PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms.Rossy Oommen

M.sc (n) 1st year

Medical surgical nursing

Year 2010-2011

ST.PHILOMENAS COLLEGE OF NURSING

#4 CAMBELLROAD, VIVEKNAGAR P.O

BANGALORE 56O 047

1


RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Ms.Rossy Oommen
1st year M.Sc nursing,
St. Philomena’s college of nursing, Bangalore-47
2 / NAME OF THE INSTITUTION / St. Philomena’s college of nursing, Bangalore.
3 / COURSE OF STUDY AND SUBJECT / 1ST Year M.Sc nursing
Medical surgical nursing
4 / DATE OF ADMISSION TO COURSE / 1ST June 2010
5 / TITLE OF THE TOPIC / A study to evaluate the effectiveness of guided imagery on pain among post operative patients in a selected hospital at Bangalore.
6. BRIEF RESUME OF THE INTENDED STUDY:
6.1 NEED FOR THE STUDY:
Imagination is only intelligence having fun”
Albert Einstein
Pain is complex, multi-dimensional experience. For some people it is major problem others it is minor. Perception of pain affects all aspects of individual’s life, it may leads to anxiety, increased heart rate and disequilibrium in the maintenance of body temperature.1,2
Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction.3
The world wide statistics of number of surgeries per day is increasing day by day. In U K total number of operations in 2005-2006 was around 7 million. From the reviews and the studies using a systematic collection of data, the estimated incidence of chronic pain after various procedure .i.e. amputation is about 60% thoracotomy 50%, breast surgery about 30%, cholecystectomy 10-20%, inguinal herrnioraphy about 10%. Pain is a significant problem in perioperative settings. Patients report a lack of information about pain control measures and ineffective pain control. 2, 4
A patient-based national survey on post operative pain management revealed that pain intensity monitoring was prescribed for only 2% of cases. However, written post operative pain evaluation was frequent in surgical wards 93.7%, at intervals of 4.1 hour. Preoperative pain was reported at the site of surgery in 62.7% of patients. Patients reporting preoperative pain had significantly more intense postoperative pain at rest (ANOVA, p=0.0002) and when moving (ANOVA, p=0.001) than patients without preoperative pain. Severe pain was present in 4.2% of patients at rest, 26.9% of patients during movement and maximal pain since surgery was severe in 50.9% of patients 5
Another study was conducted to measure the prevalence of postoperative pain and assessment was made of 1490 surgical in patients who were receiving postoperative pain treatment according to an acute pain protocol. Measurements of pain (scores from 0 to 100 on a visual analogue scale) were obtained three times a day on the day before surgery and on days 0–4 postoperatively and mean pain intensity scores were calculated. Patients were classified as having no pain (score 0–5), mild pain (score 6–40), moderate pain (score 41–74) or severe pain (score 75–100). Moderate or severe pain was reported by 41% of the patients on day 0, 30% on days 1 and 19%, 16% and 14% on days 2, 3 and 4. The prevalence of moderate or severe pain in the abdominal surgery group was high on postoperative days 0–1 (30–55%). A high prevalence of moderate or severe pain was found during the whole of 1-4 days in the extremity surgery group (20–71%) and in the back/spinal surgery group (30–64%). Researchers concluded that despite an acute pain protocol, postoperative pain treatment was unsatisfactory, especially after intermediate and major surgical procedures on an extremity or on the spine.6
Effective postoperative pain control is an essential component of the care of the surgical patient. Inadequate pain control, apart from being inhumane, may result in increased morbidity or mortality. The advantages of effective postoperative pain management include patient comfort and therefore satisfaction, earlier mobilization, fewer pulmonary and cardiac complications, a reduced risk of deep vein thrombosis, faster recovery with less likelihood of the development of neuropathic pain, and reduced cost of care. The goal of postoperative pain management is to relieve pain while keeping side effects to a minimum.7
A meta-analysis of randomized controlled trials (RCTs) assessing the effectiveness of a non pharmacological intervention on the management of pain was conducted. Forty-nine relevant primary studies were identified and retrieved. There is evidence, in the form of primary studies, to suggest that non-pharmacological nursing interventions are effective in the management of pain. 8
Guided imagery as an alternative therapy is effective in management of pain. Historically, imagination as a treatment has been used by many cultural groups, including the Navajos, ancient Egyptians, Greeks and Chinese. Imagination has also been used in religions such as Hinduism and Judaism as a healing method. Guided imagery is a simple tool which can empower any one to become a participant in their own healing.9, 10
