CHAPTER 1

THE PROBLEM AND ITS SCOPE

INTRODUCTION

Rationale of the Study

Pain, can be objective but most often subjective, can be physical or
emotional, can be little or excruciating. In the case of a Diabetic person, Diabetes
management can be a pain, literally. A person who is diagnosed with diabetes will
have to monitor the concentration of sugar in their blood by capillary blood sugar
monitoring which is performed by pricking their finger to get an ample amount of
blood to be filled on a disposable test strip which is inserted in a measuring
device called a blood glucose meter that will display the amount level of sugar in
the blood. But every time this has to be executed, a discomfort or pain can be
felt.

In addition, diabetes is a condition where a person has increased blood

sugar either because the person resists to insulin or the body cannot produce
enough insulin which results to increased glucose levels in the blood
(hyperglycemia). Insulin is a hormone produced in the islets of langerhans in the
pancreas that turns glucose into glycogen as a form of energy. Blood glucose
monitoring serves a vital role in caring for diabetic patients. It is utilized to

comprehend ones control to diabetes as well as if there are any improvements

and to evaluate the effectiveness of a certain remedy
The site of capillary blood sugar monitoring is traditionally done at the
fingertips. However, capillary blood sugar monitoring can now be performed on
palm. Furthermore, there are already countless studies made pertaining to the
comparability between the palm and the traditional site fingertips.

Many

researchers reported that the finger is much more sensitive to pain than the palm
site. The palm is also reported as suitable alternative site to fingertip testing since
the palm is considered to have few nerve endings (Chase & Fiallo-Svharer).
There were also other sites such as the forearm and thigh considered alternative
location but the most accessible is the palm (Peled, Wong, & Gwalani, 2002;
Meguro, Funae, Hosokawa, & Atsumi, 2005; Grill-Wikell,

Annersten & Frid,

2005).
Since most research studies focused on the accuracy on glucose values
between the palm and fingertips (Bloomgarden, 2003), we delve on beneficiarys
comfort upon blood withdrawal. We, the researchers have noted that some of
our affiliated hospitals and other health care facilities in the Philippines
particularly Cebu City are used to in the traditional way of acquiring capillary
blood sugar which gave us interest to contrast between the two sites. Our aim for
this study is to investigate if theres a significant difference regarding pain on the
2 sites test sites palm and fingertips and to formulate modified guidelines on
performing Capillary Blood Sugar taking.

Review of Related Literature

This review of literature is made for the purpose of the reader to
accumulate a detailed overview with regards to capillary blood sugar testing
among different alternative sites. These were gathered from different sources
such as journals, articles and previous studies.
Diabetes Mellitus is a metabolic disease in which the blood glucose or
sugar of a person is high or above its normal value, it happens when either the
insulin production is inadequate or that the body cells dont respond properly to
insulin on occasion both. Polyuria, polydipsia and polyphagia is usually
experienced by a client with high blood glucose or sugar. (Nordquist, 2010)
There are two significant classification of diabetes, the insulin-dependent
or also known as type 1 diabetes and the insulin-independent or diabetes type 2.
Insulin-dependent (diabetes type 1) patients have the inadequate production of
insulin and may not produce any insulin, to control the blood glucose levels,
insulin injection is required proximately 5% to 10% of people were affected by
this disease. Usually develops in childhood aged 7-12 years. Although this may
occur at any age. Though lot of research studies going on in the field to find a
cure, still it was negative to find a cure for diabetes type 1 discovered ( Atkinson

& Eisenbarth 2001). As for diabetes type 2 is an insulin resistance, which is

lesser insulin is produced. Approximately 90% to 95% were affected by this
disease. Usually common among people aged 30 above and obese. It can be

initially treated with diet and exercise, if increase glucose persist, oral antidiabetic
agent is recommended (Paul & Williams 2009).
Moreover, low blood sugar (hypoglycemia) is common in people with
diabetes. A person can feel the effect of low blood sugar when he is hungry or
exercised hard without eating enough. This maybe an ongoing problem that
occurs when the level of your blood sugar drops to low. The three types of
hypoglycemia include the mild, moderate and severe. (Medical Reference from
Healthwise, 2011) The mild hypoglycemia where the blood glucose falls below 70
mg/dl with the symptoms of nausea, extreme hunger, feelings nervous, rapid
heartbeat, cold and clammy and trembling. Moderate hypoglycemia, blood sugar
falls 55 mg/dL symptoms like mood changes, difficulty in thinking, blurred vision,
weakness, poor coordination, and fatigue may be experience. Severe
hypoglycemia, blood sugar falls below 35-40 mg/dL symptom includes seizure,
loss of consciousness and low body temperature (hypothermia). (University of
Michegan Health Systems health library, 2014)
While high blood glucose (hyperglycemia) happens when the body
produces too little insulin or cant use insulin properly. People with this condition
may experience hyperglycemia, increased thirst, and high level of sugar in urine
ad frequent urination (American Diabetes Association, 1995). Normal ranges for
blood glucose 80-120 mg/dL but in general fasting (early a.m before breakfast)
blood glucose ranges 70-100 md/dL, after taking a meal glucose level may

slightly rise ( Stppler,2013).

Pain maybe the reason why some clients are avoiding self-monitoring of
blood glucose. Some studies shows that they are frighten of blood and injury
associated to less frequent self monitoring. Their aim is to compare the level of
pain at any different testing sites in the palm. Composed of twenty subjects with
diabetes type 1 to pricked themselves in four different sites in the palm of the
non-dominant hand using the randomized order. With the use of the Pain-OMeter the subjects will evaluate the pain. This result presented that the pain
score has no significant difference between the experimented sites (GrillWikell,Annersten & Frid, 2005).
Blood glucose self monitoring plays an important role in the management
of diabetes. However, traditional finger prick testing causes pain and poor
compliance. Using an alternative site for sampling may reduce the level of pain
and be beneficial for improving the compliance of diabetic patients.

