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Prevention and reduction of pain,

bruise and hematoma by 'Moist Ice Pack' application


on the site of subcutaneous heparin injection
Chinnamma Varghese, Indarjit Walia, Yash Paul Sharma, Sukhpal Kaur
Abstract : Health status of individuals may be positively influenced by their well-being and
experience of comfort. The relationship between comfort and health status must be known by
nurses to initiate any term of deliberate action. Subcutaneous heparin is prescribed for impaired
mobility or prolonged bed rest. It is an extremely important part of the treatment regime for many
hospitalized and non-hospitalized patients. 1 Use of heparin as part of the patients' anticoagulant
therapy is one intervention that can be implemented to prevent the formation of thrombi.1 Subcutaneous
administration of unfractionated and low molecular weight heparin has shown to cause pain, bruising
and hematoma at the injection site by interfering with the body's clotting mechanism. 2-3 Injection site
pain, bruising and hematoma are often the result of local tissue damage that occurs during the
administration of heparin solution.2 The present study was taken up with the objective to study the
prevention and reduction of pain, bruise and hematoma by 'Moist Ice Pack' application on the site of
subcutaneous heparin injection administered to the patients. The sample size consisted of 100
injection sites each in the experimental and control group respectively. Recognizing the physiological
responses of the cell/ tissue to injury or trauma, the 'Moist Ice Pack' procedure was performed for 5
minutes at the subcutaneous heparin injection site twice daily for three days in the experimental
group. Assessment of pain, bruise and hematoma were carried out at 12, 48 and 72 hours in both the
groups. Results were statistically significant in favour of the use of moist ice pack while comparing
the pain and bruise at subcutaneous injection site between experimental and control group at 12, 48
and 72 hours in the current study. (p<0.05 & p< 0.01).

Key Words :
Pain, bruise, hematoma, moist ice pack.
Correspondence at :
Chinnamma Varghese
Holy Family Hospital, Sadaquat Ashram P.O.
Patna 10, Bihar.

Introduction
Individuals get hospitalized for a wide
range of acute illnesses and injuries. Nurses
are advocates for patient safety. They must
do what is in the patient's best interest while
causing the least harm or distress. However,
at times, and with the best intentions of

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139

nursing staff, varying degrees of discomfort


and bruising are unavoidable side effect of
patient's medical treatment. 2-3 Nurses are
routinely at the bedside to provide care,
comfort and information to the patients. This
pressure will cause nursing professionals to
explore ways to expedite a patient through the
system while maintaining a safe environment
through discipline, determination, focus and
patience. The subcutaneous administration of
the anticoagulant heparin sodium is a
frequently per formed nursing task. Pain,
bruise and hematomas are most common
complications detected at subcutaneous
injection site of heparin among the patients.
Pain at the injection site and bruising are likely
consequences of local tissue trauma that
occur during administration of subcutaneous
heparin injections. These injection site
problems cause disturbance to patients; this
can result in the avoidance of future injections
and a decrease in the potential number of
injection sites of heparin.3 Hadley, Chang and
Rogers (1996) have reported that up to 90%
individuals develop pain, br uise
and hematomas from subcutaneous
administration of heparin.4
Bugaj (1975) reported that the cooling
and analgesic effect of applying ice to the skin
is ver y beneficial, causing a numbing
sensation and relieves pain.5 This creates a
challenge for the nurses attempting to
minimize hematoma and bruise formation and

