الفهرس 
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Abstract
Children undergoing hemodialysis exposed to the fistula puncture pain every session. Providing painless free treatment is a basic right for those children that require the cooperation of caregivers, health team and children. It can be achieved through training of nurses to use appropriate and safe methods and conducting more researches at this point to improve their quality of life. Complementary and alternative medicine such as cryotherapy and aromatherapy play an effective role in managing pain. Implementation of cryotherapy and inhalation of lavander oil offers a non-pharmacological strategy to reduce arteriovenous fistula puncture pain that requires simple inexpensive equipment and can easily be used by the children themselves or their parents after educating and training them. The current study aimed to evaluate the effect of cryotherapy versus aromatherapy on pain of arteriovenous fistula puncture for children undergoing hemodialysis. A quasi-experimental research design was used in the present study. The study was conducted at dialysis unit of Pediatric Medical Department of Tanta Main University Hospital and dialysis Unit of Elmenshawy General Hospital which is affiliated to the Ministry of Health and Population. A convenience sampling consisted of sixty children undergoing hemodialysis with arteriovenous fistula was collected from the above previously mentioned settings. They were divided randomly into two equal groups namely: 1- group (I): Thirty children who received cryotherapy. 2- group (II): Thirty children who received aromatherapy (lavender oil inhalation). Inclusion criteria of children included the following: Both sexes, age from 6-15 years, capable of verbal and non-verbal communication, conscious and willing of them and their parents to participate in the study and children have functioning arteriovenous fistula. Tools of data collection: Three tools were used in the current study as the following: Tool I: Structured interview Schedule: It consisted of three parts: Part one: Sociodemographic characteristics of the studied children: The form covered the personal characteristics of the studied children, including their age, sex, educational level, and residence. Part two: It covered the medical history of children including the duration of their disease, co-morbidities, duration, and frequency of their hemodialysis and characteristics of their arteriovenous fistula as site and duration of fistula. Part three: It included data about the child-caregiver such as their age and educational level. Tool II: Pain assessment Wong-Baker faces pain rating scale: It was adopted from Wong (1988). It was used as a self-report scale to measure the subjective pain intensity of children during the fistula puncture. The scale included six drawn faces expressing various degrees of pain, severity ranged from “does not hurt” to “hurts very much”. These faces were assigned scores from 0 to 10 with a higher score indicating a higher severity of pain. Tool III: Children Behavioral Distress Observational Check List: It consisted of three parts: Part one: Children Behavioral Distress Observational Check List: It was adopted from Elliot (1987). It was used to observe children’s behavioral reactions before, during and after fistula puncture which indicated discomfort (cry, scream, physical restraint, verbal resistance, emotional support, information seeking, verbal pain, and flail) at 15- second intervals throughout the procedure ( fistula puncture), giving them score according to the severity of distress shown by the child. The scores were summed for each 15-second interval within phases of the procedure and then were divided by the number of intervals to obtain a mean score. Part two: Physiological measurements that could be influenced by pain were assessed before, during and after fistula puncture. These measurements included respiratory rate, pulse, blood pressure, and oxygen saturation. Part three: Assessment of the arteriovenous fistula puncture site: It was done before and after cryotherapy, implementation to detect any local skin reactions such as ecchymosis, swelling and skin dryness. The main results of the present study: • Regarding the age of children, it was evident that more than half of the studied children (56.7%) and 43.3% were between 12 -15 years old with the mean age were (11.37±2.84 and 11.27±2.67) years in cryotherapy and aromatherapy groups respectively. • It was clear that 60% and two thirds (66.7%) of children were females respectively, in cryotherapy and aromatherapy groups. • Regarding their residence, most of the children (80%) and two thirds (66.35%) of them respectively were from rural areas in cryotherapy and aromatherapy groups. • Regarding their educational level, it was found that 60% and half of children respectively were in primary school in both cryotherapy and aromatherapy groups. • Regarding the duration of their disease, the mean ± SD duration was 9.17±10.93 and 11.77±7.70 months respectively for children in both cryotherapy and aromatherapy groups. • As regards the duration of hemodialysis, it ranged from 8-40 months for children of the cryotherapy group, compared to 10-36 months for children in the aromatherapy group. • In addition, the duration of the fistula for cryotherapy group children ranged from 8-42 months with the mean ± SD was 17.80 ± 8.652 months. While in the aromatherapy group, it was ranged from 5-38 months with mean ± SD was 15.0 ± 8.84 months. • Regarding cryotherapy group, it was observed that the mean ± SD of Wong baker faces pain rating scale score during fistula puncture was 7.266±2.13 and 5.667±2.23 respectively on session 1 and 2 which decreased to 2.666±2.24 and 1.733±1.63 respectively on session 3 and 4. • Regarding aromatherapy group, it was evident that the mean ± SD of Wong baker faces pain rating scale score during fistula puncture was 6.666±2.42 and 6.200±2.12 respectively on session 1 and 2 which decreased to 4.866±2.60 and 4.133±2.62 respectively on session 3 and 4. • It was clarified that there was a statistically significant difference between a third and fourth session where (P=0.024 and P=0.007) respectively among children of both groups regarding their Wong- Baker faces pain rating scale scores during fistula puncture. • The current study revealed that there were statistically significant differences among children in the cryotherapy group where (P=0.000, P=0.000, and P=0.017) respectively before, during and after fistula puncture regarding their level of behavioral distress scores on 1st, 2nd, 3rd and 4th session. • It was noticed that mean ± SD of change in total behavioral distress scores pre and post the intervention (II than I) was 4.383±2.15, 4.850±2.88 and 3.183±1.76 respectively before, during and after fistula puncture among children in the cryotherapy group. • In contrast to aromatherapy group, mean ± SD of change in total behavioral distress scores pre and post the intervention (II than I) among children was 2.400 ± 2.53 before fistula puncture then became 3.8 ± 3.10 during fistula puncture and became 0.850 ± 2.32 after fistula puncture. • It was observed that there were statistically significant differences between the studied children where (P=0.000, P=0.002, and P=0.000) respectively before, during and after fistula puncture respectively regarding total behavioral distress scores post the intervention (II) between cryotherapy and aromatherapy group in session 3 and 4. • Regarding the respiratory rate, It was found that before, during and after fistula puncture, it was found that there were statistically significant differences where (P=0.000, P=0.000 and P=0.000) among the studied children in cryotherapy and aromatherapy groups regarding mean of respiratory rate on 1st, 2nd, 3rd and 4th session. • • It was evident that on the 1st, 2nd, 3rd and 4th session, there were statistically significant differences where (P=0.005, P=0.000, P=0.000, and P=0.006) respectively among the studied children of cryotherapy.