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Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1322-1327
The evaluation of Valsalva maneuver on pain intensity within the needle insertion to the arteriovenous fistula for patients undergoing hemodialysis in the selected hospitals in Isfahan in 2015

Department of Medical Surgical Nursing , Nursing and Midwifery Faculty, Isfahan (Khorasgan) Branch, Islamic Azad University, Tehran, Iran

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Date of Web Publication6-Nov-2017


Introduction: Pain is an unpleasant feeling and it is called as the fifth vital sign. Fistula cannulation in hemodialysis patients is a very stressful and painful process. Nurses can help relieve pain with the use of nonpharmacological pain management therapies, independently. This study conducted aimed to investigate and determine the effect of Valsalva maneuver on pain intensity during cannulation of arteriovenous fistula (AVF) in patients undergoing hemodialysis. Materials and Methods: This study was conducted on 35 hemodialysis patients who were selected by convenience sampling in two Amin Medical Center and Hazrat-e Zahra-e Marziye Hospital in Isfahan. Data collection was performed using an interview questionnaire developed by the researcher, Abbey pain scale, and numerical pain rating. Data analysis was done using the descriptive and analytic tests in SPSS Software Version 20. Results: Paired t-test results showed that the score average of objective and subjective pains was reduced significantly after intervention compared to before that (P < 0.001). Wilcoxon test showed that the objective pain is reduced after intervention (P < 0.001). Wilcoxon test showed that the subjective intensity due to the needle insertion had a significant reduction after intervention (P = 0.001). Conclusion: Performing the Valsalva maneuver before the AVF cannulation reduces pain in patients undergoing hemodialysis.

Keywords: Hemodialysis, pain, Valsalva maneuver

How to cite this article:
Davtalab E, Naji S. The evaluation of Valsalva maneuver on pain intensity within the needle insertion to the arteriovenous fistula for patients undergoing hemodialysis in the selected hospitals in Isfahan in 2015. Ann Trop Med Public Health 2017;10:1322-7

How to cite this URL:
Davtalab E, Naji S. The evaluation of Valsalva maneuver on pain intensity within the needle insertion to the arteriovenous fistula for patients undergoing hemodialysis in the selected hospitals in Isfahan in 2015. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Jul 12];10:1322-7. Available from:

   Introduction Top

Pain is an unpleasant feeling and an emotional experience which is associated with the actual or potential tissue damage and physiological and psychological response and the most common cause of visiting the health-care centers.[1] In this regard, the American Pain Society classifies pain as the fifth vital sign which emphasizes the importance of pain and increases the awareness of health-care professionals about its control.[2] Millions of people worldwide suffer from pain without adequate treatment every year.[3] One of the main reasons is diagnostic-therapeutic procedures.[1] Patients often claim that the pain resulting from a procedure is worse than the condition which needs the procedure. If pain is not prevented and treated, patients experience several harmful effects and its levels increase by consecutive procedures.[4] One of the most common invasive procedures in hospitals is inserting the intravenous catheters.[5] This process is painful and stressful.[6] Fear of injection by needles affects at least 10% of the population and in severe cases may lead to avoidance of medical care.[7] Hemodialysis patients are frequently exposed to the pain resulting from inserting big needles to their fistula for about 300 times which must continue in their lifetime or until a successful kidney transplant.[8] Nayak-Rao (2011) indicates that pain is associated with decrease in quality of life indicators including increased disease, depression, and decreased life satisfaction.[9] Asgari et al. (2013) quoted Taqinejad and Tahmasby who stated the important point of taking care of these patients is that they need to be supported for these complications.[10] Khalili Shumia et al. also quote Kim et al. who believed that the standard method for skin anesthesia in intravenous injections includes injection into the skin surface and subcutaneous layers using lidocaine and prilocaine using a thin needle and with respect to the injection of anesthetic material is painful, a risk of injuries caused by needle will cause discomfort, fear, and anxiety, so using it in venipuncture does not make sense.[11] Furthermore, lidocaine makes skin tighter and putting the needles harder. Injection of local anesthetics is usually not useful because of vasoconstriction, pain, and infection which often occur.[12] Nonpharmacological interventions include nursing activities that can relieve pain. Such interventions are effective, simple, and safe and do not require specific time and costly equipment. In addition, the side effects caused using medication are reduced in nonpharmacological method.[13] Valsalva maneuver is one of the nonpharmacological methods that can be used to reduce pain. Valsalva maneuver increases the intrathoracic pressure leading to activation of baroreceptors and thus stimulation of vagus.[6] Vigal stimulation causes relief pain in humans.[14] Valsalva maneuver does not require any equipment. Its learning is easy for patients and reduces the pain intensity related to peripheral venous cannulation and also has increased the success rate of venous cannulation.[7] Valsalva maneuver also reduces the pain caused by skin puncture in spinal injection.[15] This maneuver causes a distraction; therefore, this method is used to relieve the pain of venipuncture in children.[14] With respect to the patients' rights and needs of Maslow's pyramid, relieving pain is one of the basic human rights. Therefore, pain assessment and management are considered as the nursing priority and one of the important aspects of clinical nursing.[16] Hence, the need to find the new agents with maximum effect and minimal side effects which are accepted by all patients is of importance.

