INTRODUCTION:

Problems of the vascular system are common and can be serious. Heparin is widely used for thromboprophylaxis or treatment in many clinical conditions, including cardiovascular, neurovascular, orthopaedic surgery, invasive procedures, acute coronary syndromes, venous thromboembolism, atrial fibrillation, peripheral occlusive disease, dialysis, during extracorporeal circulation and who must remain in bed for a long time¹. The action of Heparin is to prevent blood clot formation and thinning the blood viscosity.

It can be administered either directly into the bloodstream or as an injection under the skin. Subcutaneous administration of heparin is frequently performed nursing intervention². Subcutaneous injection is normally chosen when slow and continuous absorption of the drug is needed. The drug is injected into fat and connective tissue underlying the dermis, where there is less blood flow and as a result a slower absorption rate. Suitable sites for subcutaneous injections are often the umbilical region of the abdomen and the lateral sides of the arms and thighs³.

Administration and injection techniques that are used for subcutaneous heparin injection may cause adverse outcomes such as bruising, haematoma and pain at the injection site^4,5. Heparin can cause not only local side effects such as local bruising, hematoma and pain at the injection site but also cause the systemic effects of bleeding and thrombocytopenia^6-13. 18.57% patients with myocardial infarction receiving heparin suffered with local bleeding¹⁴. Heparin poses many side effects include pain, erythema and ecchymosis. Hemorrhagic side effects have occurred in 3% to 7% of patients. Rarely painful red indurations and necrotic ulcerations at the injection site have been reported. Ecchymosis is one of the common side effects associated with heparin. Ecchymosis is the injury to biological tissue and capillary damage occurs, allowing blood to seep into surrounding tissue¹⁵. Bruising occurred in 53% of subjects out of a total of 43 subjects who received subcutaneous heparin¹⁶. It was reported that up to 90% individuals develop a bruise from subcutaneous administration of heparin¹⁷. These local adverse effects such as bruises and hematomas not only constitute physical trauma, but also cause changes in skin integrity and make it difficult to choose a site for future injections. This is because use of the traumatized area for later injections both causes pain and has a negative effect on the absorption of drugs^7,13,18.

The role of nurses is to minimize local side effects such as pain, ecchymosis, bruising, hematoma formation and alleviate the discomfort during the administration of heparin wherever and whenever possible. Several studies have revealed the effects of the temperature, syringe size, needle gauge, injection volume and air bubble in the syringe, etc on the incidence of bruising, haematoma and pain at the injection site^4,5. Other studies have explored the effect of the duration of the injection on the incidence of bruising and pain¹⁹. Strategies are preventing the hematoma, bruising, ecchymosis formation and decrease the level of pain during clinical practice. Administration techniques included syringe size, change of needles after drawing medication into the syringe, use of an air bubble, and type of sponge (dry or alcohol) applied to the site after injection also play a vital role in preventing bruising. The method 15 seconds injection duration and waiting for 5 seconds before withdrawing the needle is recommended to be used for subcutaneous heparin injection by clinical nurses. As to the results, the severity of pain in abdomen was lower than in thighs²⁰. In another study proved that application of ice decrease the incidence or size of hematoma; however, the subject's perception of pain was significantly less²¹.

Ice is a therapeutic agent used in medicine as an integral part of injury treatment and rehabilitation. The use of ice pack is widespread because of their effectiveness, convenience, low cost, and ease of transportation. Ice packs can be made with any form of ice; however, 2 commonly used forms are cubed ice and crushed ice as well dry cold or moist cold. Ice is believed to control pain by inducing local anesthesia around the treatment area. Application of ice reduces the perception of pain during intramuscular injection, episiotomy pain, arteriovenous fistula puncture related pain, arthritis related joint pain and pain during chest tube removal among postoperative patients^22-28. Investigators have also shown that it decreases oedema, nerve conduction velocities, cellular metabolism, and local blood flow²⁹. A dry cold application can be made by filling an ice bag with crushed ice and wrapping it in a towel or washed cloth which will be colder than moist applications. Dry cold also prevents moisture from coming in direct contact with the skin³⁰. The physiological effects of cold application are peripheral vasoconstriction, decreased capillary permeability, oxygen consumption, local metabolism, muscle tone, blood flow, lymph flow, motility of leucocytes and increased blood viscosity ³¹. Considering these potential benefits of cold application the investigators aimed to conduct the study on effectiveness of dry cold application on pain and ecchymosis.

