RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
Proforma for registration of subject for dissertation
1. / Name of the candidate and address / Mr. ARUN.S.R,ARUN NIVAS,
PAPPADU,
VATTIYOORKAVU P.O,
TRIVANDRUM-13,
KERALA
2. / name of the institution / S.B COLLEGE OF NURSING, YELAHANKA NEW TOWN,
BANGALORE.
3. / course of study and subject / Master Degree In Nursing
(Mental Health Nursing)
4. / date of admission to course / 01-06-2011
5. / title of the topic / A STUDY TO ASSESS THE LEVEL OF STRESS AMONG AMPUTEES AND TO DEVELOP RELAXATION TECHNIQUES IN SELECTED HOSPITALS, BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
6.0 INTRODUCTION
“Give your stress wings and let it fly away.”
-Terri Guillemets
“Mental health is a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a co-existence between the realities of the self and that of other people and the environment.”1
Stress is an unpleasant psychological and physiological state caused due to some internal and or external demands that go beyond our capacity.1
Stress is not directly created by external events, but instead by the internal perceptions that cause an individual to have anxiety/negative emotions surrounding a situation, such as pressure, discomfort, etc., which they then deem “stressful”. Humans experience stress, or perceive things as threatening, when they do not believe that their resources for coping with obstacles (stimuli, people, situations, etc.) are enough for what the circumstances demand. When we think the demands being placed on us exceed our ability to cope, we then perceive stress.2
Amputationis a common surgical procedure seen in most hospitals but there are no national data on the subject. Results of major studies onamputation over a 15-year period were collated and analyzed. The most frequent indications foramputationwere trauma (34%); complication of traditional bone setting (TBS) (23%); malignant tumors (14.5%); diabetic gangrene (12.3%); infections (5.1%); peripheral artery disease (2.1%); and burns (2.1%). In the southern regions, trauma is the most common indication while complications of traditional bone setting are the most common in the northern and eastern regions. The average age of an amputee is 33 years. Hospital mortality afteramputationis 10.9%. The estimated prevalence of extremityamputationis 1.6 per 100,000. Peripheral artery disease is an uncommon indication foramputationwhile trauma, complication of traditional bone setting, malignant tumors and diabetic gangrene are relatively much more common. The young male is frequently affected.3
Amputationof a limb affects almost all aspects of an individual's life. Psychological aspects are important factors for adjustment with the disability.8 Lower extremityamputationhas long been considered an end-of-life event and it is unclear if survival afteramputationhas improved over time.4
Individuals deal with perceived threats, or stress, in different ways. There are different classifications for these coping, or “defense” mechanisms, however they all are variations on the same general idea. There are good/productive ways to handle stress, and there are negative/counterproductive ways to do so. Because stress is perceived, the following mechanisms do not necessarily deal with the actual situation that is causing an individual stress. However, often they do, but they are also considered coping mechanisms if they allow the individual to better cope with the negative feelings/anxiety that they are experiencing due to the perceived stressful situation, as opposed to actually fixing the concrete obstacle causing them stress.2
Relaxation technique is any method, process, procedure or activity that helps a person to relax, to attain a state of increased calmness, or otherwise reduce levels of anxiety, stress or anger. Relaxation techniques are often employed as one element of a wider stress management program and can decrease muscle tension, lower blood pressure and slow heart and breathe rates, among other health benefits.2
6.1 NEED FOR THE STUDY
Amputationof a limb affects almost all aspects of an individual's life. Psychological aspects are important factors for adjustment with the disability. The present study was carried out on 50 consecutive male patients admitted to the Artificial Limb Centre. Base line and post therapy psychological assessment was carried out on Hospital Anxiety and Depression Scale. Findings revealed significant differences in scores. The findings indicated psychological assessment and intervention is to be included as a part of the management afteramputation. It is clear that patients are undergoing great levels of stress and psychosocial problems after amputation hence future research is needed to improve their condition and life style.5