Figure 1. Palm
Nerve ending has millions of points in your body surface that will send
messages to your brain during sensations such as pain, heat or cold.
Anatomically the palm has less nerve endings than the fingertips (Wesley
Norman, 1999).
Blood glucose monitoring is a procedure to measure the blood glucose
using a glucometer. Glucometer is used with monitoring of blood glucose is
performed by pricking the finger with the use of lancet, place a drop of blood on a
strip in order to know the amount of glucose in the blood. In additional, the finger
blood sample can now be collected from other areas of the body to reduce
discomfort. To test blood sugar, it should be check before breakfast, before lunch,
before dinner or snack and before bedtime snack (Chase, Tamborlane, Beck,

Bode, Buckingham, Clemons & Xing, 2008)

The benefit of self-monitoring of blood glucose (SMBG) is to enhance the
glycemic control in diabetic patient. This includes the ability to detect or prevent
hypoglycemia, assess treatment, and to improve diabetes mindfulness. This will
help to improve outcomes especially in patients who are treated in insulin. The
objective of this study is to identify the comfortable and painless testing in other
alternative sites. This study will determine the significant differences of alternative
testing sites compared to fingertip values (Fedele, 2004)
According to Patouraux, Djemli & Vague (2004), they concluded that in
order to improve the diabetic patients capillary blood sugar monitoring and
metabolic control, the use of an alternative site offers a solution. A probable
physiological delay in the detection of glycemic conditions is revealed in some
studies at the level of the alternative sites. Interest of the use of such alternative
sites is considered in self-monitoring and is proven to be reliable.
It has been introduce that the Alternate-site testing (AST) is one of the
solution to minimize pain and enrich compliance. (Journal Diabetes Science
Technology, 2010). One of the issue of Journal of Diabetes Science and
Technology. They study the clients who solely used the accustomed fingertip
blood glucose testing and also has been introduced the palm blood glucose
testing (PBGT). Future studies should explore and have come up solutions to
enrich compliance of diabetes care.

The AtLast Blood Glucose System has been improved to exclude painful
pricking by testing samples from less sensitive body sites. (Peled, Wong, &
Gwalani,2002). In their study they evaluate subjects under different glycemic
states in comparison of glucose concentrations in samples that were gathered
from the palm and forearm to compare the gathered data from the finger. It
shows that the palm is like the finger, but the forearm is less perfuse. They also
identified palm as the comfortable testing site from the forearm concerning in
painless testing. At times of rapid glucose changes, the palm of the hand offers a
painless sampling site that compares well with the finger.
Past studies have suggested that the absence of delay between palm
glucose and fingertip glucose, even when glucose levels are changing rapidly.
However, at any given time point, there may be differences between palm and
fingertip glucose values because of glycemic instability and/or test methodology
(Kempe, Budd, Stern, Ellison, Saari, Adiletto & Horwitz, 2005). It has been
introduced in blood glucose monitoring to approve extracting sites other than
finger. The hand, arm and leg requires 0.3 L of blood as well as finger the
accustomed site. The first study is to compare the FreeStyle measurement to YSI
Model 2300 Stat Plus Glucose Analyzer plasma measurements using venous
blood, They visited 160 clinics of 120 particular subjects with type 1 and type 2
diabetes mellitus. The second study, simultaneous measurements were done on
the arm and finger taken for every 15 minutes for 6 hours. The regression of

equation was comparable, but the data was statistically significant greater at 95%
confidence interval. In studying the glucose changes, it was attributed to time
delay in the response of the gucose on the arm with the glucose response on the
finger (McGarraugh, Price, Schwartz & Weinstein,2001).
The author of Multiple daily self-glucose monitoring used a crossover
design to measure the mean of the blood glucose and glycosylated hemoglobin
of diabetic control and comparison of results were done during episodes of
frequent and infrequent capillary blood glucose monitoring. It was concluded that
compliant patients, ages 14-21 with type 1 diabetes mellitus, were motivated.
Regular self-glucose monitoring is the most crucial for a diabetic patients
glycemic control for long-term maintenance.
According to Journal of Diabetic Science & Technology they used a
randomized, open-label, two period, crossover study, they differentiated between
the two sites, fingertip and palm sites, to compare the comfort for Alternative site
testing with diabetic patients. As a result, majority of the diabetic patient desired
to continue Alternative site testing in between two lancing sites. However, only
few patients were satisfied using the palm lancing site because some difficulties
in inserting the needle, withdrawing blood samples, and it is not enough blood to
be place in the test strip. Patient suggested the used of palm for alternative site
testing, but they required more technological advances in Alternative site testing
on palm to reduce patient discomfort.

10

According Carter, Clarke, Cox, Frederick, & Pohl (1987) the authors of
Evaluating Clinical Accuracy of Systems for Self-Monitoring of Blood Glucose
reports about the self monitoring of blood glucose (SMBG) for statistical accuracy
of systems result may not be clinically useful. They developed an error and
analysis to determine the clinical accuracy of the SMBG.
These studies will greatly aid us in pursuing our study. It will also serve as
supporting evidences that state facts pertaining to diabetes and pain which is an
element that is present in this particular study.

Conceptual Background
This study about alternative lancing site for blood glucose testing that is
less painful can be associated with the different concepts and theories of pain.

11

The feeling of pain is displeasing caused by acute or excruciating stimuli. Pain is

a major issue in considering alternative lancing sites for blood glucose testing
since pricking a needle into one's fingertip is quite painful especially when it is
done often in a day. To help us understand more about pain, a variety of theories
about pain should be introduced.
This study is supported on the Gate Control theory that was proposed by
Melzack and Wall (1967) in an attempt to improve the early theories of pain.
According to this theory, pain stimulation is caused by fine, slow fibers that will
enter the dorsal horn of the spinal cord, and then other cells send the impulses
from the spinal cord up to the brain. These fine fibers are called T-cells. These
fibers hold an impact on the smaller fibers that will carry the pain stimulation. In
some cases they can inhibit the communication of stimulation, as for other cases
it can allow stimulation to be communicated toward the central nervous system.

