7 23.33 5 16.6
c) Profession 13 43.33 15 50
d) Businessman 10 33.33 10 33.3
9.Occupation of mother
a) Housewife 12 40 10 33.3
b) Coolie 3 10 2 6.6
c) Profession 13 43.3 15 50
d) Business 2 6.6 3 10
10.Previous experience
of venipuncture
a) Nil 16 53.33 15 50
b) Within a week 0 0 0 0
c) A week back 3 10 2 6.6
d) Two weeks back 2 6.6 3 10
e) More than two 9 30 10 33.3
weeks
11.Site of venipuncture
a) Dorsum of hand 18 60 20 66.6
b) Wrist (radial) 12 40 10 33.3
c) Ankle 0 0 0 0
d) Others 0 0 0 0
The above table shows with regard to that age in months in experimental
group 7(23.33%) were in 12-18 months, 5(16.6%) were in 19-24 months, 8(26.6%)
were in 25- 30 months, 10(33.33%) were in 31- 36 months. In control group
8(26.6%) were in 12-18 months, 5(16.6%) were in 19-24 months, 10(33.3%) were in
25-30 months, 7(23.33%) were in 31-36 months.
With regard to the gender in the experimental group , 12 (40%) were males
and 18(60%) were females, where as in the control group, 13 (43.3%) were males
and 17(56.6%) were females.
35
Regarding order of birth in the experimental group,16(53.33%)were in 1st
order,10(33.33%)were in the 2nd order and 4(13.33%)were in the 3rd and above,
where as in the control group,15(50%) were in the 1st order,10(33.3%) were in the
2nd order,5(16.6%) were in the 3rd and above.
With regard to the number of siblings in experimental group,16 (53.33%) with
no siblings, 10(33.33%) with one, 4(13.33%) with two and more siblings, where as
in control group, 15(50%) with none, 10(33.3%) with one, 5(16.6%) with two and
more.
With regard to type of family in experimental group, 14(46.6%) with nuclear
family, 10(33.3%) with joint family, 6(20%) with extended family, were as in control
group, 13(43.3%) with nuclear family, 8(26.6%) with joint family, 9(30%) with
extended family.
Regarding education of father in experimental group, 0(0%) were illiterate,
2(6.6%) were primary, 5(16.6%) secondary, 23(76.66%) were collegeate,0(0%) were
others, where as in control group, none of them were illiterate, 3(10%) were primary,
5(16.6%) were secondary 22(73.3%) were collegeate, 0(0%) were others.
Regarding education of mother in experimental group, 0(0%) illiterate,
3(10%) were primary,5(16.6%) were secondary,22(73.3%) were collegeate, 0(0%)
were others, where as in control group, 0(0%) were illiterate,5(16.6%) were
primary,3(10%) were secondary, 22(73.3%) were collegeate, 0(0%) were others.
With regard to the occupation of father in experimental group, 0(0%) were is
unemployed, 7(23.3%) were coolie, 13(43.33%) were professional,10(33.33%) were
businessman, 0(0%) others. where as in control group , 0(0%) were is unemployed,
36
5(16.6%) were coolie, 15(50%) were professionals, 10(33.3%) were businessman,
none of them from other profession.
With regard to occupation of mother in experimental group, 12(40%) were
house wives, 3(10%) were coolie, 13(43.33%) were professional, 2(6.6%) were
business and 0(0%) were others, where as in control group, 10(33.3%) were
housewives, 2(6.6%) were coolie, 15(50%) were professionals, 3(10%) were
business and none of them from other profession.
With regard to previous experience of venipuncture in experimental group
16(53.33%) were in no experience, none of them were within a week,3(10%) were a
week back, 2(6.6%) were two weeks back and 9(30%) were more than two weeks,
where in control group,15(50%) were in no experience, none of them were within a
week, 2(6.6%) were a week back, 3(10%) were two weeks back and 10(33.3%) were
more than two weeks.
Regarding site of venipuncture in experimental group, 18(60%) were in dorsum
of hand, 12(40%) were in wrist (radial), 0(0%) were ankle and 0(0%) were in others,
where as in control group, 20(66.6%) were in dorsum of hand, 10(33.3%) were in
wrist (radial),0(0%) were ankle and 0(0%) were others.
37
Fig 4.1 : Percentage distribution of samples according to age in months
35.00% 33.30% 33.33%
30.00%
26.60% 26.60%
Percentage Distribution
25.00% 23.33% 23.33%
20.00%
16.60% 16.60%
Experimental group
15.00%
Control group
10.00%
5.00%
0.00%
12-18 months19-24 months25-30 months31-36 months
Age in months
38
Fig 4.2 : Percentage distribution of samples according to Gender
70%
60.00%
60% 56.60%
50%
43.30%
40%
40%
Experimental group
30%
Control group
20%
10%
0%
Male Female
Gender
39
Fig 4.3: Percentage distribution of samples according to Order of birth
18%
16%
16% 15%
14%
12%
10%10%
10%
8% Experimental group
Control group
6% 5%
4%
4%
2%
0%
First Second Third and above
Order of birth
40
Fig 4.4: Percentage distribution of samples according to Number of siblings
60.00%
53.33%
50%
50.00%
40.00%
33.33% 33.33%
30.00%
Experimental group
Control group
20.00% 16.60%
13.33%
10.00%
0.00%
Nil One Two and more
Number of siblings
41
Fig 4.5: Percentage distribution of samples according to Type of family
50.00% 46.66%
45.00% 43.30%
40.00%
33.33%
35.00%
30%
30.00% 26.60%
25.00%
20.00% Control group
15.00%
10.00%
5.00%
0.00%
Nuclear Joint Extended
Type of family
42
Fig 4.6: Percentage distribution of samples according to Education of father
90%
80% 76.66%
73.30%
70%
60%
50%
40%
Experimental group
30%
Control group
20% 16.60%16.60%
10%
10% 6.60%
0%0% 0%0%
0%
Education of father
43
Fig 4.7: Percentage distribution of samples according to Education of mother
80%
73.30% 73.30%
70%
60%
50%
40%
20% 16.60% 16.60% Control groupnt