Given that the majority of studies have emphasized on pain control during insertion of vascular needles in patients undergoing hemodialysis and pain relief should be considered as a part of their treatments.[17] Valsalva maneuver was introduced as a pain-reducing method in venous cannulation in several studies, but the effect of this maneuver in pain reduction resulted from arteriovenous fistula (AVF) cannulation in patients undergoing hemodialysis has not yet been studied; therefore, this research was conducted with the aim of identifying the effect of this treatment method in relieving or reducing the pain resulted from inserting vascular needles to the AVF in the patients undergoing hemodialysis and if it is effective, the research findings can be applied by clinical nurses in the care and relief of pain associated with AVF cannulation in hemodialysis section and also teaching these methods to the patients.

   Materials and Methods Top

This research is a quasi-experimental study design as a clinical trial. The target population of this study included all patients over 18 years, undergoing hemodialysis in Amin Medical Center and Hazrat-e Zahra-e Marziye Hospital in Isfahan. Sampling method in this study was convenience sampling in which 35 samples were selected by visiting the researchers in research environment.

To achieve to the goal of this research, three tools were used to collect data:

  • Tool 1: interview questionnaire including personal information, medical information, and information related to AVF. This research-made questionnaire is prepared to evaluate the sociodemographic and medical information of patients and includes three parts:

  • o Part one: the personal information including the information related to age, sex, occupation, education level, and marital status

    o Part two: medical information including the information about end-stage renal disease cause, term of dialysis, the presence of chronic diseases, vital signs (pulse and blood pressure), results of renal function test (blood urea nitrogen [BUN] and creatinine), dry weight of patient, and transplant history, chronic diseases

    o Part three: related information to AVF including the information about the time length of fistula and the problems related to AVF including inflammation, warmth, redness, pain, hematomas, and hemorrhage

  • Tool 2: Abbey pain scale: This scale was used to evaluate the objective behavior of pain.[3] It includes six items of vocalization, facial expressions, changes in body language, behavioral change, physiological change, and physical change. Pain is classified as multiple parts (four points) in this scale.[18] Each option is four-point Likert boxes that classified the objective behavior of pain as several subtitles. Vocalization option includes groan, shouting, and crying; facial expression option includes nervousness, scowled, and frightened face; and change in body language option includes anxiety, moving, taking a part of the body, and pulling. Behavioral change option includes confusion, refuse to eat, and change in usual patterns. Physiological change option includes changes in temperature, pulse, and blood pressure within the normal range, sweat, warmth, or paleness. Physical changes include skin puncture, arthritis, contractor, and previous injuries. The scores of each option have been arranged from 0 to 3 which 0, 1, 2, and 3 represent no pain, mild pain, moderate pain, and severe pain, respectively. All scores are added as a higher score represents the total score of pain intensity. Total score: 0–2 represents no pain, 3–7 represents low or mild pain, 8–13 indicates moderate pain, 14 and higher indicates severe pain [3]
  • Tool 3: pain numerical rating scale 0–10: this scale is provided by McCaffery and Beebe to evaluate subjective pain. This scale consists of a 10 cm line which is numbered from 0 to 10[3] where 0 represents no pain and 10 shows the most severe pain. Ranking scores as 1–3 represent mild, 4–6 represent moderate, and 7–10 represent severe pains, respectively.[6]

Content validity method was used to determine the scientific validity of interview questionnaire. So that the above questionnaire was examined by five members of the faculty of Islamic Azad University Isfahan (Khorasgan) Branch in terms of content and appearance validities and was approved after revisions. The interview questionnaire has the essential reliability due to demographic recording. Medical information was recorded based on patient records and the information related to AVF and has the required reliability. Regarding the validity of Abbey pain questionnaire, the questionnaire was examined and approved by five faculty members of Islamic Azad University Isfahan (Khorasgan) Branch. The internal consistency of questionnaire was obtained as 0.774 using alpha Cronbach's method and test-retest method was used to calculate the reliability of the tool that Pearson correlation coefficient is calculated as 0.843 and it was determined 0.87 for this tool in the study by Fareed et al.