12

FACTORS THAT OPEN AN CLOSE THE GATE:

Gender
Age
Site(palm or fingertip)

PAIN EXPERIENCED DEPENDING ON HOW FAR THE GATE IS OPENED OR CLOSE

GATE IN SPINAL CORD

13

Figure 2. Conceptual Framework of the Study

According to the theory, the gate can occasionally be overpowered by a

large number of fine activated fibers. In other words, the greater the level of pain
stimulation, the less sufficient the gate in blocking the communication of this
information.
Impulses from the small fibers that communicate to the brain can be
blocked by the large impulses. The large fibers stimulate the hypothetical "gate"
to open or close in response to pain stimulation.
When a great level of pain stimulation is present the gate can be
overwhelmed and is not able to block the communication of pain.

Melzack also added that there are three factors that causes the opening
and closing of the gates. First, the amount of activity in the pain fibers. Activity in
these fibers tends to open the gate. The stronger the harmful stimulation, the
more active the pain fibers is. Second, the amount of activity in other peripheral
fibers. Those fibers that hold information about safe stimuli or light irritation, such
as patting, rubbing, or gently scratching the skin. These are large-diameter fibers
called A-beta fibers. Activity in A-beta fibers tends to close the gate, forbidding
the perception of pain when a harmful stimulation exists.

14

This would explain why gently massaging or applying heat to sore muscles
decreases the pain felt. And lastly, Messages that derived from the brain.
Neurons in the brainstem and cortex have efferent pathways to the spinal cord,
and the impulses can send a command to open or close the gate. The effects of
some brain processes, such as those in anxiety or excitement, presumably have
a general influence, opening or closing the gate for all inputs from any areas of
the body. But the influence of the other brain processes may be very particular,
applying to only some inputs from certain parts of the body. The idea that brain
impulses influence the gating mechanism helps to explain why people who are
hypnotized or distracted by competing environmental stimuli may not notice the
pain of an injury.
By utilizing these theories we were able to determine factors that affected
pain stimulation during lancing the needle for blood glucose testing and also
helped us in determining the outcome of the study.

15

PROBLEM STATEMENT
This study sought to determine the preferred site of taking capillary blood
sugar in diabetic patients.
The following questions were answered throughout the course of this study:
1. What are the mean scores of pain after utilizing the Numeric Pain Rating Scale
in obtaining capillary blood sugar among?
1.1 Experimental group A
1.1.1. fingertips
1.1.2. palm
1.2 Experimental group B
1.2.1. fingertips
1.2.2. palm
2. Is there a significant difference between the two sites in terms of pain?

16

3. In light of the findings, what health actions on capillary blood sugar monitoring
can be recommended?

Alternative Hypothesis
There is a significant difference between capillary blood sugar taking on
two different sites: on palm and on fingertips, in terms of pain after capillary blood
sugar taking.

17

OPERATIONAL DEFINITION OF TERMS

There were terms that had been operationally defined, designed to provide
better understanding between the readers and the researchers and enumerated
the terms that belonged to the terminology of medical and nursing profession.
Alcohol Swab. used to clean the skin before pricking
Capillary Blood Sugar (CBS). blood sample collected by pricking the palm and
fingertips, use to measure blood glucose (sugar).
Clients Preferability. the ideal or desired choice of the subjects pertaining to the
site pricked whether on palm or on the fingertips.
Cotton balls. used to stop bleeding from minor punctures
Crying. to shred tears when in pain or suffering
Experimental group A. subjects who were pricked at the fingertips during taking
of capillary blood sugar for the first week and then at the palm for the succeeding
week.
Experimental group B. subjects who were pricked at the palm during taking of
capillary blood sugar for the first week and then at the fingertips for the
succeeding week.

18

Fingertips. the site that was pricked to establish a score for the level of pain felt
Frowning. facial expression showing disapproval or displeasure
Gate Control Theory. main theory utilized in this study wherein states that
severity of pain is influenced by the opening and closing of the hypothetical gate
system that can open or close the system to pain stimulation.
Glucometer. medical tool used in determining the relative concentration of blood
glucose
Glucometer strips. where the small drop of blood is placed which interfaces with
the digital meter
Grimacing. facial expression showing pain or uneasiness
Groaning. to make a deep sound indicating pain
Guarding body part. an act of defending a body after feeling intense pain
Lancet. pricking needle use to obtain drops of blood for testing
Lancet pen. aids in puncturing
Looking tense. express nervousness; rigid
Palm. the site that was pricked to establish a score for the level of pain felt that
will be used as the alternative testing site.
Rocking. to move back and forth; to sway a body part
Withdrawing to stimuli. an act of withdraw; to take back a body part
Whimpering. to utter a quiet cry; low protest or whining

19

SIGNIFICANCE OF THE STUDY

To identify the preferable site for capillary blood sugar monitoring with less
pain and more comfortable for them. This study is beneficial to:
Diabetic Patients. with the result of the study they can gain new knowledge and
use the new method in their self-monitoring and experience less pain.
Health Care Provider. will benefit from the study by gaining new knowledge and
enhancing skills that is essential in the management of care to the clients.
Department Of Health. will greatly help in disseminating the results of the study
and recommend it to both public and private hospitals, in which part of the hands
is more preferable and comfortable in Capillary Blood Sugar monitoring.
Public and Private Organizations. will help in disseminating the results and
recommend it to the community.
Hospital Administrations. are heads of hospital staff that will introduce the new
method to the members by the present study.
Future Researchers. the study can be used to open a new field for further
applied research studies. Which can give new knowledge that is useful to the
other researchers who would like to embark on a conduct of study of similar

20

nature.