10% 10%
10%
0%0% 0%0%
0%
Education of mother
44
Fig 4.8: Percentage distribution of samples according to Occupation of father
60%
50%
50%
43.33%
40%
33.33% 33.33%
30%
23.33%
20% 16.60% Experimental group

Control group
10%
0%0% 0%0%
0%
Occupation of father
45
Fig 4.9: Percentage distribution of samples according to Occupation of mother
60%
50%
50%
43.33%
40%
40%
33.30%
30%

Control group
10% 10%
10% 6.60% 6.60%
0%0%
0%
Occupation of mother
46
Fig 4.10 Percentage distribution of samples according to Previous experience of
venipuncture
60.00%
53.33%
50%
50.00%
40.00%
33.30%
30%
30.00%
Experimental group
20.00% Control group
10% 10%
10.00% 6.60%6.60%
0%0%
0.00%
Nil Within a A week Two weeks More than
week back back two weeks
Previous experience of venipuncture
47
Fig 4.11: Percentage distribution of samples according to Site of venipuncture
70% 66.60%
60%
60%
50%
40%
40%
33.30%

Conrol group
20%
10%
0% 0% 0% 0%
0%
Dorsum of Wrist(Radial) Ankle Others
hand
Site of venipuncture
48
SECTION :B
TABLE: 2 Frequency and Percentage distribution of post test level of

pain in the experimental and control group
Relaxed Mild Pain Moderate Pain Severe Pain

Group
F % F % F % F %
Experimental
0 0 0 0 15 50 15 50
Group
Control
0 0 0 0 3 10 27 90
Group
The Table 2: shows that in the experimental group majority 15 (50%) had
moderate pain,15(50%) had severe pain and in control group majority 27(90%)had
severe pain, 3(10%) had moderate pain.
49
Fig 5: Percentage distribution of post test level of pain in the experimental
and control group
100%
90%
90%
80%
70%
60%
50% 50%
Control group
40%
30%
20%
10%
10%
0%0% 0%0%
0%
Relaxed Mild Moderate Severe
50
SECTION : C
Table: 3 Comparison of post test level of pain between the