Guided imagery involves far more than just visual sense and this is a good thing given only about 55% of people have vision as their primary imaginative skill. Over past 24 years the effectiveness of guided imagery has been established by research findings and that demonstrate its positive impact on health.11
Guided imagery involves the conscious use of imagination to create positive images in order to bring about healthful changes. Even it cannot replace other medical treatment; it can be used as a complimentary therapy. Pain is a perception which can be easily diverted by pleasant imaginations. And guided imagination contributes for a comprehensive relaxation since the participant takes a very passive role. Guided imagery done during post operative period doubles the effect since it is added as a compliment with pain medications.
A study published in the journal of pain reveal that among 94 adult cancer patients, those who received imagery training reported less pain than those who didn’t receive imagery. Journal of developmental and behavioral pediatrics found that guided imagery lowered post operative pain in children.12
Nurses need to rekindle the original nursing flame to learn ways to incorporate more caring nurturing behaviors, new therapies and new nursing practices in caring their patients. Instead of being swept away by the high tech, low touch, fast paced, short staffing line, nurses need to make a difference in the patient’s lives by reestablishing and adapting newer technique and modalities in their practices
The investigator’s experience on visiting post operative wards, interviewing few nurses and talking to few patients about guided imagery revealed that nurses and patients are enthusiastic to invite such therapies in routine care.
Hence the researcher is interested to find out the healing power of guided imagery on reduction of post operative pain.
6.2 REVIEW OF LITERATURE
The literature review leads the leader through development of knowledge about chosen topic up to the present time to indicate why this current research is necessary.
Researcher has presented reviewed literature under the following domains:
  Literature related to post operative pain
  Literature related to effects of non pharmacological interventions on post operative pain
  Literature related to effects of guided imagery on different condition
  Literature related to effect of guided imagery on pain
  Literature related to effect of guided imagery on post operative pain.
1.Literature related to post operative pain
A national study was done to assess the patients post operative pain experience and the status of acute pain management with random sample of 250 adults who had undergone surgical procedures by using the telephone questionnaires. Results showed that approximately 80% of patients experienced acute pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain, with more patients experiencing pain after discharge than before discharge. Experiencing post operative pain was the most common concern (59%) of patients. Almost 25% of patients who received pain medications experienced adverse effects. Despite an increased focus on pain management programs and the development of new standards for pain management, many patients continue to experience intense pain after surgery. 13
A study was performed to assess the prevalence and course of postoperative pain in the early postoperative period after ambulatory surgery and 648 patients who underwent day-case surgery were included in study. Data were collected with interviews and questionnaires and pain intensity was measured using a visual analog scale (VAS) during 4 days after surgery. Results showed that on the day of the operation, 26% of the patients had moderate to severe pain (defined as mean VAS >40 mm). Mean VAS-scores were greater than 40 mm in 21% on postoperative day (POD) 1, in 13% on POD 2, in 10% on POD 3, and in 9% on POD 4. Operations of nose and pharynx, abdominal operations, plastic surgery of the breasts, and orthopedic operations were the most painful procedures during the first 48 hours. This study showed that an important number of patients still experience moderate to severe pain in the postoperative period after day-case surgery even after a 4 day period.14
2.Literature related to effects of non pharmacological nursing intervention on pain
