Effect of the coughing technique during subcutaneous heparin injection on pain severity and individual satisfaction

Objective: to examine the effect of the medium intensity coughing technique during subcutaneous low molecular weight heparin injection on pain severity and individual satisfaction in general surgery patients. Method: the prospective, quasi-experimental study included 100 patients who had been prescribed a subcutaneous low molecular weight heparin injection once in 24 hours. Each patient received two injections by the same researcher, one using the standard injection technique with medium intensity coughing technique and the other only the standard injection technique. Results: there was a statistically significant difference between patients’ mean scores on pain severity and satisfaction levels after injections administered by the two techniques (p= 0.000). Also, it was found that gender affected pain severity relating to the injection but did not affect the level of individual satisfaction. Conclusion: the medium intensity coughing technique was found to reduce pain severity and increase patient satisfaction in general surgery patients receiving subcutaneous low molecular weight heparin injections. Trial registration: NCT05681338.


Introduction
Today, medications are given by the oral and parenteral routes. One method of parenteral drug administration is subcutaneous injection, the method of introducing the medications under the dermis into the adipose tissue. The types of medication generally administered by the subcutaneous route are vaccinations, insulin, hormones and low molecular weight heparin (LMWH) (1) . LMWH is a type of heparin which is prepared by the depolymerization of the widespread form of heparin, and can only be given by the subcutaneous route (2)(3) .
LMWH is frequently used as a treatment and particularly as a protective in clinical situations where there is a risk of thromboembolism or where thromboembolitic events have occurred (3)(4) . LMWH has advantages such as high bioavailability, a powerful antithrombotic effect and a lowered risk of bleeding, making it increasingly preferred in clinical applications (5) .
Generally occurring local side effects of the administration of LMWH by the subcutaneous route are reported to be bruising, hematoma and pain at the injection site. One complication frequently complained of by patients is pain; this is caused by the presence of pain receptors in the subcutaneous tissue (6)(7)(8)(9)(10)(11) . Also, a sensation of pain occurs as a result of tissue damage occurring with the introduction into the tissue of the LMWH solution (12) .
This can cause adverse effects in the patient such as anxiety, a disturbance in body image, pain in the injection area, refusal of treatment, and even a loss of trust in the nurses (7) . For this reason, it is of great importance to implement strategies that will be of use in protecting patients from these kinds of adverse effects during the administration of subcutaneous heparin (12) .
In health institutions, one of the most important responsibilities of nurses is the safe administration of medications (13) . It is reported that after subcutaneous heparin injections, various factors can cause complications at the injection site (14) . In particular, factors which can lead to pain complications are seen to mostly arise from the injection technique, and there are studies evaluating nonpharmacological methods for managing pain developing in connection with subcutaneous heparin injection.
Recently, the use of the coughing technique as a different non-pharmacological method in the management of pain developing from various invasive procedures has attracted attention. It is underlined that this technique is easy to learn, does not take time, and does not involve extra cost or equipment (19)(20)(21) . It is reported that its potential mechanism relies on the Valsalva maneuver and on directing the attention elsewhere (22)(23) .
The coughing technique increases intrathoracic pressure and stimulation of the autonomic nervous system, thereby causing an increase in heart rate and blood pressure, a higher level of pressure in the subarachnoid space and baroreceptor activation (20)(21) .
The increase in pressure in the subarachnoid space brings the segmental pain prevention pathways into action, and this has the effect of reducing the perception of pain (20,22) .
It has also been reported that as a result of the Valsalva maneuver, this technique has an antinociceptive effect, reducing the perception of pain in connection with vagal nerve stimulation. During this maneuver, the vagus nerve is stimulated in connection with baroreceptor activation, and this has an antinociceptive effect (24)(25)(26)(27) .
Also, the antinociceptive effect has been explained as occurring through central inhibition relating to the noradrenergic, serotogenic and endogen opioid systems with vagus nerve stimulation (23,28) . On the other hand, it has been reported that another mechanism of the coughing technique depends on the method of directing the attention elsewhere and of diverting the attention so that the person does not feel pain (29) , and that it increases a person's tolerance of pain (23,30) . Studies in the literature dealing with the coughing technique report that it is effective in reducing pain in interventions such as peripheral intravenous catheterization (22)(23) , taking a blood sample (20) , or vaccination (19,21) .
In observing the administration of subcutaneous LMWH injection administration in the clinical setting, it is seen that there is much indecision on the part of nurses as to which technique should be used to increase satisfaction and to manage the pain which develops in relation to this frequently administered injection. In particular, in addition to factors such as an excessive amount of work, a large number of patients and a shortage of time, it was observed that there was a big gap in knowledge of the use of an effective technique which was easy for nurses to use, was simple, and did not involve equipment or cost, to increase individual satisfaction and reduce the pain relating to subcutaneous LMWH injections. Recently, despite reports that the coughing technique is effective in controlling the pain arising from invasive procedures (19,(22)(23) , it was seen that the effect of this technique had not been investigated in the administration of subcutaneous LMWH injections. Also, it was seen that there were no studies considering this technique along with individual satisfaction, which is a very important parameter in increasing patient trust. Thus, a need was felt for this study, as there were few on this topic. It is thought that Yılmaz D, Ayhan D, Yılmaz DU, Düzgün F. the results of the study will help nurses to give injections safely while reducing the pain of subcutaneous LMWH injections and increasing satisfaction with them. This study may serve as a guide for future researchers, who can use this research as a reference. Accordingly, the aim of this study was to examine the effect of the medium intensity coughing technique during subcutaneous low molecular weight heparin injection on pain severity and individual satisfaction in general surgery patients.