CHAPTER 2
METHODOLOGIES

RESEARCH DESIGN
This study utilized a true experiment design with a qualitative element that
supported the study design. In a true experiment design researchers are active
agents not passive observers. It involves the properties of manipulation, control
and randomization. Random assignment was employed when subjects were
distributed to two experimental groups that were comparable at the outset. The
experimental groups utilized the crossover design. It is a design in which subjects
were exposed to more than one experimental condition. Crossover designs are
"balance", that means all of the subjects will have to receive the similar
treatments and that all subjects will participate at the same periods.

RESEARCH LOCALE
We gathered subjects from two communities specifically Qiuot Pardo and
J. Solon Drive, Lahug. We asked the subjects for their addresses and visited

21

their residences during the implementation of the study. The subjects resided
within the walls of Cebu City for easy access.

RESEARCH SAMPLING
The study utilized purposive sampling technique, a non-probability
sampling, wherein there was no involvement of selection by random method and
was a practical sampling design (Polit & Beck, 2012). The subjects were
thoroughly selected to provide sufficient data in order to obtain reliable results.

RESEARCH SUBJECTS
The twenty subjects needed in the study were selected based from an
established inclusion criteria: (1) diagnosed with Diabetes Mellitus type 1 or DM
type 2; (2) routinely takes Capillary blood sugar, once a day(OD); (3) residing in
Cebu City, and (4) without pain medications but if the patient is able to take pain
medications within the process of data gathering, the patient results will be
disregarded and along with these inclusion criteria there also exists an exclusion
criteria which prohibited an individual from being selected as a subject for the
study: (1) individuals with any dysfunction in the hands and (2) presence of
callus at the fingertip and palm site

22

RESEARCH INSTRUMENT
In this study, we utilized the methodologic triangulation which was the
combination of quantitative and qualitative methods in gathering data, wherein
quantitative data collection and analysis was supported with the qualitative data
collection and analysis. For quantitative method of data gathering Numeric Pain
Rating Scale was utilized to measure subjective experiences such as pain right
after pricking at the site for acquiring capillary blood sugar. The scale shows a
series of numbers ranging from one to ten. Subjects chose a number from one to
ten that best described how they felt. For the qualitative method of gathering
data, after the completion of the three day procedure, we interviewed the
subjects to obtain their perception towards the pain they felt during the
procedure.
During implementation of the study, the essential tools used were the
following:

Figure 3. Lancet

Figure 4. OneTouch Lancet

Photo credit: http://stores.hhd1.com/diabetic/ (fig3)

23

http://brokenpancreas.org/reviews/delica/ (fig4)

Figure 5. Cotton balls

Figure 6. Glucometer strips

Photo credit: http://dir.indiamart.com/impcat/cotton-balls.html (fig5)

http://www.weiku.com/products/10331127/1x18w_Electronic_Ballast_TUV
_CE_CB_RoHS_for_fluorescent_lamp.html (fig6)

Figure 7. Alcohol Swab

Figure 8. Glucometer

Photo credits: http://terapisihathuffaz.blogspot.com/ (fig7)

http://www.oxygenplusmichigan.com/index.php?

24

main_page=products_all&disp_order=1&page=5 (fig8)

DATA GATHERING PROCEDURE

Preliminary Preparations
Before proceeding to actual data gathering, a transmittal letter was
submitted to the Dean of the University of San Jose-Recoletos (USJR) College of
Nursing for approval. Thereafter, a proposal letter addressed to the Head of
USJR Research Institute was sent to ask permission to conduct the study. We
also

secured

an

approval

from

lawyer

for

ethical

considerations.

Actual Data Gathering

As soon as the proposal study was approved, we looked for the subjects
within Cebu City while utilizing purposive sampling technique. Then, the subjects
were provided with informed consents. This thoroughly explained the nature of
the study, rights of the subjects, and risks and benefits. We also entertained
questions and concerns from the subjects. Afterwards we began to implement
the procedures. We visited the subjects in conducting the step-by-step process of
the experiment and obtained the desired data needed for the completion of the
study.

25

Procedure

1) A transmittal letter was submitted to

Rationale

transmittal letters are sent for

the dean of the University of San Jose-

approval

Recoletos(USJR) College of Nursing.

research

of

conducting

the

Thereafter, a proposal letter addressed

to the Head of USJR research institute.

2) We also secured an approval from a

lawyer.

approval of lawyer is necessary

for ethical considerations

3) The subjects were provided with

informed consents.

informed

consents

thoroughly

explained the nature of the study,

rights of the subjects, and risks
and benefits

26

A
4) Experimental group A was pricked at

A
-

with the use of Numeric pain

the fingertips during taking of capillary

scale we were able to determine

blood sugar. After pricking at the

the level of pain felt by the

fingertip the subjects then rated the

subject and it then served as a

pain felt using Numeric Pain Rating

quantitative evidence

Scale.

