Please. can I get some help with

Please. can I get some help with this assignment? I have attached the article and questions. Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone Stacy A. Friesner, RN, MS, ACNP, Donna Miles Curry, PhD, RNC, and Gail R. Moddeman, PhD, RN PURPOSE: The purpose of this study was to determine whether the use of a slow deep-breathing relaxation exercise, when used as an adjunct to opioid analgesia, decreases pain during chest tube removal (CTR) after coronary bypass surgery. DESIGN: A two-group quasi-experimental pretest/posttest design was used. SAMPLE: A convenience sample of 40 adults who had undergone coronary artery bypass graft surgery and met all inclusion criteria were recruited before CTR. SETTING: Data were collected in the Cardiothoracic Surgical Intensive Care Units of three acute care facilities in the Midwestern United States. METHOD: A 10-cm vertical Visual Analog Scale was used to measure pain at three points: before CTR, immediately after CTR, and 15 minutes after CTR. The experimental group received slow breathing relaxation exercises in addition to the usual opioid doses administered. FINDINGS: Data were analyzed using analysis of variance, and multivariate analysis of covariance yielded a significant difference in pain ratings immediately after CTR and 15 minutes after CTR for the group receiving relaxation exercise as an adjunct to opioid analgesic. CONCLUSIONS: This study supports the use of a slow deep-breathing relaxation exercise as an adjunct to the use of opioids for pain management during CTR among patients who have undergone coronary bypass surgery. (Heart Lung® 2006;35:269 -276.) I n 1997 in the United States, an estimated 607,000 coronary artery bypass surgeries, 2340 heart transplants, and approximately 80,000 heart valve replacements were performed,1 all requiring a postoperative chest tube with eventual removal. These chest tubes are inserted into the pleural or mediastinal spaces within the chest cavity during surgery to allow for the drainage of air, blood, or fluid from the chest cavity, which accumulates during the postoperative period. By preventing these accumulations, severe cardiac complications can be avoided.2-4 The chest tubes are typically removed within 24 to 48 hours after surgery or when the excess air, blood, or fluid has been properly drained.5 During the time the chest tubes remain in place, the endothelium that lines the chest cavity adheres to the tube. Therefore, when removed, the pulling force may shear those adhesions and cause pain.2 The removal process can result in intense, yet transient, acute pain and is described as being one of the worst memories of the patient’s perioperative experience.6-8 The pain occurring with chest tube removal (CTR) is iatrogenic pain, which is “induced as a result of a health care intervention” (p. 236).9 Previous studies suggest that the majority of patients do not have adequate pain control during CTR.10-14 Thus, the purpose of this study was to determine whether relaxation exercises added to standard medical therapy would result in improved pain-management outcomes. From the College of Nursing and Health, Wright State University, Dayton, Ohio. Reprint requests: Donna Miles Curry, PhD, RN, 130 University Hall, College of Nursing & Health, 3640 Col Glenn Hwy, Wright State University, Dayton, OH 45435. 0147-9563/$ – see front matter Copyright © 2005 by Mosby, Inc. doi:10.1016/j.hrtlng.2005.10.005 ISSUES IN PAIN MANAGEMENT HEART & LUNG VOL. 35, NO. 4 www.heartandlung.org 269 LITERATURE REVIEW There is a paucity of nursing research regarding appropriate pain-management strategies during CTR. Although opioids are traditionally used to treat acute pain, they are not associated with optimal pain control during CTR.6,7,11,14 Additional pharmacologic pain-management approaches have included anesthetic agents, either injected at the chest tube insertion site or directly into the pleural space of the chest cavity before removal.14 These approaches to pain management also are not maximally effective. Although some pharmacologic interventions have not always been effective,6,7,11,14 administering opioids or nonsteroidal anti-inflammatory drugs (NSAIDS) based on the time of the peak effect of the analgesic medication has been a factor in reducing pain ratings immediately after and 20 minutes after CTR.15 Additional studies on the issue of pain management during CTR involve the inclusion of nonpharmacologic techniques. A variety of techniques can be used to achieve relaxation, including breathing techniques, guided imagery, meditation, music therapy, progressive muscle