Study sample
A convenience sample was used, which included participants, who were consecutively accessible over a period of time and who met the eligibility criteria.
The eligibility criteria for the sample were being over the

Visual Analog Scale (VAS)
In evaluating the severity of pain felt by the patients during subcutaneous injections, a 10 cm long vertical VAS was used, on which one end represented no pain, and the other end the worst possible pain. The VAS is a commonly used pain assessment scale in clinical settings. Its validity and reliability in measuring the severity of pain in adults have been demonstrated (33) . Pain severity measurements were evaluated in millimeters.

Visual Individual Satisfaction Scale (VISS)
During the administration of the injection, an evaluation was made to determine individuals' satisfaction using the Visual Individual Satisfaction Scale, which consisted of a vertical 10 cm scale with "I'm very satisfied" written at one end of it and "I'm not at all satisfied" at the other. The Visual Individual Satisfaction Scale incorporated the characteristics of the well-known Visual Analog Scale (VAS). VISS is a valid scale widely used in adults to assess individual satisfaction (34) .

Ethical considerations
The necessary permission to conduct the research  Figure 2 shows the steps of the administration of the standard subcutaneous LMWH applied to all patients.   Distributions of descriptive information on patients obtained as a result of the study were given as means and SDs. Since the data was found to be normally distributed, the nonparametric Wilcoxon signed rank test was used in dependent groups, and the Mann-Whitney U test and Kruskal Wallis-H test were used for two independent variables. The level of statistical significance was determined as p < 0.05.

Results
It was found that 56% of the patients participating in the research were male, their mean age was 60.48±12.76 years, 29% were in the clinic for a cholecystectomy operation, 38% were overweight, and their mean BMI was 26.69±5.56 kg/m 2 ( Table 1).     Table 3).

Discussion
Subcutaneous LMWH injections are an important part of drug administration. One of the basic responsibilities of nurses is to protect patients from preventable side effects by the use of correct techniques (9,13) . Taking under control the pain which frequently occurs in the injection area in connection with the administration of subcutaneous LMWH injections will make acceptance of the treatment easier by increasing an individual's comfort and satisfaction.  (6) , and that Yılmaz D, Ayhan D, Yılmaz DU, Düzgün F. the manual pressure method increased comfort levels (12) .
Along with reduction of pain, an increase in patient satisfaction is expected. Although the methods used to control pain are different, it is seen that the techniques which were effective in reducing pain in the results of the studies mentioned above also increased satisfaction with the injection. Evaluated from this aspect, the increase in satisfaction with the injection with the coughing technique, with which patients reported less pain in our study, was assessed as a likely result.
In a study in which the effect of mechano-analgesia and cold application on bruising, pain and patient satisfaction relating to subcutaneous heparin injection was investigated, it was concluded that the mean pain severity scores of female patients were significantly higher than those of male patients, but that the variable of gender did not affect the level of patient'satisfaction (6) .
Similarly, it was found in the present study that the mean pain severity of female patients following an injection administered by the coughing technique was significantly higher than that of male patients, but that the variable of gender did not affect the level of satisfaction of patients after an injection. In some studies in the literature in which different techniques were used to reduce the pain felt during subcutaneous heparin injections, a significant correlation was found between pain severity and gender (9) , but in others, it was concluded that there was no such correlation (12,(36)(37) . It is thought that these differences between the studies mentioned above and the results of our study may arise from differences in the subcutaneous injection techniques with patients included in the study groups.
It was found as a result of this study that the variable of patients' body mass index did not significantly affect the mean scores of pain severity and satisfaction level after injection by either method. Examining studies in the literature, it was found that they concluded that the variable of body mass index had no effect on the pain severity (12,37) and satisfaction level (6,12) connected with subcutaneous heparin injection. It is seen that the findings of our study are similar to the results of these studies.
However, one study investigated the effect of manual pressure applied for different lengths of time following subcutaneous heparin injection on pain and bruising, it was concluded that the mean pain severity of overweight and obese patients was significantly greater than that of underweight or normal weight patients (9) . In our study, it was found that the pain severity of obese patients was greater than that of underweight, normal weight and overweight patients, although this did not reach the level of significance. It has been reported in other studies that obese individuals experience pain more intensely (38)(39) .
Also, it has been reported that because pain receptors are found in the subcutaneous tissue, stimulation of this region will cause a feeling of pain (6)(7)(8)(9)(10)(11) .

Conclusion
The results of the current study found that the medium intensity cough technique applied to patients during the administration of a subcutaneous LMWH injection reduced the severity of the patients' pain and Rev. Latino-Am. Enfermagem 2023;31:e3924.
increased the level of satisfaction which they felt with the injection. Also, it was found that the variable of gender affected pain severity relating to the injection, but did not affect the level of individual satisfaction. In addition, it was found that there was no correlation between the variable of BMI and the severity of pain and level of satisfaction.