MATERIALS AND METHODS:

A true experimental post-test only design was adopted to conduct the study after obtaining formal permission form the Hospital. A total of 60 samples who met the inclusion criteria were selected by using simple random sampling by lottery method and they were randomly assigned into experimental group (n=30) and control group (n=30). Patients who were receiving low molecular weight heparin (LMWH) injection subcutaneously and were oriented and able to perceive the pain intensity were included in the study. The exclusion criteria were patients with heparin injection with any other anticoagulant treatment, had previous history of coagulopathy and with skin problem such as eczema, psoriasis, vitiligo etc., Participants were explained about the purpose of the study and informed consent was obtained after assuring confidence. Each participant was assessed on the bed side. The demographic variables were collected by using structured interview questionnaire by interview method. Dry cold application was given for 3 minutes on the heparin injection site for the experimental group. Injection heparin administered subcutaneously to the experimental group before administration of heparin injection subcutaneously. Control group was received the routine care of hospital. Level of pain was assessed immediately after withdrawing the needle, 4 hours and 8 hours by using numerical pain rating scale for both experimental and control group. Ecchymosis was assessed 48 hours and 72 hours after the administration of injection by using transparent ruler scale for both experimental and control group. Confidentiality was maintained throughout the procedure. The data were tabulated and analyzed by descriptive and inferential statistics using SPSS statistical package.

RESULTS:

Table 1: Frequency and percentage distribution of demographic variables of patients receiving heparin injection. n = 60 (30+30)

Demographic Variables	Experimental Group		Control Group			Chi-Square for homogeneity
Demographic Variables	No.	%	No.		%	Chi-Square for homogeneity
Age						χ²=4.167 d.f=3 p = 0.244 N.S
21 - 30 years	0	0.00	2		6.67
31 - 40 years	5	16.67	5		16.67
41 - 50 years	10	33.33	14		46.67
Above 51 years	15	50.00	9		30.00
Gender						χ²=0.617 d.f=1 p = 0.432 N.S
Male	19	63.33	16		53.33
Female	11	36.67	14		46.67
Educational status						χ²=4.953 d.f=3 p = 0.175 N.S χ²=2.308 d.f=1 p = 0.129 N.S
Illiterate	14	46.67	13		43.33
Secondary school	12	40.00	7		23.33
Higher secondary	2	6.67	2		6.67
Graduate	2	6.67	8		26.67
Marital status
Single	2	6.67	6		20.00
Married	28	93.33	24		80.00
Widow	0	0.00	0		0.00
Occupation						χ²=1.938 d.f=3 p = 0.585 N.S
Unemployed	5	16.67	4	13.33
Coolie	11	36.67	14	46.67
Government job	2	6.67	4	13.33
Private job	12	40.00	8	26.67
Diagnosis						χ²=1.961 d.f=2 p = 0.375 N.S
Cardiovascular problems	3	10.00	6	20.00
Neurovascular problems	21	70.00	16	53.33
Others	6	20.00	8	26.67

N.S – Not Significant

The table 1 shows that in the experimental group, maximum 15(50%) were aged above 51 years, 19(63.33%) were male, 14(46.67%) were illiterate, 28(93.33%) were married, 12(40%) were employed in private, and 21(70%) were diagnosed to have neurovascular problems. Whereas in the control group, maximum 14(46.67%) were in the age group of 41 - 50 years, 16(53.33%) were male, 13(43.33%) were illiterate, 24(80%) were married, 14(46.67%) were coolie, and 16(53.33%) were diagnosed to have neurovascular problems. The chi-square was computed to check the homogeneity of the demographic variables and proves that homogeneity was maintained.