relaxation, and selfhypnosis. In a study using music as an intervention for 10 minutes before CTR, there were no significant differences among groups in self-reported pain intensity immediately after CTR and 15 minutes after CTR.10 Similar results from another study found that the combination of a quick relaxation technique and analgesia did not demonstrate any significant difference in pain ratings during CTR than when analgesia alone was administered.12 In a more recent study, procedural or sensory information was given to patients pre-CTR, in combination with an intravenous opioid or an NSAID given intramuscularly.15 There was no significant difference in pain intensity ratings or self-reported levels of distress between the groups receiving opioids or NSAIDs in conjunction with procedural and sensory information and those who received opioids or NSAIDs alone. However, the subjects had excellent pain control. Relaxation is defined as the absence of physical, mental, and emotional tension.16 According to Atsberger, relaxation is an important component toward impeding anxiety and pain.17 Research has shown a positive correlation between postoperative pain and state anxiety;18 that is, a decrease in anxiety positively correlates with a decrease in the perceived pain. Relaxation can assist in the management of pain both physiologically and psychologically. Physiologically, relaxation leads to a reduction in or reversal of the sympathetic response to pain leading to a decrease in oxygen consumption, blood pressure, heart rate, and respiration. It also leads to a decrease in muscular tension, ultimately reducing anxiety, tension, and stress.19-21 Distraction is a built-in component of relaxation and impacts pain management by decreasing the cognitive awareness of pain.22 Theoretic framework The theoretic framework that guided the study is the Gate Control Theory of Pain.23 The Gate Control Theory of Pain is based on the premise that a gating mechanism in the dorsal horn of the spinal cord can inhibit transmission of nerve impulses to the brain. In relation to the Gate Control Theory, the stimulus of CTR activates fibers within the parietal pleura, chest muscles, and chest tube insertion site. It is believed that the activation of these pain-transmitting fibers results in a release of various excitatory neurotransmitters. These substances stimulate nociceptors of the afferent pathway, thus transmitting the “fast pain” impulse through myelinated A delta fibers and “slower pain” impulses through C fibers to the spinal cord. Within the spinal cord, the peripheral pain fibers relay the pain stimulus to the substantia gelatinosa where the impulse is either blocked or passed on to the brain for interpretation.23,24 The Gate Control Theory asserts that pain has physical, affective, and cognitive components; thus, relaxation is believed to influence the affective component of pain. Relaxation may lead to a reduction in or reversal of the pain impulse by activating descending inhibitory neurons that block ascending nociceptive nerves that originate in the substantia gelatinosa. This blocking of ascending nerve impulses “closes the gate” to pain, and the brain will not interpret the impulse as painful. By reducing the anxiety, the gate also may close; this can lead to a decreased perception of pain. It is believed that opioid administration assists in reducing pain by acting on the endogenous endorphin response. The exogenous opiate will act in the same way as the endogenous endorphin response and thus relieve pain in a similar manner. The exogenous drug will attach to the opioid receptor sites and augment the natural endorphin response. With the implementation of a deep-breathing relaxation technique in conjunction with the administration of opiates, patients’ pain may be decreased during CTR. The specific aim of this study was to answer the research : How does the use of a slow deep-breathing relaxation technique with opioid administration compare with the use of opioid adComparison of two pain-management strategies during chest tube removal Friesner, Curry, and Moddeman 270 www.heartandlung.org JULY/AUGUST 2006 HEART & LUNG ministration alone for pain management during CTR? METHOD A two-group quasi-experimental pretest/posttest design was used to examine and describe the differences in the use of relaxation with opioids and the use of opioids alone in the management of pain during CTR. Because pain-management practices during CTR are inconsistent, the design facilitates further evaluation of the use of relaxation as an adjunct to opiates during the CTR process. Permission was obtained