POST TEST Mean score Mean

S.D df t value
Level of pain difference
Experimental
6.5 19.5 6.68*
group 1.66 59
(s)
Control group 8.16 34.168
Table value t = 1.66
Table:3 depicts that in the experimental group, the post test level of mean
pain score was 6.5 with S.D 19.5 and in the control group the post test mean score
was 8.16 with S.D 34.168. The mean difference score was ± 1.66. The calculated µW¶
value of 6.68* was statistically significant at P<0.05 level indicating that there was
significant difference in the post test level of pain between the experimental and
control group. Hence H1 is accepted.
51
Fig 6: Comparison of post test level of pain between the experimental and
control group
40
34.168
35
30
25
19.5
20 Experimental group
Control group
15
10 8.16
6.5
5
0
Mean Standard Deviation
52
SECTION- D
Table:4 Association of post test level of pain in the control group with
demographic variables
n = 30
CONTROL GROUP
S.No DEMOGRAPHIC DF X2 TABLE VALUE
VARIABLES
1 Age in months 9 1.95 16.92
2 Gender 3 2.735 7.81
3 Order of birth 6 0.68 12.59
4 Number of siblings 6 0.68 12.59
5 Type of family 6 12.55 12.59
6 Education of father 12 7.63 21.03
7 Education of mother 12 7.63 21.03
8 Occupation of father 12 0.6943 21.03
9 Occupation of mother 12 0.8331 21.03
10 Previous experience of 12 1.5831 21.03

venipuncture
11 Site of venipuncture 9 2.4999 16.92
Table 1.5 shows association of post test level of pain in the control group
with demographic variable. There was no association between posttest level of pain
with selected demographic variable. Hence H2 is rejected.
53
CHAPTER- V
DISCUSSION
The main aim of the study was to assess the effectiveness of cartoon
animation show during venipuncture in reducing pain perception among the toddlers.
The study was conducted by using quasi experimental design with post test only
design with control group. The present study was conducted in Jeyaharan hospital ,
Nagercoil, Kanyakumari District. The sampling technique is purposive sampling
technique was used for this study . The total sample size was 60, among them 30
were in the experimental group and 30 were in the contrl group. FLACC (Face, Leg,
Activity, Consolability, Cry) developed by S Merkal in 1997 was used for data
collection. After data collection, data was organized, tabulated, summarized and
analyzed. The study findings were discussed in this chapter with reference to the
objectives of the study.
The objectives were,
¾ To assess the pain perceived by the toddlers during venipuncture in both A
and B group.
¾ To assess the effect of cartoon animation show in reducing pain during
venipuncture by comparing the pain scores among both groups .
¾ To determine the association of pain perceived by the toddlers in the control
54
The first objective was to assess the pain perception by the toddlers during
venipuncture in both A and B group.
In the experimental group out of 30 15(50%) was moderate and 15(50%) was
severe in pain during venipuncture. In control group out of 30 3(10%) was moderate
and 27(90%) was severe during venipuncture.
The second objective was to assess the effect of cartoon animation show in
reducing pain during venipuncture by comparing the pain scores among both
groups.
In the experimental group , the post test level of mean pain score was 6.5
with S.D 19.5 and in the control group the post test mean score was 8.16 with S.D
7KHFDOFXODWHGµW¶YDOXHRIZDV VWDWistically significant at p<0.05 level
indicating that there was significant difference in the post test level of pain between
the experimental and control group.
Hence the hypothesis H1 is accepted and stated that there is significant
difference of pain level during venipuncture between group A and group B.
The third object was to determine the association of pain perceived by the
toddlers in group B with their selected demographic variables
The association table that the demographic variables had not shown any
statistically significant association with the level of pain in the control group.
The conceptual framework of WKLV VWXG\ ZDV EDVHG RQ &DOOLVWD 5R\¶V
adaptation model (1999). This model describes the goal of nursing is to facilitate
adaptation between person and the environment through the management of stimuli.
55
The focal stimuli is considered as starting venipuncture because the toddlers pain is
related responses were tested as a result of intravenous therapy. The contextual
stimuli order of birth, number of siblings, education of father, education of mother,
occupation of father, occupation of mother, previous experience of venipuncture, site
of venipuncture and residual stimuli are age and gender as a response to focal,
contextual and residual stimuli the responses exhibited out in physical and
psychological aspects. The physical responses to pain are facial expression,
crying,breathing pattern, arms restrained, leg restrained ,state of arousal and
psychological response. The investigator shown cartoon animation show to toddlers
and assess the pain level through (FLACC) by evaluation of post assessment level of
pain.
The findings concluded that the toddlers in the experimental group had
reduction in the level of pain when compared with control group .Hence the cartoon
animation show was responsed to reduce the venipuncture pain among toddlers.
56
CHAPTER VI
SUMMARY, CONCLUSION AND RECOMMENDATIONS

