الفهرس 
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Abstract
Preterm neonates admitted to NICUs are exposed to a variety of environmental stressors. This is in addition to their daily exposure tomany painful procedures such as endotracheal suctioning, intravenous cannulation and blood sampling. Pain can evoke negative physiologic and behavioral responses in preterm neonates. As a matter of fact, evaluation of pain during the neonatal period is difficult because neonates cannot verbalize the perceived pain. The neonatal nurse has a crucial role in pain assessment, management and prevention. This is important for prevention of any adverse effects on preterm neonates. She should use non-pharmacologic techniques as sensory stimulation pain relieving strategies in an effective and safe manner to relieve neonatal pain. Therefore, this study was carried out to determine the effect of tactile versus auditory stimulation on pain associating blood sampling among preterm neonates.
The study was conducted in NICUs at El- Raml Children’s Hospital (Wingat) in Alexandria and Kafer El-Dawar General Hospital (El-Shamla) in Al-Behera. A convenience sampling of 90 preterm neonates admitted to NICU two days after delivery compromised the subject. They were free from cardiac congenital malformations and did not receive any sedatives. Neonates were divided equally into three groups (30 neonates each) as follows; preterm neonates receiving tactile stimulation, preterm neonates receiving auditory stimulation and preterm neonates receiving routine hospital care only.
Two tools were used to collect the data. Tool one was developed by the researcher and is concerned with characteristics and Medical History of Preterm Neonates. While, tool two dealt with Neonatal Infant Pain Scale (NIPS). This tool was developed by Lawrence et al in (1993)(62). It was updated by the University of California, San Francisco Children’s Hospital Medical Center in (2005)(63). Thetool was used to assess pain experienced by preterm neonates through assessing their physiological and behavioral parameters. The NIPS scale is divided into eight subscales to assess preterm neonates’ facial expression, cry, breathing patterns, arms and legs movements, state of arousal, heart rate, and oxygen saturation. The total score ranged from 0-10, where zero score represents no pain, a score of 1-3 represents mild pain, a score of 4-6 represents moderate pain and a score of 7-10 represents severe pain. Assessment of pain was performed before obtaining the blood sample for each preterm neonate in the three groups. It was also assessed during puncture, immediately after puncture and five minutes later once a day in the morning shift for two days.
Stimulating the preterm neonates in both groups (group 1 and group 2) was performed five minutes before performing the blood sample procedure. It was continued throughout the puncture, immediately after the puncture and five minutes later once a day in the morning shift for two days.
The main findings of this study showed the following:
Characteristics and Medical History of Preterm Neonates
• Ages of preterm neonates in the tactile stimulation group, the auditory stimulation group and the control group were 2 to less than 9 days (50.0%, 43.3% and 66.7% respectively).
• Male preterm neonates constituted 53.3%, 56.7% and 53.3% among the tactile stimulation group, the auditory stimulation group and the control group respectively.
• Preterm neonates in the tactile stimulation group, the auditory stimulation group and the control group suffered from jaundice (43.3%, 46.7 % and 46.7% respectively).
Effect of Tactile and Auditory Stimulations on Different Indicators of Pain
• During puncture, grimace was noticed among all preterm neonates in the three groups in the first and second assessment (100% each). Amazingly, all preterm neonates in the tactile stimulation group and the majority of those in the auditory stimulation group showed relaxed facial expression five minutes following blood puncture procedure in both the first (100% and 86.7% respectively) and second assessment (100% and 93.3% respectively). On the other hand, relaxed facial expression was recognized among very low percentages of preterm neonates in the control group in the first and second assessments (3.3% and 6.7% respectively). The difference was statistically significant between the three groupswhether in the first and second assessments (p= 0.000each).
• During puncture, the first and second assessments showed that 73.3% and 86.7% of preterm neonates in the tactile stimulation group and 50% and 56.7% of preterm neonates in the auditory stimulation group respectively showed relaxed breathing pattern compared to none and only 3.3% of those in the control group respectively. The difference was statistically significant between the three groupsin both assessment periods(p=0.000 each). Fortunately, all preterm neonates in the tactile and auditory stimulation groups showed relaxed breathing pattern five minutes after puncture in both the first and second assessment (100% each) compared to 46.7% and 70.0% of those in the control group respectively. The relation between the three groupsin the first and second assessments was statistically significant (p=0.000 each).
• During puncture it was observed in the first and second assessment that, flexed/extended arm movements were noticed among 76.7% and 73.3% of preterm neonates in the tactile stimulation group respectively. Meanwhile, the same kind of movements was recognized among equal percentages of preterm neonates in the auditory stimulation group (80% each) compared to all of those in the control group (100% each). There was statistical significant difference between the three groups(p=0.000). Relaxed arm movements was recognized among (100% and 96.7%) of preterm neonates in the tactile and auditory stimulation groups five minutes after puncture in both the first and second assessments respectively compared to 3.3% and 6.7% of those in the control group respectively. The relation was statistically significant between the three groupswhether in the first or second assessment (p=0.000each).