The scientific validity and reliability of numerical rating scale of the pain were considered as 0–10 in several studies. Asgari et al. stated that the results of Hoggart and Williamson study regarding this tool show that this tool has appropriate validity and reliability and actually can be used in treatment. In the study by Fareed et al., the Pearson correlation coefficient for pain numerical rating scale of 0–10 was determined 0.94.

In this study, the following inclusion criteria were considered: 1 - patients treated with hemodialysis, 2 - dialysis is performed through AVF, 3 - patients desired to participate in the study, 4 - they should be older than 18 years, 5 - they should be fully conscious and have the ability to respond the questions, 6 - verbal and visual communication can be achieved, 7 - without feeling severe pain in the area of the body before inserting needles into the fistula, 8 - no history of drug use, 9 - analgesics or sedatives were not used within 6 h before hemodialysis,[10] 10 - AVF cannulation is possible over a time, 11 - without the history of diseases such as Alzheimer, dementia, peripheral vascular disease, neuropathy disorders due to diabetes, 12 - without the history of heart diseases, glaucoma, increased pressure in the brain, and recent eyes surgery,[7] 13 - without inflammation and damage, redness, pain, and bruising in the skin where needle is inserted into the fistula, and 14 - be able to perform the Valsalva maneuver and keep the column of mercury up to 20 mmHg for 20 s.[6]

Exclusion criteria in this study were determined by researchers as: 1 - unwillingness of patients to continue to participate in the study, 2 - death or not to continue treatment in the second session, 3 - lack of proper venipuncture with an attempt at the second session of treatment, 4 - taking a tranquilizer before the start of the second session of hemodialysis, and 5 - inability to correctly perform the Valsalva maneuver.

In the procedure, after obtaining the necessary permits from the Islamic Azad University Isfahan (Khorasgan) Branch and Isfahan University of Medical Sciences and obtaining a code of ethics, coordination with the authorities was done and after selecting the samples and informed consent from them, patients were evaluated at two consecutive sessions of dialysis. In the first session without intervention, 10 min before AVF cannulation and 5 min after it, patients' pulse and blood pressure were checked and recorded by the researcher. Before fistula cannulation, evaluation of subjective pain caused by inserting needle to the fistula based on pain numerical rating scale was taught by the researcher to patients. Then, arterial cannulation with the needle gauge 16 was performed by nurses at least from a distance of 5 cm of fistula at an angle of 30°–45° while the bevel edge of needle was high.[10]

In the second session or intervention and 10 min before cannulation, patients' blood pressure and pulse were controlled and recorded, and the methods were taught by researcher to each patient. Then, electrodes of heart monitoring device were attached to the patient in lying position and heart rhythm and pulse rate of the patient were controlled during exercise. Then, the patients were requested to blow into the hole of disposable syringe which was mounted in one side of plastic tube of sphygmomanometer and its other side was connected to manometer of sphygmomanometer, and the mercury column was brought up to 20 mmHg and kept there for 20 s. The tube had a small hole that made maneuver with closed epiglottis difficult and thus opening epiglottis and performing correct at time of maneuver was provided.[19] Arterial cannulation was performed by the nurse 20 s later.[7] The syringe was used for personal hygiene. Abbey pain questionnaire was filled by the researcher during cannulation and immediately after fixing needle, researcher asked patient to express the score of subjective pain due to the needle insertion. 5 min after cannulation, patient's pulse and blood pressure were controlled and recorded by the researcher, again.

Data analysis

All data were collected and the analysis results were determined using paired t-test and Wilcoxon test. P < 0.05 was considered statistically significant.


According to the research results, the medical and demographic statistics show that the most percent of the studied units' frequency (37.1%) is related to two age groups of 50–59 and 60–69 and by sex, men: 62.9%, occupation (homemakers and unemployed): 45.7%, primary education: 28.6%, married: 94.3%, the cause of chronic renal failure (diabetes): 34.3%, term of dialysis (1–3 years): 51.4%, duration of fistula (1–3 years): 42.9%, no aneurysm fistula: 57.2%, no history of transplantation: 85.7%, no chronic diseases (hepatitis C): 97.2%. Mean of dry weight: 65.6 kg, BUN: 113.4 ± 28.2 mg/dl, and creatinine: 8.01 ± 2.19 mg/dl.