This chapter deals with summary, conclusion, limitations and
recommendations for further studies. Further it includes implications of findings of
this study in Nursing Practice, Nursing Education, Nursing Administration and
Nursing Research.
SUMMARY OF THE STUDY
The aim of the study was to assess the effectiveness of cartoon animation
show during venipuncture in reducing pain perception among the toddlers in
Jeyaharan Hospital, Nagercoil ,Kanyakumari District.
The objectives of the study were,
¾ To assess the pain perceived by the toddlers during venipuncture in both A
and B group.
¾ To assess the effect of cartoon animation show in reducing pain during
venipuncture by comparing the pain scores among both groups .
¾ To determine the association of pain perceived by the toddlers in the control
The target population is comprised of all toddlers admitted at Jeyaharan
hospital .
57
Accessible population refers to the aggregate of cases which conform to the
designated criteria and which to accessible the researchers as a pool of subjects for
the study. In this study is comprised of toddlers those who are in admitted in the
Hospital. The physical location and conditions in which data collection take place in
a study. The study will be conducted in Jeyaharan hospital. It is 46km away from
Global College Of Nursing, Nattalam. The total bed strength of the hospital is 200.
This setting was selected because of the availability of participants and
feasibility of conducting the study.
A quasi experimental design in nature. Post test only design with control
group was chosen for this study. Purposive sampling technique was used for this
study. Subjects were selected based upon the inclusion and exclusion criteria. 60
subjects were selected for the study. Purposively 30 Subjects were assigned to group
A and 30 subjects were assigned to group B.
The tool used to collect the data consisted of two parts, section A: consisted
of the demographic Variables with age in months, gender, order of birth, number of
siblings, type of family, education of father, education of mother, occupation of
father, occupation of mother, previous experience of venipuncture, site of
venipuncture. Section B consisted of FLACC (face, leg, activity, consolability, cry)
developed by S Merkel in 1997. FLACC interpretation:
0 - Relaxed and comfortable.
1±3 - Mild discomfort.
4±6 - Moderate pain.
7 ± 10 - Severe pain
58
validity of the tool was not obtained because the investigator selected a standardized
FLACC Scale developed by S Merkel in 1997. Reliability of the tool was tested by
using test-UHWHVWPHWKRGWKHIRUPXODZDVU G[G\¥G[2îG\2ሺ‫ ݎ‬ൌ ͲǤ͹ͷሻǤData
collection was done for 4 weeks. Sample subjects were selected based on the
inclusion and exclusion criteria. Demographic variables were collected. Post test
was done by using FLACC pain Scale. Intervention was done with showing
cartoon animation show to the selected toddlers during venipuncture .
After that collected data were analyzed by both descriptive statistics
(inclusive of mean,standard deviation ,frequency and percentage) and inferential
VWDWLVWLFV LQFOXVLYH RI GHSHQGHQW DQG SDLUHG µW¶ WHVW FKi-square) and results were
interpreted in the forms of tables ,figures and diagrams.
Major Findings of the Study:
With regard to the level of venipuncture pain among toddlers, most of them
were found to have severe and moderate pain in the group B, as measured by
FLACC scale and group A exhibited only moderate and severe . It revealed that the
pain during venipuncture which denotes that the reduction of pain was due to
showing cartoon animation show.
Out of 30 samples that in the experimental group majority 15 (50%) had
moderate pain,15(50%) had severe pain and in control group majority 27(90%)had
severe pain, 3(10%) had moderate pain.
It depicts that in the experimental group, the post test level of mean pain score