Table 3: Frequency and percentage distribution of post-tests level of pain among patients receiving heparin injection in the control group. n = 30

Test	No Pain (0)		Mild Pain (1 – 3)		Moderate Pain (4 – 6)		Severe Pain (6 – 9)		Worst Pain (10)
Test	No.	%	No.	%	No.	%	No.	%	No.	%
Post Test 1 (After withdrawal)	0	0	6	20.0	21	70.0	3	10.0	0	0
Post Test 2 (After 4 hours)	0	0	10	33.33	16	53.34	4	13.33	0	0
Post Test 3 (After 8 hours)	0	0	11	36.67	14	46.66	5	16.67	0	0

The table 3 depicts that in post-test 1 (after withdrawal) 21(70%) had moderate pain, 6(20%) had mild pain and 3(10%) had severe pain. In post-test 2 (after 4 hours), 16(53.34%) had moderate pain, 10(33.33%) had mild pain and 4(13.33%) had severe pain. In post-test 3 (after 8 hours), 14(46.66%) had moderate pain, 11(36.67%) had mild pain and 5(16.67%) had severe pain. among patients receiving heparin injection in the control group.

Table 4: Frequency and percentage distribution of post-tests level of ecchymosis among patients receiving heparin injection in experimental group. n = 30

Test	Small Size (0.1 – 1 cm²)		Moderate Size (1.1 – 2 cm²)		Big Size (2.1 – 3cm²)
Test	No.	%	No.	%	No.	%
Post Test 1 (After withdrawal)	30	100	0	0	0	0
Post Test 2 (After 48 hours)	30	100	0	0	0	0
Post Test 3 (After 72 hours)	30	100	0	0	0	0

The table 4 shows that after the administration of dry cold application in post-test 1 (after withdrawal), post-test 2 (after 48 hours) and post-test 3 (after 72 hours) almost all 30(100%) had small size (01.-1cm²) of ecchymosis.

Table 5: Frequency and percentage distribution of post-tests level of ecchymosis among patients receiving heparin injection in the control group. n = 30

Test	Small Size (0.1 – 1 cm²)		Moderate Size (1.1 – 2 cm²)		Big Size (2.1 – 3 cm²)
Test	No.	%	No.	%	No.	%
Post Test 1 (After withdrawal)	27	90.0	3	10.0	0	0
Post Test 2 (After 48 hours)	28	93.3	2	6.67	0	0
Post Test 3 (After 72 hours)	29	96.7	1	3.33	0	0

The table 5 portrays that in post-test 1 (after withdrawal) 27(90%) had small size of ecchymosis and 3(10%) had moderate size of ecchymosis. In post- test 2 (after 48 hours), 28(93.33%) had small size of ecchymosis and 2(6.67%) had moderate size of ecchymosis. In post-test 3 (after 72 hours), 29(96.67%) had small size of ecchymosis and only one (3.33%) had moderate size of ecchymosis.

Table 6: Comparison of post-tests level of pain among patients receiving heparin injection within the experimental group. n = 30

Test	Pain		Paired ‘t’ Test Value
Test	Mean	S.D	Paired ‘t’ Test Value
Post test1 (After withdrawal)	2.17	1.89	t = 3.247 P=0.003, S**
Post Test 2 (After 4 hours)	1.50	1.43	t = 3.247 P=0.003, S**
Post Test 2 (After 4 hours)	1.50	1.43	t = 4.205 P=0.0001, S***
Post Test 3 (After 8 hours)	0.67	1.06	t = 4.205 P=0.0001, S***
Post test1 (After withdrawal)	2.17	1.89	t = 4.677 P=0.0001, S***
Post Test 3 (After 8 hours)	0.67	1.06	t = 4.677 P=0.0001, S***

***p<0.001, **p<0.01, S – Significant, N.S – Not Significant

The table 6 portrays that, the mean score of pain in post-test 1(after withdrawal) was 2.17±1.89, the mean score of pain in post-test 2 (after 4 hours) was 150±1.43 and the mean score of pain in post-test 3 (after 8 hours) was 0.67±1.06. The calculated paired ‘t’ value of t = 3.247 between post-test 1 and post-test 2 was found to be statistically moderately significant at p<0.01 level. The table further revealed that the calculated ‘t’ value of t = 4.205 between post-test 2 and post-test 3 and t = 4.677 between post-test 1 and post-test 3 was found to be statistically highly significant at p<0.001 level. This clearly indicates that the administration of dry cold application before heparin injection among patients was found to be effective in reducing the level of pain in the experimental group