patient discomfor t during the treatment


regime. 6 In order to deal with the
complications review of literature suggest that
ice application at the injection site is effective
in preventing and reducing pain, hematoma
and br uise. 6 The primar y physiological
responses of ice pack application results in
reducing the initial inflammatory response to
trauma, thus minimizing the barriers to wound
healing and facilitate tissue repair.7
Physiological findings indicate that
topical cold application has much greater
potential for restorative, therapeutic effect than
topical heat, which has only palliative effect.
By educating and encouraging patients in the
self-application of these modalities the nurse
can promote self - efficacy in health care by
providing an alternative to reliance on
prescription. Since patients can receive any
number of subcutaneous injections, any
procedure that can be shown to reduce
bruising and hematoma caused by heparin
will give nurses more potential sites for future
injections and promote patient confidence for
their caregivers.7 Many studies have shown
great variations in the recommendations for
prevention and reduction of pain, bruise and
hematoma at subcutaneous heparin injection
site. In India no study has been conducted till
date. Therefore a quasi-experimental study
was undertaken with the objective to prevent
and reduce pain, bruise and hematoma by
'moist ice pack' application on the site of
subcutaneous heparin injection.

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140

Materials and methods


The study was conducted in Coronary
Care Unit & Cardio Thoracic Unit, Nehru
Hospital, Post Graduate Institute of Medical
Education and Research, Chandigarh in the
months of January and February 2006. All
the injection sites (236) of patients receiving
subcutaneous heparin admitted in coronary
care unit and cardio thoracic unit during the
study period were included in the study. Study
Sample comprised of 200 injection sites of
the selected patients. Simple random method
was used to randomize the patients to be
included in the experimental or control group.
Experimental group was selected as even
number and control group was as odd
number. The sample size consisted of 100
injection sites each in the experimental and
control group respectively. Concepts of this
study were based on the "Twenty One Nursing
Problems by Faye Glenn Abdellah".9
Data was collected by using Interview
Schedule and Assessment Proformas. The
assessment proforma comprised of a
numerical pain rating scale from 0 to 10
measurements in which 0 score indicated no
pain, 1-3 mild, 4-6 moderate, and 7-10 score
indicated severe pain. This scale was used to
evaluate the intensity of pain at the injection
site experienced by the study subjects on the
1st day i.e.12 hours af ter the first
subcutaneous heparin injection, at 48 hours,

and at 72 hours. The subjects in the


experimental group were administered 'moist
ice pack' for 5 minutes twice daily for 3 days.
The outline of various measurements
of bruise and hematoma were traced on a
transparency. The injection sites were marked
around with a marker pen. The traced out
outlines placed on the injection site were used
to measure the bruises and hematomas.
Measurement of bruise was calculated in mm2
by multiplying the maximum length and
breadth. The bruise size above 5 mm2 was
considered as large, between 2-5 mm2 as
small, and below 2-5 mm2 was considered
as no bruise. Hematomas were measured in
cms considering the maximum width, and the
measurement above 1.0 cm was considered
as large and between 0.2-1.0 cm as medium.
The other two measurements were pinpoint,
and no hematoma. 4 Bruise and hematoma
were measured on the 1st day i.e. at 12 hours
after the first subcutaneous heparin injection,
at 48 hours and at 72 hours in both the
groups. The data was analyzed as per
objectives by applying both descriptive and
inferential statistics.
Results
Mean age S.D. of the subjects was
52.60 17.24 & 59.32 15.41 in
experimental and control group respectively
with range between 20-92 and 22-87

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141

Table 1 : Age wise distribution of the subject


Age in years

Expt. Group
n=100

Control Group
n=100

20-30

16

31-40

41-50

16

20

51-60

24

19

61-70

20

20

71-80

13

26

81>

Range

20-92

22-87

Mean SD

52.6017.24

59.3215.41

Maximum numbers of subjects i.e. 24%


in experimental group were between 51-60
years and in control group (26%) were
between 71-80 years. Both the groups had
20% subjects each between 61-70 years. Both
the groups were comparable. (Table1)
Out of the total subjects 57% were male
in experimental and 67% in control group.
For ty-three percent and 33% in both the
groups were females. Both in experimental
and control group 41% & 39% respectively
were illiterate. About one third of the subjects

in both the groups i.e. 35% & 30% respectively


had completed matric. Remaining subjects
were graduates or postgraduates in both the
groups. Majority of the subjects i.e. 38% in
experimental and 53% in control group had
coronary ar tery disease. Twenty percent
subjects in experimental and 14% in control
group had complete hear t block. Sixteen
percent subjects in experimental and 17% in
control group were suffering from Myocardial
Infarction. Experimental group had 14% of
subjects with Rheumatic Heart Disease where
as control group had only 3%. (Fig. 1)