by the institutional review board, the three tertiary care facilities, and the cardiothoracic surgeons. Confidentiality was ensured by assigning an identification number to all data-collection forms. Consent was obtained from the patient before CTR. The times and routes of opioid administration, and types of opioid before and during CTR were recorded. Setting Data were collected in the cardiothoracic surgical intensive care unit at three acute care facilities ranging in size from 285 to 827 beds. All facilities were located in the Midwestern United States. Sample A convenience sample was used in this study. Although 41 white subjects met the inclusion criteria and consented to participate in the study, 40 remained in the sample; the 41st subject withdrew. The sample size needed for this study, determined by a power of .80 with a medium effect size at a .05 level of significance, consisted of 40, with 20 in each group. The patients were recruited into the study before CTR and gave informed consent at that time. The demographic characteristics of the 40 participants are presented in Table I. Selection criteria for participants in this study included subjects aged more than 21 years who (1) gave informed consent; (2) comprehended and verTable I Frequencies and percentages of demographic characteristics, types of surgical procedures, medical history by group Variable Total sample N 40 (%) Treatment group n 19 (%) Control group n 21 (%) Gender Male 30 (75) 14 (74) 16 (76) Female 10 (25) 5 (26) 5 (24) Age in years Minimum 39 54 39 Maximum 84 80 84 Mean 63 69 63 Surgical procedure CABG 36 (90) 18 (95) 18 (85) CABG with valve 3 (7) 1 (5) 2 (10) Myxoma 1 (3) 0 (0) 1 (5) Medical history Diabetes 12 (30) 6 (32) 6 (29) Renal insufficiency 7 (17) 2 (11) 5 (24) Liver disorder 1 (2) 1 (5) 0 (0) Anxiety* 2 (5) 0 (0) 2 (10) Depression* 1 (2) 0 (0) 1 (5) Obesity 21 (52) 10 (53) 11 (52) Pertinent medications Aspirin 40 (100) 19 (100) 21 (100) Toradol 3 (8) 2 (11) 1 (5) CABG, Coronary artery bypass surgery. *Those meeting inclusion criteria. Friesner, Curry, and Moddeman Comparison of two pain-management strategies during chest tube removal HEART & LUNG VOL. 35, NO. 4 www.heartandlung.org 271 balized English; (3) were cognitively oriented to person, place, and time; (4) had undergone coronary artery bypass graft surgery; (5) had two mediastinal chest tubes in place with or without a pleural chest tube or those with a pleural chest tube alone; (6) received morphine sulfate, Percocet® (Acetaminophen with Oxycodone, Endo Pharmaceuticals, Inc., Chadds Ford, PA), or Tylenol® No. 3 no more than 1 hour or less than 15 minutes before the procedure; (7) had creatinine levels 3 mg/dL or less; (8) had been weaned from the ventilator; (9) did not have air leak, pleural effusion, or pneumothorax; and (10) chest tube drainage had decreased to less than 100 mL per 8-hour shift. Instruments The instruments used included a 10-cm vertical Visual Analog Scale (VAS). The vertical VAS was anchored with the words “no pain” on the “0” end and “worst pain possible” on the “10” end of the scale. The VAS has been recognized by the Institute for Clinical Systems Improvement25 and validated through use in many studies. A vertical VAS was used in this study, taking into consideration that it has been deemed easier to read and mark than a horizontal VAS.26 Procedure The researcher monitored the units on a daily basis for potential subjects. Once patients were informed of the potential for CTR, the researcher approached them for consent (before narcotic administration). At this time the researcher evaluated and confirmed proper orientation status. Participants were informed that they would receive routine pain medication with or without relaxation exercise. The first 20 subjects were randomly assigned to the experimental or control group by the flip of a coin. Once the first 10 subjects were obtained in each group, every new subject thereafter was matched to a subject of comparable age and gender and assigned to the opposite treatment group. Vital signs and oxygen saturation levels were recorded before CTR. After informed consent was obtained, all subjects received morphine sulfate 1 to 10 mg intravenously or intramuscularly, Percocet® one to two tablets, or Tylenol® with Codeine (Acetaminophen with Codeine, McNeil Pharaceuticals, Inc., Fort Washington, PA) No. 3 one to two tablets orally at least 15 to 60 minutes before CTR. The time of opioid administration was recorded, and morphine equivalents were calculated. On arrival, the researcher asked each subject a series of questions to evaluate and confirm adequate orientation