Table 7: Comparison of post-tests level of ecchymosis among patients receiving heparin injection within the experimental group. n = 30

Test	Ecchymosis		Paired ‘t’ Test Value
Test	Mean	S.D	Paired ‘t’ Test Value
Post test1 (After withdrawal)	0.03	0.10	t = 1.975 P=0.058, N.S
Post Test 2 (After 48 hours)	0.01	0.04	t = 1.975 P=0.058, N.S
Post Test 2 (After 48 hours)	0.01	0.04	t = 1.000 P=0.326, N.S
Post Test 3 (After 72 hours)	0.00	0.00	t = 1.000 P=0.326, N.S
Post test1 (After withdrawal)	0.33	0.10	t = 1.775 P=0.086, N.S
Post Test 3 (After 72 hours)	0.00	0.00	t = 1.775 P=0.086, N.S

N.S – Not Significant

The table 7 portrays that, the mean score of ecchymosis in post-test 1(after withdrawal) was 0.03±0.10, the mean score of ecchymosis in post-test 2 (after 48 hours) was 0.01±0.04 and the mean score of ecchymosis in post-test 3 (after 72 hours) was 0.00±0.00.

The calculated paired ‘t’ value of t = 1.975 between post-test 1 and post-test 2, t = 1.000 between post-test 2 and post-test 3 and t = 1.775 between post-test 1 and post-test 3 was not found to be statistically significant. This clearly indicates that most of the patients had no ecchymosis after the administration of dry cold application in the experimental group

Figure 1: Comparison of post-tests level of pain among patients receiving heparin injection between the experimental and control group.

The figure: 1 depicts that the calculated unpaired ‘t’ value t = 5.902, t = 6.963 and t = 8.826 was found to be statistically highly significant at p<0.001 level. This clearly indicates that there was significant difference in the level of pain scores between the experimental and control group at the level of post-test 1 (after withdrawal), post-test 2 (after 4 hours) and post-test 3 (after 8 hours). This clearly indicates that dry cold application administered to the patients receiving heparin injection was found to be effective in reducing the level of pain in the experimental group than the patients in the control group.

Table 8: Comparison of post-tests level of ecchymosis among patients receiving heparin injection between the experimental and control group. n = 60(30+30)

Test	Experimental Group		Control Group		Unpaired ‘t’ Value
Test	Mean	S.D	Mean	S.D	Unpaired ‘t’ Value
Post test1 (After withdrawal)	0.03	0.10	0.28	0.46	t = 2.833 p=0.008, S**
Post Test 2 (After 48 hours)	0.01	0.04	0.23	0.39	t = 3.040 p=0.005, S**
Post Test 3 (After 72 hours)	0.00	0.00	0.19	0.37	t = 2.814 p=0.009, S**

**p<0.01, S - Significant

The table 8 shows that the calculated unpaired ‘t’ value t = 2.833, t = 3.040 and t = 2.814 was not found to be statistically significant. This clearly indicates that there was no significant difference in the level of ecchymosis scores between the experimental and control group at the level of post-test 1 (after withdrawal), post-test 2 (after 48 hours) and post-test 3 (after 72 hours).

The table 9 shows that the demographic variable diagnosis had shown statistically significant association with post- test 3 (After 8 hours) level of pain score at p<0.05 level.

DISCUSSION:

Anticoagulation has proved to be an important treatment modality in preventing thrombus formation for the treatment of vascular problems of heart, lung conditions, during cardiothoracic, cardiovascular and orthopedic surgery and kidney dialysis, the most commonly used route of administration is subcutaneous which can causes the local side effects of pain, bruising, ecchymosis, hematoma formation. The current study intensively analyze the side effects of pain and ecchymosis and to prove the hypothesis of significant reduction in the level of pain and size of ecchymosis after administration of dry cold application in experimental group than control group. Regarding demographic variables majority of the participants were male with the age group of above 50 year and on the treatment of LMWH for neurovascular problems. Many other studies have conducted with the participants who had cardiovascular problem. The present study findings observed that the participants were experienced pain and ecchymosis due to the administration of heparin injection subcutaneously. The level of pain was assessed immediately after withdrawing from the needle, after 4 hours and after 8 hours of administration of both experimental and control group. They perceived the level of pain from no pain to moderate pain and none of them have perceived severe to worst pain in the experimental group. The highest percentage was observed 9(307%) had moderate pain after withdrawal of the needle but only one (3.333%) had moderate pain after 8 hours of injection. Whereas in control group 21(70%), 16(53.34%) and 14(46.66%) had moderate pain immediately after withdrawal, after 4 hours and after 8 hours of injection respectively and 3- 5(10-16%) had severe pain too. Paired t test also reveals that there is a significant reduction in the level of pain between post-test 1&2, 2&3 and 1&3 at the level of p<0.001. Un-paired‘t’ value t = 5.902, t = 6.963 and t = 8.826 was found to be statistically highly significant at p<0.001 level. This clearly indicates that there was significant difference in the level of pain scores between the experimental and control group at the level of post-test 1 (after withdrawal), post-test 2 (after 4 hours) and post-test 3 (after 8 hours). This finding of the present study was supported by the study conducted by Emine Korkmaz Kilic at al who found that two-minute cold application before and after subcutaneous heparin injections reduced pain score and the size of bruises 48 and 72 hours after heparin. However in the current study dry cold application was given 5 minutes prior to the injection³². Similarly another study by Batra G who proven the same evidence that 3 minutes of ice application significantly reduce the level of pain and ecchymosis³³. The present study also observed the size of ecchymosis was within 0.1-1 cm²in experimental group when it was assessed immediately after withdrawal, after 48 hours and after 72 hours of heparin injection administration. Whereas in control group, very few three (10%) had moderate size and none of them had big size of ecchymosis. Within the experimental group paired t test reveals no significant difference between post-test 1 and 2, 2 and 3 and 1 and 3. Mean score of experimental and control group was compared by unpaired t test and found to be no significant difference in the size of ecchymosis between the experimental and control group. This finding is closely in line with the result finding of the study by Shijila S et al and concluded that application of dry cold is effective in reducing the level of pain perception and ecchymosis among patients receiving low molecular weight heparin³⁴. Similarly, Lt Col Rajeena et al and, who found that ice cold application was effective in reducing pain and ecchymosis and enhancing the comfort of patient³⁵. In another study by Supreet Rupam et al who demonstrated that cold application is effective in reducing the pain and size of bruising among hospitalized receiving subcutaneous heparin³⁶. Amaniyan S et al stated that cold application as a fundamental nursing intervention can be an effective intervention to prevent adverse drug reactions at the injection site in terms of the occurrence and size of bruising in patients receiving subcutaneous heparin³⁷. But current study is limited to assess the bruising. The study conducted by Varghese et al with the objective of prevention and reduction of pain, bruise and hematoma by 'Moist Ice Pack' application on the site of subcutaneous heparin injection administered to the patients and the results showed that 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 hours³⁸. The present study limits to assess the hematoma hence further study can be conducted to assess hematoma, bruising with the comparison of moist and dry cold application. Many studies have explored that both moist and dry application shows the significant effect however comparative study between dry and moist cold application will give better evidence to utilize for the cold application reducing the local effects thereby relive the psychological distress, better absorption of heparin and improve the comfort of the patients. Hence the stated hypothesis of reduction level of pain was accepted and rejected the reducing the size of ecchymosis from the study findings.

CONCLUSION:

The findings of the present study concluded that the application of the dry cold prior to the administration of heparin injection subcutaneously can significantly reduce the level of pain and the size of ecchymosis not reduced statistically. In order to comply with treatment modality, pain reduction and thereby physical and psychological comfort to the patients is considered the most important factor. It is incumbent upon health care professionals to be knowledgeable and sensitive towards adverse outcomes result from heparin therapy and promote safety and relieve physical discomfort of the patient.

ACKNOWLEDGEMENT:

The authors would like to thank all the participants for participating in this research study and also thank the health care team members for their support to complete the study successfully.

CONFLICT OF INTEREST:

Authors declare no conflict of Interest

REFERENCES:

1. Chong B H. Heparin‐induced thrombocytopenia. Journal of Thrombosis and Haematosis. 2003; 1(7): 1471–1478.

2. Wooldridge JB, Jackson JG. Evaluation of bruises and areas of in duration after two techniques of subcutaneous heparin injection. Heart and Lung the Journal of Critical Care. 1998; 17(5): 476-482.