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142

100

Experimental Group
Control Group

80
60
40
20

ar
r
nm ied
ar
rie
d

Ill
i te
ra
te
M
a
G tric
ra
d
PG ua
&A te
bo
ve
Sk
ille
Un
d
sk W
ille or
d ker
W
Pr
o
of rke
es
r
s
H ion
ou al
se
w
i fe

M
a
Fe le
m
al
e

% of Study Subjects

120

Figure 1: Distribution of Subjects as per Sex, Educational Status, Occupation and Marital
Status

The comparison of pain, bruise and


hematoma at subcutaneous heparin injection
sites in both the groups revealed that at 12
hours 12% injection sites of the subjects in
experimental group developed severe pain
where as in the control group 8% experienced
severe pain (p< 0.05). For ty six percent
developed moderate pain in the experimental
group while in the control group 20% had
moderate pain at 12 hours (p<0.05). At 48
hours 25% injection sites of the subjects in
experimental group and 28% in control group
experienced moderate pain (p>0.05). Only 3%
had moderate pain in the experimental group
hours (p <0.05). (Table2)
At 12 hours only 4 % injection sites of
the subjects in the experimental group had
large bruises where as 12 % in control group
had large br uises. Eight percent in
experimental group and 9% in control group
had small bruises. No bruise was observed

in 88% of the injection sites of the subjects in


the experimental and 79% in the control group
at 12 hours. In the control group 23%
injection sites of the subjects had large bruises
at 48 hours where as only 7% had it in
experimental group. Seventy seven percent
of the injection sites of the subjects in the
experimental and 64 % in the control group
had no bruise at 48 hours (p<0.05). At 72
hours only 4% in the experimental group
developed large bruise where as in the control
group there were 26 % who developed large
bruises. Majority of the injection sites of the
subjects (86%) did not develop any bruise in
the experimental group and 54% had no
bruise in the control group at 72 hours (p<
0.05). (Table2)
Majority of the subjects did not develop
hematomas in experimental and control
groups (p>0.05). (Table 2)

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144

46
40
2

Moderate

Mild

No pain

8
88

Small

No Bruise

2
98

Medium

Pin point

No hematoma

NS=Not Significant

Large

Hematoma

Large

Bruise

12

96

79

12

11

61

20

12 hours
Expt.
Control
n=100
n=100

Severe

Pain

Variables

NS

NS

P<0.05

Df = 3

21.64

X2

98

77

16

14

61

25

Expt.
n=100

94

64

13

23

62

28

48 hours
Control
n=100

NS

p<0.05

df=2

10.04

NS

X2

99

86

10

66

31

Expt.
n=100

Table 2 : Comparison of pain, bruise and hematoma at injection sites in both groups

94

54

20

26

57

35

72 hours
Control
n=100

NS

p<0.05

df=2

26.78

P<0.01

df=3

83.31

X2

N=200

Figure 2 & 3 depict the distribution of


pain at 12, 48 and at 72 hours in experimental
and control groups. The number of subjects
in the experimental group who experienced
pain at the injection site had been gradually
decreasing from 12, 48 to 72 hours. On the

contrary in the control group it is observed


that the number of subjects experiencing pain
had been increasing from 12, 48 to 72 hours.
A large number of subjects did not experience
pain at 72 hours in the experimental group as
compared to control group.
Severe

% of subjects

Moderate
Mild

70%
60%
50%
40%
30%
20%
10%
0%

No Pain

12 hrs

48 hrs

72 hrs

Figure 2 : Distribution of Pain in Experimental Group

Severe
Moderate
Mild
No Pain

70%
% of subjects

60%
50%
40%
30%
20%
10%
0%
12 hrs

48 hrs

72 hrs

Figure 3 : Distribution of Pain in Control Group


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145

Figure 4 & 5 reveal the distribution of


bruise at 12, 48 and 72 hours in experimental
and control groups. Large and small bruises
were decreasing in size in experimental group

when compared with control group from 12,


48 to 72 hours. The number of subjects with
no bruise was more in number in experimental
than in control group.