A study was conducted which aimed to compare the adjustment of individuals who have a positive appraisal of their amputation. 16 individuals who had a lower limbamputation(9 men and 7 women) completed questionnaires during hospitalization, rehabilitation and after discharge. A subsample (n= 10) also participated in semi-structured interviews. Participants who had a positive appraisal of theiramputationshowed greater functional independence and greater body image satisfaction than those with negative appraisal. From interviews, the perceived benefits identified were less pain, more social contacts, fewer health concerns and fewer demands from family and friends. Positive appraisal of theamputationis experienced by many people, thus requiring more attention in future research.6
Lower extremityamputationhas long been considered an end-of-life event and it is unclear if survival afteramputationhas improved over time. A retrospective cohort comprised from a statewide, hospital discharge database was used to determine if survival afteramputationimproved with time. The cohort included all patients (older than 18 years) with non traumatic, lower extremityamputations(1987 to 2000). Survival analysis was used to determine the adjusted hazard ratio of survival as it related to the era ofamputation. This report stated that patients after the surgery felt depressed and had high levels of stress. Thus further research is required to improve their life style.4
A report stated that Patients (58) underwent lower limbamputationfor arterial disease over a 30-month period. Mean age of the patients was 72 years. Cardiopulmonary and metabolic risk factors were present in the majority of the patients. Postoperative one-year and three-year mortality rates were 24, 40, and 76%, respectively. Older patients were seen with higher stress levels and psychosocial problems, only younger and healthier patients returned to a meaningful social life after appropriate prosthetic fitting. Therefore the report stated that stress management and psycho therapies can improve the mental status and living conditions and further future research is required to reduce the morbidity levels.7
A cross-sectional qualitative exploration on how individuals cope with a lower limb amputationand to examine the influence of positive coping andstress-related psychological growth on adjustment was conducted.12patientswith a lower limbamputation participated. Coping strategies evolve, reflecting the changes in psychological demands post amputation. Positive coping and psychological growth facilitates psychological adjustment. Clinicians may facilitate adaptive outcomes by appreciating the positive psychology perspective. Hence further studies are required to understand the varying levels of stress and help the patients aid in coping with their environment.8
Amputationof a limb affects almost all aspects of an individual's life. Psychological aspects are important factors for adjustment with the disability. The present study was carried out on 50 consecutive malepatientsadmitted to the Artificial Limb Centre. Base line and post therapy psychological assessment was carried out on Hospital Anxiety and Depression Scale. Psychological intervention was given to them on a therapy module. Findings revealed significant differences in scores before and after therapy. The analysis of prevalence score of above 50 and less than 50 indicated Confident/ Asserting, Submissive/Yielding, having significant change after therapy on score of anxiety. The personality dimension of dutiful and conforming had shown significant influence after therapy on score of depression. Thus the findings indicated that psychological assessment and interventions are to be included as a part of the management afteramputation and further studies are needed to improve their psychological condition.9
Depression and stress is associated with complications and mortality. We examined depression and stress in incident lower limbamputees. This was a retrospective cohort study from 2000-2004 that included 531,973patients. Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minoramputations. Depression was present in 33% higher risk after major lower limbamputation. Further study is needed to understand this relationship and to determine whether depression screening and treatment inpatientscould improve their condition and reduce complications.10
The stress level of patients who had under gone amputation will be very high as they need lots of support and help to go on with their day to day activities. Getting adjusted to their new lifestyle is very difficult and it takes a lot of time for them to come to a normal living. The only way the patients who had to face amputation can cope with their environment is through constant support and giving them proper relaxation through therapies. The researcher found that the stress levels in amputees were very high, which motivated me to select this topic as my research problem.
6.2 REVIEW OF LITERATURE
Review of literature is an important step in the development of a research project. It involves the systematic identification factors and summary of written material that contain information of research. Nursing research may be considered a continuing process in which knowledge gained from earlier studies is an integral part of research in general.11
In order to accomplish the goal in the present study, an attempt has been made to review and discuss the literature.