3. Hunter J. Subcutaneous injection technique. Nursing Standard.: 2008; 22(21): 41‐44.

4. Chan, H. Effect of injection duration on site-pain intensity and bruising associated with subcutaneous heparin. Journal of Advanced Nursing. 2001; 35(6): 882-922.

5. Kuzu N, Ucar H. The effect of cold on the occurrence of bruising, haematoma and pain at the injection site in subcutaneous low molecular weight heparin. International Journal of Nursing Studies. 2001; 38(1): 51‐9.

6. Visvanathan V. Slow vs. fast subcutaneous heparin injections for prevention of pain and bruising. American Journal of Nursing. 2015; 115(12): 27.

7. S, Ozer N. The Precautions taken by the nurses to prevent the bruise hematoma and pain associated with subcutaneous heparin. Journal of Anatolia Nursing and Health Sciences. 2010; 13(4): 19-25.

8. Rızalar S, Güner T, Kitap T, et al. Subkütan antikoagülan uygulanan hastalarda ekimoz oluşma sıklığı. Ondokuz Mayıs Üniversitesi Tıp Dergisi. 2007; 24(3): 95–99.

9. Kucukguclu O, Okumus H. Subkutan antikoagülan uygulanan hastalarda enjeksiyon öncesi ve sonrası cilde doğrudan buz uygulamasının ekimoz oluşumu üzerine etkisi. DEUHYO ED. 2010; 3(4): 182-6.

10. Zaybak A, Khorsid L. Subkutan heparin uygulamasında ilacın veriliş süresinin ekimoz, hematom ve ağrı üzerine etkisinin incelenmesi. Ege Tıp Dergisi. 2005; 44(2): 95-9.

11. Şenturan L, Karabacak Ü, EcevitnParlar S, Sabuncu N. et al. Effects of Cold Application on Pain and Bruising Complications Associated with Subcutaneous Heparin in Intensive Care Patients International Journal of Health Sciences and Research. 2017; 7(9): 182

12. Avşar G. Kaşıkçı M. Subkütan heparin enjeksiyonlarında ekimoz, hematom ve ağrıyı önlemek için nelere dikkat edilmeli?, İ.Ü.F.N. Hem. Derg. 2012; 20(3): 239-46.

13. Avşar G. Kaşıkçı M. Assessment of four different methods in subcutaneous heparin applications with regard to causing bruise and pain. Internattional Journal of Nursing Practice. 2013; 19(17): 402–8.

14. Ruheena Yasmeen, N. Krishna Reddy, Marina. G. D’ Souza, B. Swathi, Anas Abdul Waheed, Katakam Chinmayee, J. Vineeth Reddy. Study of Anticoagulants low molecular weight heparin and Unfractionated heparin in the management of Non-St elevation Myocardial Infarction. Research J. Pharm. and Tech. 2020; 13(7): 3151-3155.

15. Melba. C & Priyalatha. Effect of dry cold application on the occurrence of bruising and pain at the subcutaneous injection site of LMWH. Asian Journal of Cardiovascular Nursing. 22 (3):201;10-15.

16. Vanbree NS, Hollerbach AD, Brooks GP. Clinical evaluation of three techniques for administering low‐dose heparin. Nursing Research. 33(1): 1984;15‐9.

17. Hadley SA, Chang M, Rogers K. Effect of syringe size on bruising following subcutaneous heparin injection. International Journal of Trauma Nursing. 1996; 2(4): 119‐20.

18. Şendir M, Büyük yılmaz F, Çelik Z, Taşköprü İ. Comparison of 3 methods to prevent pain and bruising after subcutaneous heparin administration. Clinical Nurse Specialist. 2015; 29(3): 174-80.

19. Zaybak A, Khorshid L. A study on the effect of the duration of subcutaneous heparin injection on bruising and pain. Journal of Clinical Nursing. 2008; 17(3): 378‐85.

20. Pourghaznein T, Azimi AV, Jafarabadi MA. The effect of injection duration and injection site on pain and bruising of subcutaneous injection of heparin. Journal of Clinical Nursing. 2014; 23: 1105–1113

21. Ross S, Soltes D. Heparin and haematoma: does ice make a difference?. Journal of Advanced Nursing. 1995; 21(3): 434-9.