5) The subjects then continued this

procedure for 3 days.

by letting the subjects conduct

the procedure consistently for
days we were able to obtain the
mean scores of pain felt by the
subjects which were used in
determining an accurate score of
pain. It also ensured the validity
of the scores because the longer
the subjects are exposed to pain,
the higher their pain tolerance
will become

27

6) After 3 days of conducting capillary

blood

sugar

at

the

fingertips

we

the

subjects

valuable

in

answers

were

determining

interviewed the subjects in regards to

subjective evidence since pain is

their perception of the pain felt.

such a complex feeling that

quantitative evidences are not
enough to measure its severity
-

7)

The

next

days,

the

in doing so, were able to obtain

same

data on the different site which

procedure was conducted but at a

was used for contrasting the

different site which was the palm.

level of pain felt at the 2 different

sites

28

Procedure

Rationale
B

B
8) Experimental group B was pricked at

with the use of Numeric pain

the palm during taking of capillary

scale we were able to determine

blood sugar. After they were pricked at

the level of pain felt by the

the palm, the subjects rated the pain

subject and it served as a

felt using Numeric Pain Rating Scale.

quantitative evidence

9)

The

subjects

procedure for 3 days.

continued

this

by letting the subjects conduct

the procedure consistently for 3
days we were able to obtain the
mean scores of pain felt by the
subjects which was used in
determining an accurate score of
pain. It also ensured the validity
of the scores because the longer
the subjects are exposed to pain
the higher their pain tolerance
will become

29

10) After 3 days of conducting capillary

blood

sugar

at

the

fingertips

the

subjects

answers

were

we
valuable

in

determining

interviewed the subjects in regards to

subjective evidence since pain is
their perception of the pain felt.
such a complex feeling that
quantitative evidences are not
enough to measure its severity
11) The next 3 days, the same
-

in doing so, we were be able to

procedure was conducted but at a

obtain data on the different site
different site which was the fingertip.
which was used for contrasting
the level of pain felt at the 2
12)

The

data

gathered

from

the

different sites
mean scores of the data was

procedures was collected, analyzed

used

in

completion

and interpreted.

research. T-tests and arithmetic

mean was utilized

Table 1. Data Gathering Procedure

CAPILLARY BLOOD SUGAR TESTING PROCEDURE

of

the

30

Procedure

Rationale

1. Gathered all required equipment, the

to guarantee accuracy of the

following was performed:

result. The quality control and

a)

checks have been carried out in

Ensured that test strips were available

order to ensure the safety of the

and within expiry date, if previously

patient; this should be performed

opened, ensured they have been re-

as a daily event for areas that

sealed and not left exposed to the air.

are required to use the machine

b)

on patients, or weekly if use of

That the monitor and the test strips

the machine is not required

have been calibrated together, if a new

set of strips is needed, the monitor will
need re-calibrating
c)
That a high and low internal quality
control test had been accomplished
prior to the patient sample being
measured,

and

this

had

been

documented in the log book and

signed.
d)

31

An

appropriate

disposable

lancing

device had been selected.

2. Explained the procedure to the

to reduce the risk of needle stick

injury and cross infection

patient, some patients may want to

the patient should be aware of

the procedure in order to allay

look away at the sight of the needle

some of his/her anxieties, and to

be able to co-operate in the
procedure
-

3. Patients were advised to wash and

to ensure a non-contaminated
result

dry their hands thoroughly prior to

blood sampling. The use of alcohol rub
was avoided. Advised patients to keep
their hands warm until sampling had
been performed.

4. Instructed the patient to sit or lie

to encourage good blood flow

to make sure that the patients

down.

5. Washed our hands, and applied

protective non-sterile gloves

safety, as

some patients may

32

feel faint when blood is taken

6. Used a disposable lancet

to prevent the risk of crossinfection. To minimize the risk of

contamination and sharps injury.

7. Took a blood sample from the side of

the finger using the lancet, ensuring

to prevent the risk of cross

infection.

that the site of piercing was rotated.

Disposed of lancet immediately into
sharps box.
Avoided repeated use of the index

the side of the finger is used, as

finger and thumb. Allowed 5 seconds to

it is less painful and easier to

elapse after lancing the finger rather

access a hanging droplet of

than to squeeze at the site of puncture,

blood and to reduce the risk of

milked the blood down the hand

needle stick injury and comply

towards the finger.

with waste regulation, the site is

rotated to decrease the threat of
infection from multiple stabbing,
the areas becoming toughened
-

8. Touched the drop to the front edge of

and to reduce pain

the window on the test strip

33

the yellow window of the test strip. Did

allows verification of a correctly

not put blood on top of the strip.

dosed strip. Inaccurate results

Ensured the yellow window was full

may be obtained

with blood.

9. Once the result was attained,

recorded immediately, Informed Senior

to guarantee the accuracy of the

result

staff of any blood results not within the

normal parameters.

10. Switched off the meter.

-

to

demonstrate

the

end

of

testing.
to reduce the risk of cross-

11. Disposed of waste appropriately.

infection and comply with Trust

Removed gloves and dispose.

waste policy

Table 2. CAPILLARY BLOOD SUGAR TESTING PROCEDURE

34

Figure 9. The different testing sites: (A) fingertips (B) palm

35

Ethical Considerations
Informed consent is a legal written document that contains all the essential
information in line to the study as well as giving the subjects the time to decide
and consider in partaking.
They were oriented on the rights of subject to self-determination which
means that the subject has the right to make a decision that is voluntary and is
free from coercion as to whether or not to participate or withdraw from the study.
They also knew about the right to full disclosure which means that the subjects
have the right to know everything in regards with the study. We informed the
subjects of the risk and the benefits of the study. We also told them about their
right to privacy and dignity which means that the subjects have the right to
choose what they want to be done to them and has the right to control the
information about them is to be shared or not to be shared with others.
Anonymity and confidentiality had been introduced to them which mean that the
subjects have the right to be respected of the gathered information about them
kept in a manner that only they and we will know; they also have the right to not
let others know that they are participating in the study. Fair treatment was also
observed. The subjects have the right to be treated equally in the course of the
study with no favoritism or misjudgment that came from us. They were protected
from discomfort and harm, they have the right to be protected from any form of
threats and to be assured that harm will be minimized while maximizing the
potential benefits of the study.

