الفهرس 
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Abstract
Open heart surgery is associated with severe postoperative procedural pain. Despite global attention to pain management, pain management is still one of the biggest challenges in intensive care units. Therefore, attention to postoperative procedural pain after CABG is important. Procedural pain could be managed using pharmacological and non-pharmacologic interventions. Today the strong emphasis is on non-pharmacological pain relief methods. Cold therapy is a non-pharmacological and a cost-effective way of relieving pain in both surgical and medical interventions. Cold therapy increases the pain threshold, decreases the use of analgesics and anti-inflammatory agents, relaxes spasms, increases mobility, improves rehabilitation, and decreases the duration of hospital stay.
Cold therapy has been used frequently to reduce surgical incision pain and other tissue injuries. Cold application is commonly used in orthopedic, gynecologic, abdominal surgery and sport medicine. However, there is a paucity of scientific evidence about the use of cold application on procedural pain after CABG surgery. Therefore, this study conducted to examine the effect of cold therapy on procedural pain among postoperative coronary artery bypass grafting patients’.
Aim of the study
Determine the effect of applying cold therapy on procedural pain among post coronary artery bypass grafting patients.
Research hypothesis:
Post coronary artery bypass grafting patients who undergo cold therapy exhibit less procedural pain than those who do not.
Setting
This study was conducted in the department of cardiothoracic surgery at open heart surgery intensive care unit of Alexandria Main University Hospital.
Subjects
A convenience sample of 60 newly admitted adult postoperative coronary artery bypass grafting patients to open heart surgery intensive care unit were included in the current study.
Tools
Two tools were used by the researcher to collect data after extensive reviewing the relevant literature (Berman et al., 2016; Boyer, 2009; Burton & Ludwig, 2014; Carrillo-Torres et al., 2016; A. B. Carvalho et al., 2016; Gélinas, 2010, 2016; Gélinas, Arbour, et al., 2011; Ignatavicius & Workman, 2015; Johnson, 1973; Lewis et al., 2016; McCaffery et al., 1989; Mohan et al., 2010; Olsen et al., 2016; Olsen et al., 2015; Paulson-Conger et al., 2011; Peate & Wild, 2018; Rahu et al., 2013; Rijkenberg et al., 2017a; Robleda et al., 2016; Sole et al., 2013; Stites, 2013; Treas & Wilkinson, 2013; L. D. Urden et al., 2015; Zaccagnino & Nedeljkovic, 2017).
Tool one: “Subjective pain assessment sheet”
It is used to assess subjective components of pain. This tool consists of three parts. Part one namely “pain intensity scale”, part two namely “pain distress scale” and part three namely “patient self-report of pain”.
Tool two: “Objective pain assessment sheet”
It is used to assess objective components of pain. This tool consists of two parts. Part one namely “Physiological indicators of pain assessment” and part two namely “Critical Care Pain Observation Tool”.
• Approval of the ethics committee of the faculty of nursing was obtained.
• An official letter from the faculty of nursing was delivered to the hospital authorities in the Main University Hospital and approval to conduct this study was obtained after providing explanation of the aim of the study.
• Content validity of the tools was done by five experts in the field of the study and necessary modifications were done accordingly.
• Reliability of the tools was tested using Cronbach’s Alpha test and
result was 80.02 which is accepted.
• A pilot study was carried out on 10% of the total subjects to assess the clarity and applicability of the research tools.
• The studied patients’ consent for participation in the study was obtained after explanation of the purpose of the study.
• All enrolled post-operative CABG patients were assessed for pain using tool one and two before and after performing each procedure in which each patients was utilized as his/her own control for two consecutive days in which each day consist of two different phases. The first phase (control phase) which was done without cold gel pack application and the second phase (intervention phase) which was done with cold gel pack application. Two hours duration was washout time between both each phase and each procedure.
• Statistical analyses were performed using Statistical Package for the Social Science (SPSS) version 23.
The main findings of the current study revealed that
It was noted that 75% of the studied patients’ age more than 60 years old and the majority of the studied patients (80%) were male. Moreover, 65% of them were married whereas; only 5 % of them were divorced. It was also found that approximately two third of them (60%) have a social support system. In addition, it was found that 53.3% of them were working besides; the majority of them were educated (81.7%).
Regarding the studied procedures, it was found that pain intensity, distress and CPOT scores were significantly reduced after cold gel pack application (P=0.00*). Moreover, pain intensity, distress and CPOT scores were significantly elevated immediately after performing the studied procedures (P=0.00*). Further, it was revealed that post-operative procedural pain level descend significantly by the time after cardiac surgery (P=0.00*).
Moreover, cold application before performing the studied procedures is associated with significant decrease in both bio physiological parameters of pain and patients self-report of pain.
It can be also noted that the mean pain intensity score associated with coughing exercises was 2.7±0.3 which indicates that coughing exercises is significantly considered to be the most painful performed procedure postoperatively. Whereas, the mean score of pain intensity regarding dressing over median sternotomy incision was 0.3±0.8 which denotes that dressing over median sternotomy incision is significantly found to be the least painful performed procedure postoperatively.
It can be concluded from the present study that
Cold application significantly reduces procedural pain intensity, distress as well as CPOT associated with performing the studied procedures (deep breathing exercises, coughing exercises, dressing over median sternotomy, walking around the bed and incentive spirometry exercises). Further, mean pain intensity, distress and CPOT scores for post-operative CABG patients significantly increased after performing the studied procedures. Moreover, post-operative CABG pain is reduced significantly by the time.
Cold application before performing the studied procedures is associated with significant decrease in both bio physiological parameters of pain and patients self-report of pain.
Coughing exercises elicited the highest level of pain intensity; next, in order, are mobility exercises, deep breathing exercises and incentive spirometry whereas, dressing over median sternotomy is shown to be the lowest degree of pain intensity among the studied procedures.
The following are the main recommendations of the study
Pain assessment tools should be incorporated into daily practice; this will assist health care professionals in the early identification and efficient management of procedural pain and also optimum use of sedatives and analgesics in the post-operative CABG patients. Clinical and theoretical training on pain assessment should be included in nursing and medical core curriculum. Moreover additional researches are needed to address the barriers of pain assessment and to provide alternative strategies.