22. Jyoti Dube. Effect of Application of Ice on Episiotomy. Asian J. Nur. Edu. and Research Oct.- Dec., 2013; 3(4): 207-210.

23. Bini, Reeta Jebakumari Solomon, V. Ahitha. Effectiveness of Cold Application on Episiotomy Pain among Postnatal Mothers in selected Hospitals at Kanyakumari District. Asian J. Nursing Education and Research. 2019; 9(2): 188-192

24. Jancy J. Effect of cold needle on perception of pain during Intra Muscular Injection. Asian J. Nursing Education and Research. 2019; 9(4): 483-487.

25. Lijiya Jose, Diana Lobo. Effectiveness of Cryotherapy on Arteriovenous Fistula Puncture related Pain among Hemodialysis Patients in Selected Hospitals, Mangalore. Int. J. Adv. Nur. Management July- Sept. 2015; 3(3): 267-272.

26. Dayalal Patidar, Kaushal Patidar, Amita parmar. Effectiveness of Cryotherapy on Arteriovenous Fistula Puncture related Pain among Patients on Hemodialysis in selected Hospital at Mehsana District. Int. J. of Advances in Nur. Management. 2019; 7(3): 221-224.

27. Hiren Tilala, Suneesh P.M., Jeenath Justin Doss. K.. A Study to Assess the Effectiveness of Cryotherapy on level of pain among patient with Arthralgia in selected Orthopedic Hospital at Rajkot. Int. J. of Advances in Nur. Management. 2020; 8(1): 69-71

28. Sruthimol V.S, S. Aruna. Assess the Effectiveness of Ice Pack Application on Pain Prior to Chest Tube Removal among Post Operative Patients. Int. J. Nur. Edu. and Research. 2016; 4(4): 406-410.

29. Sheikh, I. Effectiveness of Ice Cube Application in Reducing Pain before Giving Intra Muscular Injection. 2010; 2(1): 45.

30. Pamela, J. Lippincott text book of nursing assistance (6th edition). 2005. Lippincott Williams and Wilkins publishers.

31. Nancy. Stepanies principles and practice of nursing procedures. (6th edition). 2010. Indore: N. R. publishing house.

32. Emine Korkmaz Kilic1, Tulay Sagkal Midilli. Effects of Cold Application on Pain and Bruising Complications Associated with Subcutaneous Heparin in Intensive Care Patients. International Journal of Health Sciences & Research. 2017; 7(9): 173-183.

33. Batra, G. Application of ice cube prior to subcutaneous injection of heparin in pain perception and ecchymosis of patients with cardiovascular problems. The Nursing Journal of India. 2014; 4: 155-159.

34. Shijila. S, Jean Tresa. J. Effect of Dry Cold Application on Pain Perception and Ecchymosis among Patients Receiving Low Molecular Weight Heparin. Asian J. Nur. Edu. and Research. 2016; 6(4): 503-505.

35. Lt Col Rajeena Enoch. The effectiveness of cold compress on pain and ecchymosis in patients getting subcutaneous low molecular weight heparin in a selected tertiary care hospital. International Journal of Current Research. 2018; 2(1): 67195- 67199.

36. Supreet Rupam, Poonam Sheoran, Tarika Sharma. Effectiveness of dry cold application on pain intensity and bruise at the subcutaneous injection site among patients admitted in selected hospital of Mullana Ambala. Research J. Pharm. and Tech 2018; 11(4): 1559-1562.

37. Amaniyan S, Akram G, Mojtaba V. Cold Application on Bruising at the Subcutaneous Heparin Injection Site: A Systematic Review and Meta-Analysis. Sage Open Nursing Journal, 2020; 6: 1-10.

38. Varghese C et.al. Prevention and reduction of pain, bruise and hematoma by 'Moist Ice Pack' application on the site of subcutaneous heparin injection. Nursing and Midwifery Research Journal, 2016; 2(4): 34

Received on 14.04.2020 Modified on 21.09.2020

Research J. Pharm. and Tech 2021; 14(11):5790-5796.

DOI: 10.52711/0974-360X.2021.01007