A study was conducted on “supplementing relaxation and music for pain after surgery” and in this study, 517 patients having abdominal surgery and receiving patient controlled analgesia (18-75years) recruited into to 4 groups: patient teaching for pain management (PT), relaxation and music (RM), combination (PTRM) and control group. A 2*2factorial design was used to assess PT effects and RM effects. Immediate effects on pain were measured on visual analogue sensation and distress scales before and after five tests (20 minutes) in the first 2 days. Using multivariate analysis of covariance with contrasts and pretest control, immediate effect on pain were found at day 1 am (p<.001), day 1pm (p=.o4) and day 2 am (p=.04). In this study patient teaching did not result in less pain and did not support the theoretical proposition that reduces pain. However the immediate RM effects supported the proposition that non pharmacological adjuvants to analgesics can ease pain without adding side effects.15
A randomized control trail was conducted on “relaxation and music reduce pain after gynecologic surgery” with patients (n=311), age 18 -70 from five Midwestern hospitals. They were randomly assigned using minimization to either three intervention groups or control group and were tested during ambulation and rest on post operative days 1 and 2.. Pain sensation and distress were measured using visual analogue scales. Multivariate analysis of covariance of posttest sensation and distress was used with pretest control and priori contrasts. The intervention groups had significantly less posttest pain than control group (p=022-001) on both days. The three interventions were similar in their effect on pain. Patients who received the interventions plus patient controlled analgesia (PCA) had 9%-29% less pain than controls who used PCA alone. Reduced pain was related to amount of activity, mastery of the use of intervention. Decreased pulse, respiration and those who slept well had less pain the following days. researchers suggested that nurses who care for gynecologic surgery patients can provide soft music relaxation tapes and instruct the patients to use them during post-operative ambulation and also at rest on days16
3. Literature related to effects of guided imagery on different condition
A randomized control trial, was conducted on 26 COPD patients and participants (n=26) were allocated to control group (n=13) and treatment group (n=13). Six practice sessions of guided imagery were given to the experimental group, while control group was instructed to take rest. Partial percentage of oxygen saturation, heart rate, upper thoracic surface electromyography, skin conductance and peripheral skin temperature were recorded during 30 minute session and Mann Whitney test was used to compare the change of perceived dyspnea between the groups. Results showed there was a statistically significant (p<0.05) increase in partial percentage of oxygen saturation in treatment group.17
A study of a pretest posttest experimental design was conducted on the effect of relaxation with guide imagery on anxiety, depression and self-esteem in primiparous with convenience sampling of 60 subjects (n=60) during first four weeks of post-partum period. The result showed that the experimental group had less anxiety and depression and greater self-esteem than did the control group at the end of period. Positive correlation were obtained between anxiety and depression, negative correlation between self-esteem and anxiety and depression. All findings were significant at the 0.005 level.18
4. Literature related to effect of guided imagery on pain
A study was conducted on evaluation of guided imagery as a treatment for recurrent abdominal pain in children. Children (n=22) with recurrent abdominal pain were randomly assigned to experimental and control group children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain .i.e. 67% in experimental group and 21% in control group (p=0.05) after one episode and after two episodes of intervention it became 82% versus 45% (p<0.01).19
A prospective randomized controlled pilot study was conducted on the topic “guided imagery for women with interstitial cystitis” and in this study, 30 women diagnosed with interstitial cystitis were randomized into 2 equal groups, treatment group listened to a 25 minutes guided imagery twice daily for 8 weeks. Baseline and end-of-study assessment questionnaires (interstitial cystitis symptom index & problem index [IC-SIPI], IC self-efficacy scale, a visual analogue [VAS] scale for pain, and a global response assessment [GRA]), 2-day voiding diaries, and 24-hour pain diaries were completed by the subjects and were evaluated. More than 45% of the treatment group were responders to guided imagery therapy noting a moderate or marked improvement. Responders had significant reductions in IC-SIPI scores (problem index, p = 0.006; symptom index, p = 0.004). In addition, responders on the GRA had significant (p = 0.039) improvements in mean pain scores from 5.50 to 2.57 at the end of the study in contrast to the non responders, whose pain levels remained the same (4.89 to 4.39). Researcher concluded that guided imagery may be a useful tool to offer women with IC for pain and IC symptom management.20