was 6.5 with S.D 19.5 and in the control group the post test mean score was 8.16
with S.D 34.168. The mean difference score was ± 1.66. TKHFDOFXODWHGµW¶YDOXHRI
59
6.68* was statistically significant at P<0.05 level indicating that there was significant
difference in the post test level of pain between the experimental and control group.
With regard to the association of post test level of pain in the control group with
demographic variable. There was no association between post test level of pain with
selected demographic variable.
CONCLUSION:
The study finally concluded that showing cartoon animation show during
venipuncture, has a positive effect on reducing pain for the toddlers. This conclusion
ZDVPDGHEDVHGRQWKHµW¶ test value which was found to be highly significant.
IMPLICATIONS OF THE STUDY FINDINGS:
Nursing implications denotes the utility of study findings in various fields of
nursing such as Nursing practice, Nursing education, Nursing administration and
Nursing research.
Nursing Practice :
x Showing cartoon animation show during venipuncture for reducing
pain perception can be included as nursing procedure to while
providing care for toddlers during venipuncture.
x The mothers of toddlers undergoing venipuncture can be encouraged
to carry out this method if nurses are occupied by venipuncture
procedure.
60
x Cartoon animation show alleviates the anxiety and discomfort with in
the mother who may feel very much comfortable and happy due to
pain reduction in the child and the child is calm.
x The cartoon animation show can be effectively instituted in the
pediatric ward as the toddlers are temporarily separated from mother.
Nursing Education:
x Showing cartoon animation show during venipuncture for toddlers can be
included in the curriculum for 3rd year Bsc nursing course ,along with
pediatric care in the pediatric ward.
x Nursing students should be supervised by instructors while showing
cartoon animation show during venipuncture so that it can become a
routine in pediatric ward.
x Adequate inservice training can be given to the nursing staff and students
regarding showing cartoon animation show in reducing pain perception.
x Health education can be given to mothers of toddlers in pediatric ward.
Nursing Administration:
x The Nurse administrators can initiate showing cartoon animation show to
reduce the venipuncture pain through developmental programme like in-
service education and continuing nursing education programme.
x Nurse administrator can prepare written policies and protocols regarding
cartoon animation show during venipuncture for all toddlers in pediatric
ward.
61
Nursing Research:
x The nurse researcher can conduct many more studies in different areas of
pediatric units to bring about newer perspective in nursing care.
x The study finding will motivate the initial researchers to conduct the same
study on large scale and study will be the reference for the extensive and
intensive nursing care.
Limitation:
No limitation was encountered by the investigator during or after the study.
Recommendations:
x A similar study can be replicated on a large sample size.
x A similar study can be conducted in different settings such as newborn care
units or infant care units.
62
BIBLIOGRAPHY
TEXT BOOKS
1. Ball and Blinder. (1995). Pediatric Nursing ± Causing for children. (6th ed.),
Norwalk: Appleton and Lange Company Publications.
2. Behrman et al. (1995). Textbook of Pediatrics. (15th ed.).Philadelphia : W.B
Sunders Company Publications..
3. +RFNHQEHUU\ -0 :RQJ /' :RQJ¶V QXUVLQJ FDUH RI LQIDQWV DQG
children. (5th ed.) Philadelphia: Mosby Publishers;
4. Dorothy Marlow K, (2008) Textbook of padiatric nursing, New Delhi.
Published by elsevier a division of reed elsevier India private limited.
5. -DQH%DOODQG5XWK%LQGOHU³3HGLDWULF1XUVLQJFDULQJIRUFKLOGUHQ´ nd ed.)
Prentice hall publication