to person, place, and time, and to assess the subject’s level of sedation. Subjects in each group were asked to mark the vertical VAS 15 minutes before the procedure began. All subjects were instructed on the CTR procedure. The VAS was administered by the principal investigator. With CTR instructions, subjects in the relaxation group were instructed on the techniques for the deep-breathing relaxation exercise. The breathing exercises included inhaling slowly through the nose and exhaling slowly through pursed lips. These subjects initiated the technique 5 minutes before removal. The subjects either closed their eyes or focused on an object within the room. In addition, the subjects were instructed to focus on their breathing and to relax. While the subjects continued with the relaxation technique, both the chest tube dressing and sutures were removed. Then the patient was instructed to hold his or her breath during CTR. Chest tubes were removed by the physician, physician’s assistant, or registered nurse. Pain ratings were reported using the VAS immediately after CTR and application of dressing. The participants in the relaxation group were instructed to continue with the slow deep-breathing exercise as long as they desired. The researcher monitored all subjects until they returned to baseline oxygen saturation and vital signs. Pain levels were reassessed for all subjects 15 minutes after CTR. Throughout the entire CTR procedure subjects were evaluated to ensure they were lucid and capable of giving valid pain ratings. Opioid administration, relaxation initiation, time of CTR, and each pain rating were recorded. In addition, a commonly used chart of morphine equivalents for frequently prescribed oral analgesics was used to compare all opioids administered.27 Findings Statistical calculations were performed using the standard version of Statistical Packages for the Social Sciences (SPSS 8.0; SPSS Inc, Chicago, IL). Descriptive statistics were used for subjects’ demographic data and the number of chest tubes inserted. One-way analysis of variance and repeated-measures multivariate analysis of covariance (MANCOVA) were used to evaluate the effects of treatment on pain ratings. MANCOVA statistically controlled for the effects of opioid levels and duration of chest tube placement on pain ratings (Table II). The total sample had from one to four chest tubes (median 3, 72%), and more than 80% of all Comparison of two pain-management strategies during chest tube removal Friesner, Curry, and Moddeman 272 www.heartandlung.org JULY/AUGUST 2006 HEART & LUNG subjects had both mediastinal and pleural chest tubes. The chest tube size was 36 French for more than 95% (n 38) of all subjects. Groups did not differ on the duration of the chest tube placement; for all subjects the range was from 13 to 67 hours (mean 40 hours). Last, the time between opioid doses and time between opioid administration and CTR were recorded and presented in Table III. The mean time from the last opioid received before being premedicated for CTR was 4 hours 42 minutes (range of 52 minutes-22 hours). The mean time from the premedication for CTR was 35.95 minutes (range of 15- 60 minutes). No significant difference in opioid dose and self-reported pain was found before CTR between groups (P .29). Fig 1 demonstrates a comparison of pain ratings on the written vertical VAS between the two groups before, immediately after, and 15 minutes after CTR. The mean VAS pain rating before CTR was 5.05 (range of 0 -10, standard deviation [SD] 2.86) for the treatment group and 5.04 for the control group (range of 0 – 8, SD 2.44). Immediately after CTR, the mean rating was 6.57 (range of 3-10, SD 2.61) for the treatment group and 8.61 (range of 5-10, SD 2.96) for the control group. Fifteen minutes postCTR, the mean rating for the treatment group was 3.07 (range of 0 -10, SD 2.45) and 5.57 for the control group (range of 0 -9, SD 2.96). Final results showed a significant decrease in pain ratings with use of the relaxation treatment immediately after CTR and 15 minutes after when compared with the control group (F [1, 38] 8.15, P .007; F [1, 38] 8.31, P .006). All subjects within the treatment group continued with the relaxation exercise after CTR, and pain ratings remained sigTable II Summary of variables in relation to opioid administration Variable Total sample N40 (%) Treatment group n 19 (%) Control group n 21 (%) Last opioid dosage before CTR (mg) Minimum 3.00 3.00 3.00 Maximum 10.00 10.00 10.00 Mean 6.99 6.66 7.29 Type of opioid with route of administration before CTR Morphine sulfate (IV) 2 (5) 1 (5) 1 (5) Morphine sulfate (IM) 