Large
Small
No Bruise

% of subjects

100%
80%
60%
40%
20%
0%
12 hrs

48 hrs

72 hrs

% of subjects

Figure 4 : Distribution of Bruise in Experimental Group


Large
Small
No Bruise

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
12 hrs

48 hrs

72 hrs

Figure 5 : Distribution of Bruise in Control Group


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146

Discussion
The subcutaneous administration of the
anticoagulant heparin sodium is a frequently
performed nursing task. Pain, bruise and
hematomas are most common complications
detected at subcutaneous injection site of
heparin among the patients. The literature
reports a high degree of incidence (up to 90%)
of bruising from any subcutaneous heparin
injections. 4 Pain at the injection site and
bruising are likely consequences of local
tissue trauma that occur during administration
of subcutaneous heparin injections. The
physiological responses of cell/tissue to injury
were recognized as pain, br uise and
hematomas at subcutaneous heparin injection
site. The hypothesis formulated by the
investigator in this study was that there was
no significant difference in prevention and
reduction of pain, bruise and hematoma with
application of moist ice pack at injection site.
The investigator selected a course of action
from the problem solving approach of
Abdellah's theor y by developing and
implementing the moist ice pack at the
injection site. The comparison of pain at 12
and at 72 hours between the experimental and
control groups have identified the statistical
significance. Regarding the bruise, statistical
significance was observed at 48 and 72 hours
between experimental and control groups as
the measurements of the bruise became
smaller in size in experimental group, where
as control group had larger bruises. Majority
of the subjects did not develop hematoma in
both the groups.

Lehmann J F (1982) describes the


effects of therapeutic cold in the treatment. A
direct effect on the conduction of pain
receptors and neurons, reducing the velocity
and number of impulses is one way of
alleviating pain. It is evident that latter effect
would only occur in the skin if the temperature
were reduced. The clinical application of cold
in mechanical trauma is primarily based on
vasoconstriction, which leads to reduction of
swelling and bleeding.10
Rusk (1977) recommended cold
application for 5-10 minutes for its
effectiveness.11 Cooling is just long enough
to prevent swelling and bleeding.10
When the findings of the current study
were compared with the findings of similar
studies, it was seen that bruise incidence was
less and bruise surface areas were smaller in
the experimental group. It was observed in
the present study that application of moist ice
pack at the injection sites have prevented and
reduced the number and size of bruises in
experimental group. This especially supported
the effectiveness of the moist ice pack
application in the current study and proposed
in the literature as well. Bruising usually peaks
at 48 hours and begins to resolve at 72 hours
after the injection.12 This has been observed
in the current study where the size of the
br uise was increased at 48 hours and
decreased in size at 72 hours. Therefore, on
applying the non-parametric Chi- Square test,
statistical significant difference was observed
between the two groups in terms of
prevention and reduction of pain & bruise at

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147

subcutaneous heparin injection site. Thus the


null hypothesis was rejected. Therefore, it is
concluded that the application of 'moist ice
pack' can be effective in preventing and
reducing pain, bruise and hematoma at
subcutaneous heparin injection site. As the
nursing profession becomes more grounded
in research, nurse initiated interventions such
as those in this study provide for the medical
and physical (e.g. comfor t) needs of the
patient. Based on present study findings it is
recommended that replication of this study
with a larger sample using more than one
setting. A further study is recommended with
prior and post application of 'moist ice pack'
versus post application at the subcutaneous
heparin injection site. Application of 'moist ice
pack' and follow up of the injection site for
five days.

4.

References

10.

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