st
6. 6XUDM *XSWKD µSHGLDWULFV¶ ed. ), New Delhi, published by New
Age International Ltd.

th
7. Behrman, Kliegman, Jenson. (2004). Nelson Text book of pediatrics. (17
ed), India: Thomson Press Publication.
8. 0F*UDWK 3- DQG 8QUXK $0 ³0HDVXUHPHQW DQG DVVHVVPHQW RI
SHGLDWULF SDLQ´ LQ 7H[WERRN RI 3DLQ th ed.) New York, Churchill
Livingstone, Publication.
9. Basavanthappa. (2005). Pediatric Nursing. (1st ed). New Delhi: Ahuja
Publishing house.
10. Waecher. H. and Enginia. (1988). Nursing care of children. (10th ed).
Philadelphia : J.B Lippincontt company Publication.
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11. Wood Labrondo and Haber Judith. (1997). Nursing research methods, -
critical appraisal and utilization. (3rd ed.) Philadelphia : Mosby Company
Publication.
12. Basavanthappa BT (2007) .Nursing Research . New Delhi: Jaypee
Publications.
13. Polit, D.F, Beck. (2007).Nursing research (8th edition), Wolters Kluwers
publishers private limited.
14. Suresh. K. Sharma (2008).Nursing research and statistics, (Ist ed), Elsevier
medical publishers.
15. Sundar Rae P.S et al. (1999).An introduction to biostatistics, a manual for
students in Health sciences.(2nd ed.) Vellore: Christian medical college.
JOURNAL REFERNCE
1. Jackson Debra Broad well and Sounders and Rebecca. (1993). Child health
nursing ± A comprehensive approach to the care of children and their
families. (12th ed.), New York: MC Graw Group Hill, 26-32
2. 0F*UDWK 3- DQG )UDJHU * ³Psychological barriers to optimal pain
management in infants and children´ The Clinical Journal of Pain, vol. 12,
no. 2, pp. 135±141, 1996.
3. 0RUWRQ16³3DLQDVVHVVPHQWLQFKLOGUHQ´Pediatric Anaesthesia, vol. 7, no.
4, pp. 267±272, 1997.
4. Franck LS, Greenberg CS, Stevens B. Pain Assessment in Infants and
Children. Pediatric Clinic North American. 2000; 47:487-512.
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5. Abu-6DDG ++ DQG +DPHUV -3 ³'HFLVLRQ-making and pediatric pain: a
UHYLHZ´Journal of Advanced Nursing, vol. 26, no. 5, pp. 946±952, 1997.
6. 0HUNHO6/HZLV79DQG0DOYL\D6³3DLQDVVHVVPHQWLQLQIDQWVDQG\RXQJ
FKLOGUHQWKH)/$&&VFDOH´American Journal of Nursing, vol. 102, no. 10,
pp. 55±68, 2002.
7. Wanga ZX, Sunb LH, Ping AC. Swiss Med Wkly 20 08; 138(39±40):579±
584
8. Harrison, Denise. (2006). Pain assessment and Procedural pain management
practices in children. Journal of Pediatrics and Child Health, 42, 6 ± 9.
9. Navjot Kiran, Sukjit Kaur (2013). Effect of icepack application at the site
prior to venipuncture on intensity of pain among children. Nursing and
midwifery Research Journal, Vol. 9, No.4, 160.
10. Sinno.H.P.Simons and Monique van Dijk. (1997). A Prospective study of
procedural pain and analgesia in neonates, Journal of Arch Pediatrics, Vol.
100, 626 ± 632.
11. Upadhyah A, Aggarwal R, (2003). All India Institute of Medical Sciences,
WHO Collaborating centre for training and research.76, 96 ± 109.
12. Fowler ± .HUU\ V ODQGHU -5 ³0DQDJHPHQW RI ,QMHFWLRQ SDLQ LQ FKLOGUHQ´
Pain 1987 Aug; 30 (2): 169-75.
13. 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.
65
14. Cohen LL, Blount RC, 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.
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Bright NS pain reduction during pediatric immunizations. Paediatrics. 2007
May: 119(5): 84-98.
16. Willis et.al, FLACC behavioral pain assessment scale: a comparison with the
FKLOG¶VVHOI-report. Pediatric nursing. May 1, 2003
17. /DVVHWWHU -+ ³7KH HIIHFWLYHQHVV RI FRPSOHPentary therapies on the pain
experiences of hospitalized children. J. Holist nurse. 2006 Sep; 24(3):196-
208.
18. %HOOLHQL FYHWDO ³$QDOJHVLFHIIHFW RIZDWFKLQJ 79GXULQJ9HQLSXQFWXUH´
Arch dis child. 2006 Dec; 91 (12) : 1015-7. E pub 2006 Aug 18.
NET REFERENCE:
1. 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
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67
APPENDIX ± I
i
ii
APPENDIX-II
Tools For Data Collection
Section : A
Demographic variables
1. Age in months
a) 12-18
b) 19-24
c) 25-30
d) 31-36
2. Gender
a) Male
b) Female
3. Order of birth
a) First
b) Second
c) Third and above
4. Number of siblings
a) Nil
b) One
c) Two and more
5. Type of family
a) Nuclear
b) Joint
c) Extended
6. Education of father
a) Illiterate
b) Primary
c) Secondary
d) Collegiate
e) Others-specify
iii
7. Education of mother
a) Illiterate
b) Primary
c) Secondary
d) Collegiate
e) Others- specify
8. Occupation of father
a) Unemployed
b) Coolie
c) Professional
d) Businessman
e) Others ± specify
9. Occupation of mother
a) House wife
b) Coolie
c) Professional
d) Business
e) Others ± specify
10. Previous experience of venipuncture

a) No
b) Within a week
c) A week back
d) Two weeks back
e) More than two weeks
11. Site of venipuncture

a) Dorsum of hand
b) Wrist (radial)
c) Ankle
d) Others
iv
Section B:
It deals with FLACC pain rating scale score.
CATEGORIES FINDINGS SCORING SCORE
Face No particular expression 0