32 (80) 16 (85) 16 (76) Tylenol® No. 3 (PO) 4 (10) 1 (5) 3 (14) Percocet® 2 (5) 1 (5) 1 (5) Opioid dosage for chest tube removal (mg) Minimum 2.00 2.00 2.00 Maximum 10.00 10.00 10.00 Mean 6.23 6.09 6.35 Type of opioid with route of administration for CTR Morphine sulfate (IV) 8 (20) 4 (21) 4 (19) Morphine sulfate (IM) 27 (68) 14 (74) 13 (63) Tylenol® No. 3 (PO) 3 (7) 1 (5) 2 (9) Percocet® 2 (5) 0 (0) 2 (9) Time between the two opioid dosages Minimum 52 (min) 60 (min) 52 (min) Maximum 22 (h) 9.25 (h) 22 (h) Mean 4.45 (h) 4.29 (h) 5.35 (h) CTR, Chest tube removal; IV, intravenous; IM, intramuscular; PO, by mouth. Friesner, Curry, and Moddeman Comparison of two pain-management strategies during chest tube removal HEART & LUNG VOL. 35, NO. 4 www.heartandlung.org 273 nificantly lower in the treatment group than in the control group 15 minutes later (P .006). MANCOVA was used to evaluate the treatment effects. Opioid dosage immediately before CTR and the duration of chest tube placement were covaried with the pain ratings before, immediately after, and 15 minutes after CTR. Table III shows the significant difference between the groups’ ratings of pain experienced immediately after CTR (P .004) and 15 minutes after CTR (P .006). Next, analysis of variance was performed to further examine the significance of the treatment (Table IV). The treatment had no significant effects on pain ratings before CTR (F [1,38] 0, P .995). The findings confirmed the positive effects of the treatment demonstrated by results of the MANCOVA. DISCUSSION Both groups of patients in this study reported unacceptably high pain ratings pre-CTR and immediately after CTR. However, the control group continued to report very high pain ratings 15 minutes after CTR, whereas the group receiving slow deep relaxation demonstrated a statistically significant decrease in their pain ratings. This suggests that opioids alone were not sufficiently managing patients’ pain before, immediately after, and 15 minutes after CTR for the control group. Because patients’ pain management is a priority, nurses are in a unique position to provide comfort measures during CTR. The nurse’s role is to support and assist the patient through the discomfort in the best possible way.28 To successfully accomplish this, the nurse must comprehend the patients’ experiences during CTR and possess the knowledge to properly manage their pain. The CTR experience can be managed using both pharmacologic and nonpharmacologic approaches. As an adjunct to routine pharmacologic measures, the use of slow deep-breathing relaxation exercise can be used to assist in the pain-management process. The findings of this study are in contrast with the results of research by Broscious10 and Houston and Jesurum,12 which did not find the use of such nonpharmacologic approaches such as music or quick relaxation in adjunct to pharmacologic intervention to have statistically significant improvement in pain management. It might be speculated that the underlying pathways stimulated by these two nonpharmacologic approaches is different that those stimulated by more physical actions used in deep breathing. As long as a decade ago, Kinney and colleagues13 identified a need for guidelines for pain management during CTR, yet each hospital and surgeon may have their own protocol. However, when such guidelines are developed, independent nursing actions should include the use of slow, deep-breathTable III Summary of multivariate analysis of covariance of pain scores with opioid administration duration of chest tube placement and treatment Source Dependent variable Sum of squares df Mean square F P Opioid before chest tube removal Pain score before 7.71 1 7.71 1.17 .29 Pain score after .30 1 .30 .06 .81 Pain score 15 min after 1.71 1 1.71 .24 .63 Duration of chest tube placement Pain score before 21.21 1 21.209 3.22 .08 Pain score after 10.88 1 10.883 2.15 .15 Pain score 15 min after 24.86 1 24.863 3.49 .07 Treatment Pain score before 3.31E-02 1 3.31E-02 .01 .94 Pain score after 43.89 1 43.89 8.66 .006 Pain score 15 min after 66.13 1 66.13 9.28 .004 Fig 1 Mean pain response before, immediately after, and 15 minutes after CTR with or without relaxation. CTR, chest tube removal. Comparison of two pain-management strategies during chest tube removal Friesner, Curry, and Moddeman 274 www.heartandlung.org JULY/AUGUST 2006 HEART & LUNG ing exercise for relaxation. When one evaluates such significant problems, guidelines supporting an effective way to manage pain during CTR are a necessity to the health care professional. As a result, nurses should be concerned and seek collaboration with