• During puncture, it was observed in the first and second assessment that, flexed/extended leg movements were noticed among 56.7% and 40.0% of preterm neonates in the tactile stimulation group respectively. While, 80% and 70.0% of those in the auditory stimulation group showed flexed/extended leg movements respectively compared to 96.7% and100% of preterm neonates in the control group respectively. There was statistical significant difference between the three groups (p=0.000). While assessment after five minutes of puncture illustrated that all preterm neonates (100%) in the tactile stimulation group and the majority of preterm neonates (93.3%, 96.7%) in the auditory stimulation group respectively had relaxed legs compared to only 20% each of preterm neonates in the control group who had relaxed legs while the majority of them (80%) had flexed/extended leg movements during the both assessment periods. There were statistical significant differences between the three groups(p=0.000).
• During puncture, the first and second assessments revealed that 73.3% and 76.7% respectively of preterm neonates in the tactile stimulation group were in fussiness and restlessness condition. The same conditions were recognized among the majority of preterm neonates in the auditory stimulation group (93.3% and 96.7% respectively) while, all preterm neonates in the control group were fussy and restless in the first and second assessment (100% each). There was statistical significant difference between the three groups whether in the first or second assessment (p=0.000 each). Fortunately, all preterm neonates in the tactile and the auditory stimulation groups were in the sleeping/Awake state five minutes after puncture in both the first and second assessments (100%each) compared to none and only 3.3% of those in the control group respectively. The difference was statistically significant between the three groups (p=0.000).
• The first and second assessments also portrayed that all preterm neonates in the tactile and auditory stimulation groups (100% each) were not in need of oxygen throughout the sampling procedure i.e. during, immediately after and five minutes following blood puncture. On the contrary, the first and second assessments revealed that during puncture 56.7% and 73.3% of preterm neonates in the control group were in need of oxygen respectively. Furthermore, the need for oxygen immediately after puncture was 46.7% and 50% among preterm neonates in the control group respectively and the relation during and immediately after puncture was statistically significant between the three groups in both assessment periods (p=0.000 each).
• During puncture, the first and second assessments reflected that heart rates were within 10% of the baseline among all preterm neonates in the tactile stimulation group (100% each) and 70% and 90% in the auditory stimulation group respectively compared to only10% and 20% of those in the control group respectively. The difference was statistically significant between the three groups(p=0.000). While, immediately after puncture, the first and second assessment highlighted that heart rates were also within10.0% of the baseline among all preterm neonates in the tactile stimulation group (100% each) and (73.3% each) in the auditory stimulation group compared to only 30% and 26.7% of those in the control group respectively. The difference was statistically significant between the three groups in both assessment periods (p=0.000 each).
• During puncture, the first and second assessment of cry revealed that 56.7% and 73.3% of preterm neonates in the control group had vigorous cry compared to none of neonates in the tactile stimulation group and only 16.7% and 6.7% of preterm neonates in the auditory stimulation group respectively.Fortunately, it was obvious in the first and second assessment that all preterm neonates in the tactile stimulation group (100%each) and the majority of preterm neonates in the auditory stimulation group (90% each) did not cry at all five minutes following puncture compared to 26.7% and 60% of those in the control group respectively and the difference was statistically significant between the three groups in both assessment periods (p=0.000 each).
• The first and second assessment of painduring puncture, showed that the majority of the preterm neonates (90% and 86.7%) in the control group had severe pain respectively compared to 43.3% and 16.7% of preterm neonates in the auditory stimulation group. While, such kind of pain was not felt among preterm neonates in the tactile stimulation group. Five minutes later portrayed that all preterm neonates of the tactile stimulation group (100%) and the majority of preterm neonates in the auditory stimulation group (86.7%, 90%) respectively had no pain compared to none of preterm neonates in the control group. The difference was statistically significant between the three groupsin both assessment periods (p=0.000 each).
Comparison between Pain Experienced by Preterm Neonates in the Tactile Stimulation Group, the Auditory Stimulation group and the Control group
• Comparison between pain experienced by of preterm neonates in the tactile stimulation and the control groups illustrated that, the differences were statistically significant between the two groupsthroughout puncture in both assessment periods (p=0.000each).
• Comparison between pain experienced by preterm neonates in the auditory stimulation group and the control group clarified that, there were statistical significant differences between the two groupsthroughout puncture whether in the first or second assessment periods(p= 0.000each)
• Comparison between pain experienced by preterm neonates in the tactile and auditory stimulation groups during puncture revealed that, the difference was statistically significant between the two groups whether in the first (p= 0.000) or second assessment (P=0.016). Five minutes after puncture,the same table illustrated that, the difference was statistically significant between the two groups in the first assessment (p= 0.038).