Occasional grimace 1
Clenched jaw, quivering 2
chin.
Legs Relaxed. 0
Uneasy,restless,tense. 1
Kicking or legs drawn up. 2
Activity Lying quietly. 0

Shifting back, tense 1
Jerking 2
Cry No cry 0
Cries 1
Screams 2
Consolability Relaxed 0
Hugging 1
Difficult to console 2
Total
0= no pain 4-6=moderate pain
1-3=mild pain 7-10=severe pain
The flacc pain scale can be used with infant and paediatric pateints age 0-3
years who are unable to communicate pain.
The flacc pain assessment scale by S.Merkel, 1997.
v
Section: C
Intervention:
Intervention was given during venipuncture for the toddlers. The Cartoon
animation show of Tom and Jerry was played at initiation, at five minutes and at
termination of venipuncture. The cartoon animation show was showed to the toddlers
during venipuncture.
vi

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A STUDY TO ASSESS THE EFFECTIVENESS OF CARTOON

ANIMATION SHOW DURING VENIPUNCTURE IN

REDUCING PAIN AMONG TODDLERS IN

THE SELECTED HOSPITAL AT

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI

IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE

AWARD OF DEGREE OF MASTER OF

Certified that this is the bonafide work of

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI

PROFESSOR IN NURSING RESEARCH

CLINICAL SPECIALITY EXPERT

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI

IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE

AWARD OF DEGREE OF MASTER OF

Internal Examiner External

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI

IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE

AWARD OF DEGREE OF MASTER OF

effectiveness of cartoon animation show during venipuncture in reducing pain

year October 2013-2015.

Name and Signature of the guide : -----------------------------------------------

Mrs. VIMALA. M.Sc(N)

Assistant Professor in Nursing.

Name and Signature of the Head of Department : -----------------------------------

Mrs. VIJILA BERLIN, M.Sc(N)

Associate Professor in Nursing.

wisdom, knowledge, strength and guidance to complete this study successfully.

Secretary Mrs. Sakhila Santhakumari, MA.,M.Phil, the managing Trustee of

conduct this study.

I consider myself fortunate to have been piloted by Prof. Mrs. Josephine

Ginigo, M.Sc(N), Principal, Global College of Nursing whose guidance and

constant encouragement, valuable in-depth discussions and suggestions throughout

the study and has made it a successful one.

I am privileged to express my hearty thanks to Mrs. Helen Mary,

motivation to proceed with the study.

I extent my gratitude to Mrs. Vimala, M.Sc(N), Asst.Prof. of Child Health

I extent my gratitude to Mrs. Vijila Berlin, M.Sc(N), Associate Professor

this dissertation work.

I express my sincere thanks to Mrs.Jeyanthi, M.Sc(N)., Department of

encouragement to complete this dissertation successfully.

My deep sense of gratitude is expressed to Dr. Sashya, M.B.B.S, D.C.H

study could not have been completed successfully.

I am very much obligated to Mr.P.Anto, M.Sc, M.Ed, M.Phil, PGDBS,

of data in this study.

I am grateful to Print Land for having patiently deciphered the manuscripts

into a legible piece of work.

My immense thanks to Mrs.Sindhu Librarian of Global College of

Words are beyond expression for meticulous effort of my parents and my

brother for their encouragement towards the completion of study.

I am thankful to all my classmates and friends who directly and indirectly

contributed towards the completion of my project.

CHAPTER CONTENTS PAGE NO

Need for the study 4-5

Statement of the Problem 5

Delimitations of the study 7

Conceptual Framework 7-10

¿ Studies related to venipuncture or any

¿ Studies related to non pharmacological

¿ Studies related to the effectiveness of

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