the procedural pain committee at their facility. Ultimately, the need still exists to seek an optimal pain-relief regimen for those undergoing CTR.15 Researchers have an obligation to continue exploring pain-management options for patients experiencing CTR. Further research can assist in identifying optimal, consistent techniques that include nonpharmacologic methods, as well as the usual opioids or NSAIDS. This study had several limitations. Because a small, conveniently selected sample of patients who underwent cardiac surgery participated in this study, the findings are not generalizable to all patients experiencing CTR. Although all data were collected by the principal investigator, subjects were recruited from three different sites. Using multiple sites can increase confounding variables because of a difference in protocols for CTR, types of analgesics administered, and policies and procedures of the facilities. In addition, the principal investigator in this study was not blinded to whether a subject had received the relaxation intervention. When one evaluates confounding variables that can impact pain intensities, the effects of opioid doses before CTR, around-theclock opioid administration, NSAID use, and drug metabolism and excretion should be further analyzed. In addition, differences in techniques with insertion and removal were not evaluated. Last, fear and anxiety levels are known to influence the amount of pain experienced before CTR. Mimnaugh and associates7 and Moddeman18 found that higher pain intensity scores were positively associated with a higher level of anxiety. These two factors, addressing the affective component of pain, were not measured before CTR and thus are a limitation to the study. This limitation brings about the discussion of whether the study or the protocol should have included any use of anxiolytics. RECOMMENDATIONS FOR FUTURE RESEARCH Replication of this study with a larger sample could increase support for the use of slow deepbreathing relaxation exercise. To evaluate the effectiveness of relaxation exercise, the influence of other confounding variables, for example, age, education, state anxiety, prior pain experience, and peak effect time of pre-CTR analgesia administration on pain ratings, should be explored. Various factors affecting opioid levels should also be thoroughly evaluated. These factors include the pre-CTR use of around-the-clock opioid administration, NSAIDs, and liver and renal effects on the metabolism and excretion of these drugs. When effective opioid administration was evaluated in this study, the type, dose, and route of administration consistently varied among the nurses administering them. Such inconsistencies compare with and are supported by the findings of Kinney and colleagues.13 Health care professionals should acknowledge that the procedure is painful and recognize the importance of effective methods for managing the pain associated with the CTR process. Future evaluation and documentation of such inconsistencies may prompt additional researchers and procedural pain committees to formulate evidence-based guidelines. SUMMARY Participants in this study had poor pain management before, immediately after, and 15 minutes after CTR, which should not be unexpected because there are no definitive guidelines to effectively manage pain during the CTR process. As a result, current pain-management practices are inconsistent and often ineffective. The findings of this study support the need for use of slow deep breathing as an adjunct to analgesia. With the use of a slow deepTable IV Analysis of variance: Comparison of the treatment at each pain rating interval Source Sum of squares df Mean square F P Treatment before 2.506E-04 1 2.506E-04 .00 .995 Treatment immediately after 41.56 1 41.52 8.15 .007 Treatment 15 min after 61.97 1 61.97 8.31 .006 Friesner, Curry, and Moddeman Comparison of two pain-management strategies during chest tube removal HEART & LUNG VOL. 35, NO. 4 www.heartandlung.org 275 breathing exercise as an adjunct to opioid administration before, immediately after, and 15 minutes after CTR, pain can be better managed during the CTR process. This study demonstrated that painintensity ratings were consistently lower for the group receiving slow deep-breathing relaxation when compared with the group receiving opioid analgesia alone. With the use of relaxation, nurses can enhance the care patients receive by providing better pain management. However, further use and evaluation of this technique are warranted. Through implementation of practice guidelines that provide measures for the appropriate assessment and management of pain during CTR, nurses can provide more effective and consistent pain management during the removal process. Further evaluation can provide components of guidelines for pain management during CTR and advance our current practice patterns, thus improving patient care and patient outcomes. REFERENCES 1. American Heart Association. 