36

STATISTICAL TREATMENT
In analyzing and interpreting the data, we utilized the following formulas:
Frequency was used to show the number of observations of pain scores.
Arithmetic mean was used to express the average of the scores of pain in the
data set.
Paired t- tests was used to differentiate the means of two sets of scores which
are not independent.

t- Test for Independent Groups

EXPERIMENTAL GROUP A vs EXPERIMENTAL GROUP B
t- Test for Dependent Groups
EXPERIMENTAL GROUP A
Fingertips versus Palm
EXPERIMENTAL GROUP B
Palm versus Fingertips

37

SCOPES AND LIMITATIONS

The extent of this study is only up to subjects whose characteristics were
included in any of these exclusion criteria: people outside Cebu, people who
were algophobic (fear of pain), people who were hypersensitive to pain due to
personal reasons, diabetic patients who were taking pain medication, patients
with a terminal disease and patients with psychiatric disorder.
Every study has limitations. In this study, one of the uncontrollable
elements are the non-compliance of fasting obligations of capillary blood sugar
taking, second is the inevitable taking of CBS within only an hour of all 20
subjects due to different residences of Experimental group A from Experimental
group B with the use of only one glucometer set.

38

CHAPTER 3
PRESENTATION, ANALYSIS
This chapter presents, analyzes and interprets data. It sought to answer the
research study problems being formulated and proposed.
The researchers had 20 subjects and were chosen through inclusion criteria
made by the researchers. 10 subjects were taken from Quiot Pardo and the other
10 were taken from Lahug. The subjects ages were ranged from 25 to 60 years.
There were 4 females and 5 males situated in Quiot Pardo and 9 females and 2
males situated in Lahug. Our subjects are diagnosed with diabetes either type 1
or type 2 diabetes. The subjects were divided into two groups which is the
Experimental group A and Experimental group B. Experimental group A is
composed of 10 members and Experimental group B is composed of 10
members. Moreover, the subjects had no known skin diseases, did not take
medications for pain prior and during the procedure. The 20 subjects were able
to finish the procedure in 6 days.

39

Table 1. GROUP A: MEAN SCORES OF PAIN LEVEL

Subject 1
Subject 2
Subject 3
Subject 4
Subject 5
Subject 6
Subject 7
Subject 8
Subject 9
Subject 10
Average

FINGER
2.67
4.33
0.67
3.33
2.67
5.00
4.67
3.33
2.67
2.00
3.13

PALM
1.00
5.00
1.33
3.33
0.33
2.00
2.33
5.00
1.33
1.67
2.33

This table shows the mean scores of the subjects. The first table shows the
mean scores of subjects from Group A. Based on the result, 7 out of 10 from the
subjects of Group A scored higher on the fingertip than the palm. With the mean
score of 3.13 on the fingertip and 2.33 on palm, it simply means that subjects in
Group A felt more pain on the fingertip than on the palm. Based on the survey
questionnaire 70% of the subjects from group A claimed that the fingertip site
hurts more than the palm site. Based on our observational assessment tool, 3 out
of 10 subjects showed signs of mild to moderate pain while being pricked at the
finger. On the other site only 1 out 10 subjects showed sign of moderate pain
which suggests that more pain in the fingertip was felt. The fingertips has
numerous nerve endings that makes routine capillary blood sugar testing, painful
and can lead to damage of tissues in the local areas (Dale L., 2010).
Table 2. GROUP B: MEAN SCORES OF PAIN LEVEL

40

Subject 11
Subject 12
Subject 13
Subject 14
Subject 15
Subject 16
Subject 17
Subject 18
Subject 19
Subject 20
Average

PALM
1.67
0.67
2.33
2.67
3.00
3.00
2.67
2.00
2.33
1.67
2.20

FINGER
1.33
1.67
3.00
4.00
3.00
2.33
5.00
1.67
2.33
1.33
2.57

This table shows the mean scores of subjects from Group B. Based on the
result, from the 10 subjects they felt more pain on the fingertip with the mean
score of 2.57. Based on the survey questionnaire 60% of subjects said that they
felt more pain on the fingertip which reinforces the idea that the fingertip site is
more painful. Our observational assessment tool also showed that 3 out of 10
showed signs of mild to moderate pain on fingertip and only 1 out of 10 showed
signs of moderate pain on palm site which supports the result that more pain felt
on the fingertip than the palm. Nerve ending has millions of points in your body
surface that will send messages to your brain during sensations such as pain,
heat or cold. Anatomically the palm has less nerve endings than the fingertips
(Wesley Norman, 1999)

Table 3.GROUP A & B: MEAN SCORES OF PAIN LEVEL

Group A

FINGER
3.13

PALM
2.33

41

Group B
Average

2.57
2.91

2.20
2.27

This table shows the average of the mean scores of the palm and the
average of the mean scores of the fingertips from group A and B. According to
the result, the fingertips is still on the lead with the average of 2.91, the palm had
an average of 2.27 indicating that the both groups agree that the level of pain felt
on the fingertips is higher than the level of pain felt at the palm. Also, studies
have shown that using the palm (at the base of the thumb) is less painful (Dale,
L., 2008).

Table 4. PAIRED t-TEST: MEAN SCORES OF FINGER AND PALM

Group A
Group B
Group A & B

p-value
0.138
0.255
0.776

This table shows the p-values in relation of fingertip and palms difference
in level of pain felt. A p-value tells you how likely it is that such a difference would
appear in two samples from the same population. The lower the p-value is, the
less likely it is that you would find a difference. A cut-off point also called as
significance level is usually set at 0.05 or 0.01(Statistics Tutorial, 2010). Group A
with a p-value of 0.138 and Group B with a p-value of 0.255 showed no
siginificant difference. Relationship between Group A and B with a p-value of
0.776 showed that there is no significant difference.

42

Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such damage. Pain is
subjective, and it varies both with the physical state of the individual and his/her
state of mind (Merskey, H.,1991). Since pain is subjective, utilization of a survey
questionnaire was used to support the objective data obtained from the scores of
pain scale. Based on the results on our survey, 13 out of 20 subjects verbalized
that finger hurts more than the palm. And in terms of preference 14 out of 20
subjects claimed that they prefer finger as a lancing site simply because they
were used to prick at the finger site.