[Table 1] shows that the averages of objective and subjective pain scores before intervention are 2.9 ± 0.7 and 5 ± 1.6 and after intervention are 2.4 ± 0.7 and 4.1 ± 1.7, respectively. Paired t-test showed that the averages of objective and subjective pain scores after intervention are decreased significantly (P < 0.001) compared to before intervention.
Table 1: Score averages of objective pain and subjective pain before and after intervention

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Results of [Table 2] show that 31.4% and 68.6% of the studied units were without pain or with a mild pain, respectively, before intervention and in terms of inserting needle to AVF. After intervention, 71.4% were without pain while 28.6% had a mild pain and none of them felt the objective pain with high intensity. Wilcoxon test results showed that the objective pain intensity is decreased after intervention (P < 0.001).
Table 2: Objective pain intensity before and after intervention in the research units

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Results of [Table 3] showed that 14.3%, 71.4%, and 14.3% of the studied units had mild, moderate, and severe pain, respectively, in terms of subjective pain due to needle insertion before intervention. After intervention, 42.9%, 45.7%, and 11.4% had mild, moderate, and severe pain, respectively. Wilcoxon test results showed that the subjective pain intensity due to needle insertion was decreased significantly, after intervention (P = 0.001).
Table 3: Subjective pain intensity before and after intervention in the research units

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   Discussion Top

The demographic (age and sex) and medical statistics (diabetes) in patients are not a measure of hemodialysis in all patients as these patients were selected based on having the AVF. Yevzlin et al. indicated that the success of AVF in patients over 65 years, females, and diabetics is lesser.[20] According to the results of this study to compare the severity of pain within the needle insertion to AVF in Valsalva maneuver before and after intervention, [Table 1] shows that the score averages of objective and subjective pains decreased significantly in Valsalva maneuver group (P < 0.001) which is inconsistent with the results of VR et al. study conducted with the aim of evaluating the effect of Valsalva maneuver on pain intensity before peripheral intra venous cannulation. In this study, 100 patients participated. Subjects were allocated into control (50) and intervention group (50). Their study showed that the average score of subjective pain was 3.98 ± 1.48 and 4.7 ± 1.75 in intervention (Valsalva maneuver) and control groups, respectively. The score average of subjective pain in intervention group was significantly less than control group (P < 0.01) which is in consistent with the results of this study. In Mohammadi et al. study, the average score of subjective pain in Valsalva maneuver group was significantly less than control and ball groups (P < 0.001) which is consistent with the results of the study. Suren et al. study evaluated and compared the effect of using Valsalva maneuver and eutectic mixture of local anesthetics (EMLAs) on pain intensity due to venipuncture on three groups: C, V, and E. The average of pain intensity after venipuncture in Group C was evaluated in the range of 0–3.9, while the averages of pain intensities in E and V groups were evaluated as 0–2.7 and 1–2.8, respectively. Valsalva maneuver shows similar results with EMLA in terms of pain reduction within venipuncture which is in consistent with results of the present study. Therefore, Valsalva maneuver method is effective in reducing of subjective pain due to needle insertion to AVF of hemodialysis patients. Based on [Table 2] in terms of objective pain intensity within needle insertion to AVF before and after intervention, Wilcoxon test results showed that objective pain intensity reduced after intervention (P < 0.001). The researchers worked hard to find other similar studies about the score average of objective pain using Valsalva maneuver, but no research was found to confirm or reject these results. According to [Table 3] and in terms of subjective pain intensity within needle insertion to AVF before and after intervention, Wilcoxon test results showed that objective pain intensity is reduced significantly after intervention (P = 0.001) which results of VR study indicated that 66% of patients in the intervention group had a mild pain while 64% of them in the control group had moderate pain. Only 2% in the intervention group had severe pain while 10% of individuals in the control group had a severe pain which is almost in consistent with the present study.

   Conclusion Top

Based on the result of this study, it can be said that Valsalva maneuver method reduces the intensity of objective and subjective pains due to the needle insertion in patients undergoing hemodialysis as a simple nonpharmaceutical and cost-effective method. Thus, this method is recommended for pain management in hemodialysis patients before AVF cannulation.


This article is a part of master's thesis which has been registered in Clinical Trial Center of Iran, with the code of IRCT2015081423615N1. We thank and appreciate all the authorities and personnel of Amin and Hazrat-e Zahra-e Marziye hospitals and also all patients who help us in this project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Suren M, Kaya Z, Ozkan F, Erkorkmaz U, Arlcl S, Karaman S. Comparison of the use of the Valsalva maneuver and the eutectic mixture of local anesthetics (EMLA) to relieve venipuncture pain: A randomized controlled trial. Jpn Soc Anesthesiol 2013;27:407-11.  Back to cited text no. 7
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Correspondence Address:
Sayedali Naji
Nursing and Midwifery Faculty, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_202_17

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