2001 Heart and Stroke Statistical Update [on-line]. Available at: http://www.american heart.org/statistics/pdf/2000 Stats.pdf. Accessed January 18, 2001. 2. Gray E. Pain management for patients with chest drains. Nurs Stand 2000;14:40-7. 3. Gross S. Current challenges, concepts, and controversies in chest tube management. AACN Clin Issues 1993;4:260-75. 4. Thomson S, Wells S, Maxwell M. Chest tube removal after cardiac surgery. Crit Care Nurs 1997;17:34-8. 5. Bojar R. Manual of perioperative care in cardiac surgery. Maldin, MA: Blackwell Science, Inc; 1999. 6. Gift A, Bolgiano C, Cunningham J. Sensations during chest tube removal. Heart Lung 1991;20:131-7. 7. Mimnaugh L, Winegar M, Mabrey Y, Davis J. Sensations experience during removal of tubes in acute postoperative patients. Appl Nurs Res 1999;12:78-85. 8. Soehren P. Stressors perceived by cardiac surgical patients in the intensive care unit. Am J Crit Care 1995;4:71-6. 9. Puntillo KA, Miaskowski C, Summers G. Pain. In: CarrieriKohlman V, Lindsey AM, West CM, editors, Pathophysiological phenomena in nursing: human responses to illness. 3rd edition. St. Louis, MO: Saunders; 2003. p. 235-55. 10. Broscious S. Music: an intervention for pain during chest tube removal after open-heart surgery. Am J Crit Care 1999; 8:410-5. 11. Carson M, Barton D, Morrison C, Tribble C. Managing pain during chest tube removal. Heart Lung 1994;23:500-5. 12. Houston S, Jesurum J. The quick relaxation technique: effect on pain associated with chest tube removal. Appl Nurs Res 1999;12:196-205. 13. Kinney M, Kirchhoff K, Puntillo K. Chest tube removal practices in critical care units in the United States. Am J Crit Care 1995;4:419-24. 14. Puntillo K. Effects of interpleural bupivacaine on pleural chest tube removal pain: a randomized controlled trial. Am J Crit Care 1996;5:102-8. 15. Puntillo K, Ley SJ. Appropriately timed analgesics control pain due to chest tube removal. Am J Crit Care 2004;13:292- 301. 16. Benson H. The relaxation response. New York, NY: William Morrow; 1975. 17. Atsberger D. Relaxation therapy: its potential as an intervention for acute postoperative pain. J Post Anesth Nurs 1995; 10:2-8. 18. Moddeman GR. Factors influencing the postoperative pain experience of adult females. CINAHL. Dissertation Abstracts. Publication Number: AAT 998028;2000. 19. Melzack R. Pain—an overview. Acta Anaesthesiol Scand 1999;43:880-4. 20. McCubbin JA, Wilson JF, Bruehl S, Ibarra P, Carlson CR, Norton JA, et al. Relaxation training and opioid inhibition of blood pressure response to stress. J Consult Clin Psychol 1996;64:593-60. 21. Lai H. Music preference and relaxation in Taiwanese elderly people. Geriatr Nurs 2004;5:286-91. 22. McCaffery M, Beebe A. Pain: clinical manual for nursing practice. St. Louis, MO: Mosby; 1989. 23. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971-9. 24. Porth CM. Pathophysiology: concepts of altered health states (6th edition). Philadelphia: Lippincott, Williams & Wilkins: 2002. 25. Institute for Clinical Systems: Improvement: Health Care Guideline Assessment and Management of Acute Pain [online]. Available at: http://www.ICSI.org. Accessed October 18, 2000. 26. Stephenson N, Herman J. Pain measurement: a comparison using horizontal and vertical visual analogue scales. Appl Nurs Res 2000;13:157-8. 27. City of Hope: Pain Resource Center, Nursing and Education, 1999. 28. Carr D, Jacox A. Acute pain management: operative or medical procedures and trauma. Clinical practice guidelines [online]. Available at: http://www.ahrq.gov/clinic/medtep/ acute.htm. Accessed October 16, 2000. 2023 Appraisal Format to be used with the attached Quantitative Research Article Description of the Study What was the purpose of the study? Why was this study needed? Does it contribute to nursing knowledge? Did the abstract describe the study succinctly? Was the TITLE short), but included the patient/subjects, design of study, interventions, comparison/controls and sometimes outcome? Was the study feasible (in terms of funding, equipment, setting, population, qualified researchers)? Did the study have a research (no relation direction) or a hypothesis (direction of relation between variables)? “If I apply the new intervention (independent variable),

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