To obtain more comprehensive data, we ventured an evidence based

approach with the use of an observational assessment tool. Based on the results
from the observational assessment tool, 6 out of 20 subjects showed signs of
mild to moderate pain felt in the finger and only 2 out of 20 subjects showed
signs of moderate pain felt in the palm. This simply suggests that there were
more pain felt in the finger than the palm.

43

CHAPTER 4
SUMMARY OF FINDINGS
The researchers conducted the therapy for 6 days. With that span of time we
were able to gather the desired data needed for the completion of the study.
The palm is really a less painful site in taking capillary blood sugar than the
fingertips. The average of the mean scores of pain from experimental group A
and Experimental group B both agreed that the fingertips provide a higher pain
level than the palm. Majority of the subjects rated the pain level felt at the
fingertips higher than the pain level felt at the palm, this is supported by the pain
assessment questionnaires which produced a result that the fingertips is a more
painful site in taking capillary blood sugar than the palm. Although the results,
favored the palm as the new testing site for Capillary blood sugar, majority still
voted for the fingertips as the site they prefer to prick at during capillary blood
sugar testing. Most of the subjects who preferred the fingertips said that they got
used to the fingertips as the testing site and that blood flows out faster in the
fingertips than from the palm.
After computing all the mean measurements of level of pain felt in finger
and palm it revealed the following scores, 2.91 for the finger and 2.27 for the

44

palm which simply means that more pain felt on finger.

To provide some support to the objective scores of pain felt in the finger
and palm, analysis of the survey questionnaire then followed. 13 out of 20
subjects agreed that finger hurts more than the palm. Subjective testimonies from
the subjects reinforces the result from pain scale that finger has a higher level of
pain. But when subjects were asked for their preference in CBS taking, 14 out of
20 claimed that they prefer the finger site for they are used to it and said that the
blood flows faster in the finger than the palm.
In order to obtain more comprehensive result an observational assessment
tool was utilized which serves as an evidenced based approach in gathering
data. 6 out of 20 subjects showed signs of feeling mild to moderate pain in the
fingers and only 2 of 20 subjects showed signs of feeling moderate pain in the
palm. It tells us that the finger site is more painful than the other.
Paired t-test was utilized to determine the whether there was a significant
difference between the finger and palm in terms of pain. Paired t-test within the
Group A was first computed with a p-value of 0.138 which shows no significant
difference. Then within the Group B with a p-value of 0.255 also shows no
significant difference. And then paired t-test between the Group A and Group B
was computed with a p-value of 0.776 which also means that there was no
significant difference between the two sites.

45

CONCLUSION
In the findings of the study, the mean scores of pain felt in the finger is
equal to 2.665 and the mean scores of pain felt in the palm amounted to 2.450
which concludes that there were more pain felt in the finger than the palm. But
the overall data p-value is equal to 0.776 which is more than the significance
level. Therefore, there is no significant difference between capillary blood sugar
taking on two different sites which is the palm and the finger in terms of pain
leading to the rejection of the alternative hypothesis that was established. But
although there was no significant difference between the two sites, clients
preference in taking CBS favors the finger site than the palm. Through this study
it confirmed that there is no significant difference in CBS taking between finger
and palm site.

46

RECOMMENDATIONS
Based on the results of our study, we recommend the following for future
researchers:
1. A replication study with more numbers of subjects. The replication of this
study would strengthen the findings of the previous researchers.
2. A comparative study on the most accessible site in obtaining blood
between the two proposed lancing sites fingertip and palm.
3. A comparative study on accuracy of the blood sugar levels between
fingertip and palm.
4. A study on other possible lancing sites aside from the proposed sites
fingertip and palm.
5. More studies need to be done using different function devices and more
sites to be investigated.

47

BIBLIOGRAPHIES
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glucose).Retrieved from http://www.diabetes.org/living-with-diabetes/treatmentand-care/blood-glucose-control/hyperglycemia.html
Atkinson, M. A., & Eisenbarth, G. S. (2001). Type 1 diabetes: new perspectives
on disease pathogenesis and treatment. The Lancet, 358(9277), 221-229.
Bloomgarden, Z. T., MD (2003). Blood Glucose Monitoring. Medscape

Clarke, W. L., Cox, D., Gonder-Frederick, L. A., Carter, W., & Pohl, S. L. (1987).
Evaluating clinical accuracy of systems for self-monitoring of blood
glucose. Diabetes care, 10(5), 622-628.
Department of Internal Medicine | University of Michigan Health System. (n.d.)
(2014). Division of Metabolism, Endocrinology & Diabetes (MEND). Retrieved
from http://www.med.umich.edu/intmed/endocrinology/patients/Type2.htm
Dufaitre-Patouraux, L., Djemli, K., & Vague, P. (2004). How and when to use an
alternative site in self-monitoring of blood glucose. Diabetes & metabolism,30(5),
471-477.
GrillWikell, H., Annersten, M., & Frid, A. (2005). Pain in connection with capillary
blood test at different sites in the palm. European Diabetes Nursing, 2(2), 65-68.
Ito, T., Kamoi, K., Minagawa, S., Kimura, K., & Kobayashi, A. (2010). Patient
Perceptions of Different Lancing Sites for Self-Monitoring of Blood Glucose: A
Comparison of Fingertip Site with Palm Site Using the OneTouch Ultra Blood
Glucose Monitoring System. Journal of diabetes science and technology,4(4),
906-910.
Kempe, K. C., Budd, D., Stern, M., Ellison, J. M., Saari, L. A., Adiletto, C. A., ... &
Horwitz, D. L. (2005). Palm Glucose Readings Compared with Fingertip
Readings Under Steady and Dynamic Glycemic Conditions, Using the
OneTouch Ultra Blood Glucose Monitoring System. Diabetes technology &

48

therapeutics, 7(6), 916-926.