A cross-sectional survey of 34 patients who had emergency hand amputation at a trauma center was selected. This study's goal was to assess the psychological outcomes, including symptoms of major depression, posttraumaticstressdisorder (PTSD), and other psychosocial variables. The overallscore was 27. The mean score for PTSD was 13 and 29% of respondents had high levels of both depression and PTSD. High pain scores were strongly correlated with both depression and PTSD symptoms. This study found high levels of psychological distress in patients after hand Amputation. Hand disability was stronglyrelatedto pain, depression, and PTSD symptoms. This study shows that the psychological problems of hand amputation can persist long after the surgery.12
A longitudinal study was conducted to analyze the characteristic relationship among pain, psychological distress, and physical function after major lower extremity amputation. A 2-year observational study of 327 patients who were treated at different trauma centers was selected. Data were gathered at 3, 6, 12, and 24 months after surgery. In the models tested, higher levels of depressive and anxious distress at the preceding time point was relatedto lower levels of functioning at 6, 12, and 24 months. The combination of depressive and anxious distress plays an increasingly important role in mediating the impact of pain on physical function as the recovery from lower extremity surgery progresses from early to later stages. Both pain and psychological distress contribute to reduced function during the first year after the surgery. Thus the study concluded that increased levels of stress and psychosocial distress prolonged recovery and patients had difficulty to adjust with the environment and their daily activities.13
A study was conducted to explore the prevalence and types ofstressreactions among arm–hand-amputees. A total of 24 patients participated,an average period of 7.5 months after surgery. Type of injury, length of time since injury, and gender did not influence scores. Thus the study concluded that the patient may require attention to learn how to engage in the therapy process while experiencingstressreactions which can help the patients to cope with the situations.14
A comprehensive study was conducted with a total of 658 participants that compared treatment efficacy to the levels of stress and other psychosocial problems. Differences in the psychosocial outcomes of treatment and control participants were examined. 95% confidence intervals were used to evaluate the significance of results.Significant improvements incopingskills andstrategies, community integration, and depression were observed with modest improvements in quality of life maintained at 12 months post-intervention. The results suggest that lower stress levels can improve the treatment modality and help adults in adjusting to a physical disability.15
A comparative study was conducted on individuals with traumatic (TE) vs. non traumatic amputationetiology (NTE) on pain, psychological, and social variables over the first 12 months post amputation. There were 111 adults with newly acquired limb loss.A medical center and a trauma hospital in a large metropolitan area were selected.Main Outcome was to Measure the Characteristic Pain Severity, Depression, Post traumaticStressDisorder. The NTE group was significantly older, had lower income, and had greater medical co-morbidity, pre amputation pain, and physical disability. The etiology groups did not differ significantly in mean levels of outcome variables except that the TE group reported greater aversive emotional support at 6 and 12 months. The TE group demonstrated a quadratic change in pain interference, with highest levels at 6 months and a linear increase in social constraints. Thus the findings suggest that the year afteramputationmay be a time of greater change for those with traumaticamputationcompared to those with non traumatic amputation but the stress levels were significantly high in both the groups.16
Posttraumaticstressdisorder (PTSD) is an important source of morbidity in military personnel, but its relationship with characteristics of battle injury has not been well defined. The aim of this study was to characterize the relationship between injury-relatedfactors and PTSD among a population of battle injuries. An experimental study was conducted with a total of 831 military personnel injured and amputated during combat between September 2004 and February 2005 composed the study population. Patients were followed through November 2006 for diagnosis of Posttraumaticstressdisorder (PTSD) or any mental health outcome. During the follow-up period, 31.3% of patients received any type of mental health diagnosis and 17.0% received a PTSD diagnosis. Injury severity was a significant predictor of any mental health diagnosis and PTSD diagnosis. Thus concluded that further studies are needed to replicate these results and asses the stress levels and give proper management.17
A study was conducted to understand the mental status of patients who had under gone lower extremity amputation. A total of 13,807 patients underwentamputation. The gender and age standardized frequency ofamputationremained essentially stable. During follow up, 49.2% of patients died, with significantly worse outcomes for more proximal levels ofamputation. After controlling for potential confounders, including age, gender, level ofamputation, co-morbid illness, emergency status of procedure, hospital type, and payer of the procedure, patients undergoingamputationin more recent years (1995 to 2000) had a 28% lower hazard of dying during the study period than those undergoing operation before 1995. The study concluded that presently long term survival afteramputationhas improved considerably with time. The reasons underlying this improvement was due to proper counseling and better managements like stress management therapies.4