Lapolla, A., Fedele, D., Reitano, R., Aric, N. C., Seraglia, R., Traldi, P., ... &
Tonani, R. (2004). Enzymatic digestion and mass spectrometry in the study of
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McGarraugh, G., Price, D., Schwartz, S., & Weinstein, R. (2001). Physiological
influences
on
off-finger
glucose
testing. Diabetes
Technology
&
Therapeutics,3(3), 367-376.
Meguro, S., Funae, O., Hosokawa, K., & Atsumi, Y. (2005). Hypoglycemia
detection rate differs among blood glucose monitoring sites. Diabetes care,28(3),
708-709.
Melzack, R., & Wall, P. D. (1967). Pain mechanisms: a new theory. Survey of
Anesthesiology, 11(2), 89-90.
Nordquist, L., Shimada, K., Ishii, T., Furuya, D. T., Kamikawa, A., & Kimura, K.
(2010). Proinsulin Cpeptide prevents type1 diabetesinduced decrease of renal
Na+K+ATPase 1subunit in rats. Diabetes/metabolism research and
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Medical-surgical Nursing. Lippincott Williams & Wilkins.
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capillary blood samples obtained from a variety of body sites. Diabetes
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Stppler, M. C. Medical Editor.
Tamborlane, W. V., Beck, R. W., Bode, B. W., Buckingham, B., Chase, H. P.,
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49

1464-1476.

APPENDICES
APPENDIX A - Tools
A. NUMERIC PAIN RATING SCALE

Figure 10. Numeric pain rating scale

B. Data Gathering Tool

DAY 1
A.

Experimental

DAY 2

Fingertips
Palm
B. Experimental

Fingertips
Palm
Table 3. Data Gathering Tool

DAY3

50

APPENDIX B Transmittal Letter to the Dean of College of Nursing

JANUS S. FUERTES, RN MAN

Dean, College of Nursing
University Of San Jose-Recoletos
Dear Mr. Fuertes,
Good day!
We, the BSN-3 students of University of San Jose-Recoletos would like to
request for your approval in conducting an experimental study entitled Clients
Preference in capillary blood sugar testing: fingertips or palm? as partial
fulfillment of the subject Nursing Research I.
In connection with this, we humbly ask for your support with regards to this
concern.
Rest assured that the results will be treated with utmost confidentiality and for
study purposes only.
Thank you very much and we will look forward to your favorable response. Your
cooperation would go a long way in the success of the study. Adelante!

Sincerely Yours,
JONH NICHOLE C. AVELINO
Group Leader

Noted By:
TONETTE M. VILLANUEVA RN, MAN

51

Research Team Adviser

APPENDIX C- Informed Consent (English)

APPENDIX D- Informed Consent (Cebuano)
APPENDIX E- Researchers Made Tools

52

APPENDIX F- CBS monitoring procedure (Experimental Group A)

PAIN SCALE
INSTRUCTIONS: From the scale of 0-10, zero as no pain and 10 as the worst possible pain, we
want you to give us an estimate of the severity of the pain you felt during the CBS taking
procedure in the finger and palm.
(Paghuman sa CBS, eskori ang sakit nga imong nabati gikan sa 0-10 ug ang 0 ang walay sakit
ug 10 ang pinakasakit.)

FINGER
DAY 1
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 2
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 3
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

53

PAIN SCALE
INSTRUCTIONS: From the scale of 0-10, zero as no pain and 10 as the worst possible pain, we
want you to give us an estimate of the severity of the pain you felt during the CBS taking
procedure in the finger and palm.
(Paghuman sa CBS, eskori ang sakit nga imong nabati gikan sa 0-10 ug ang 0 ang walay sakit
ug 10 ang pinakasakit.)

PALM
DAY 4
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 5
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 6
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

54

APPENDIX G- CBS monitoring procedure (Experimental Group B)

PAIN SCALE
INSTRUCTIONS: From the scale of 0-10, zero as no pain and 10 as the worst possible pain, we
want you to give us an estimate of the severity of the pain you felt during the CBS taking
procedure in the finger and palm.
(Paghuman sa CBS, eskori ang sakit nga imong nabati gikan sa 0-10 ug ang 0 ang walay sakit
ug 10 ang pinakasakit.)

PALM
DAY 1
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 2
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 3
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

55

PAIN SCALE
INSTRUCTIONS: From the scale of 0-10, zero as no pain and 10 as the worst possible pain, we
want you to give us an estimate of the severity of the pain you felt during the CBS taking
procedure in the finger and palm.
(Paghuman sa CBS, eskori ang sakit nga imong nabati gikan sa 0-10 ug ang 0 ang walay sakit
ug 10 ang pinakasakit.)

FINGER
DAY 4
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 5
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

DAY 6
0
1
No pain
(Walay Sakit)

10
Worst
possible
pain
(pinaka sakit)

56

APPENDIX H- Timetable
APPENDIX I- Personnel
APPENDIX- J- Expenses

57

APPENDIX K- Curriculum Vitae

Name
Contact Number
Email Address
Date of Birth
Place of Birth
Civil Status
Religion

:
:
:
:
:
:
:

Pesical Krystel P.
09332469830
krys_pes@yahoo.com
December 14,1994
Cebu City
Single
Roman Catholic

Educational Background
Tertiary
Secondary
Elementary

:
:
:

University of San Jose-Recoletos

Saint Marys Academy of San Nicolas
Cherubs Academy

Membership
Nursing Student Council (2011- present)

Seminars and Trainings Attended

Medical Tourism
Drug Education and HIV Awareness Seminar

58

Nursing Core Competency Standards and NLE Test Framework

Ethical Issues in Nursing
Nutrition and Diet Therapy
1st International Recoletos Education Congress

Motto: Expect Nothing, Appreciate Everything