RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES BANGALORE ,KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS
/ Ms.NINU SOPHIAIst YEAR M.Sc NURSING
SRILAKSHMI COLLEGE OF NURSING
SUNKADAKATTE
BANGALORE-91.2 / NAME OF THE INSTITUTION / SRILAKSHMI COLLEGE OF NURSING.
3 / COURSE OF THE STUDY
AND SUBJECT / M.SC NURSING 2008-10
MEDICAL –SURGICAL NURSING.
4 / DATE OF ADMISSION TO THE COURSE / 17.6.08.
5 / TITLE OF THE STUDY / ‘A STUDY TO EVALUATE THE EFFECTIVENESS OF EARLY AMBULATION AND POST OPERATIVE RECOVERY OF PATIENTS WHO HAD UNDERGONE ABDOMINAL SURGERY IN SELECTED HOSPITALS, BANGALORE, KARNATAKA.’
6. BRIEF RESUME OF THE INTENDED WORK :
6.1 INTRODUTON :
“I say to you, arise, take up your bed, and
go to your house’’. Immediately he rose
up before them ,took up what he had lying
on ,and departed to his house, glorifying God’’
[BIBLE]
Procedure to accelerate the ability of a patient to walk or move about by reducing the time to AMBULATION. It is characterized by a shorter period of hospitalization or recumbency than is normally practiced. 15
Less than a hundred years ago the surgeon rarely operated within the abdominal cavity . Today surgery of every organ in the abdomen is accomplished with an ascounding degree of safety and success . Advancement in surgical procedures demands advancement in nursing skills. The surgeon now shares many of his responsibility with the nurse . It is a recognized fact that ‘the role of the nurse in surgery is not secondary to that of surgeon; it is equally important. 1
Nurses play an important role during the treatment process of patients and , thus , help mitigate their suffering and ailment . Besides rendering various types of services pertaining to their profession , they also give a healing touch to the patients through their gentle and affectionate behaviour . According to international council of nurses “ nursing is the unique function of the nurse ,that is to assist the individual sick or well in the performance of those activities contributing to health or its recovery or to a peaceful death that he would perform unaided if he had the necessary strength ,will or knowledge .
Most surgical patients are encouraged to be out of bed as soon as possible. Early ambulation reduces the incidence of postoperative complications, such as atelectasis, hypostatic pneumonia , gastro intestinal discomfort , and circulatory problems . Ambulation increases ventilation and reduces the stasis of bronchial secretions in the lung . It also reduces post operative abdominal distention by increasing gastro intestinal tract and abdominal wall tone and stimulating peristalsis .
Thrombophlebitis or phlebothrombosis occurs less frequently because early ambulation prevents stasis of blood by increasing the rate the rate of circulation in the extremities . Pain is also often decreased when early ambulation is possible , and the hospital stay is shorter and less costly ,a further advantage to the patient and the hospital .
Despite the advantage of early ambulation, patients may be reluctant to get up the evening of the surgery . Reminding them of the importance of early mobility in preventing complications may help them to overcome their fears. 2&3
6.2 NEED OF THE STUDY
One of the first to provide useful information about patient preferences for their postoperative recovery was Fredrick Orkin , who reported results from a survey of nurses, anaesthetists,support staff, and computer personnel at a national meeting.Forty-seven subjects were asked to rate 16 scenarios of immediate post operative recovery and 15 min were given to perform therating. Conjoint analysis was used to judge the relative contributionof each item on the final scenario rating. It was found that postoperative nausea and vomiting (PONV) was a major concern.To prevent this complication, they were willing to accept otherside-effects, including extra payment (15–50 US$). Althoughthe interesting data have not yet been published as a full paper,numerous authors have quoted the abstract to confirm the importanceof antiemetic strategies 16
According to Lawrence Dulake , Healthy people resent illness, particularly if it necessitates complete confinement to bed . It implies a surrender of the will to others together with loss of normal privacy , and a state of imposed helplessness related to personal cleanliness , excretory functions , feeding , posture and sleep . It is a strange therefore how a complacently the medical and surgical professions have for a long time acce pted humiliating experience of confinement to bed as an often essential part of treatment.4
Hospital is a place were the sick and injured are cared and treated . Many a time an individual may face situation when he/she has to visit a hospital . It can be for diagnostic or treatment purposes . More over, for many people surgery is the most fearful event of dramatic significance whether it is elective or emergency5
Early ambulation is one of the important aspect of early recovery of patients who undergone abdominal surgery without any complications .The concept of early ambulation is widely spread and concurrently is accepted and appreciated by majority of surgeons . Early ambulation reduces the post operative complications such as atelectasis , hypo static pneumonia , gastro intestinal discomfort and circulatory problems .Ambulation increases ventilation and reduces the stasis of bronchial secretions in the lung .It also reduces the post operative abdominal distention by increasing gastro intestinal tract and abdominal wall tone and stimulating peristalsis .
Thrombophlebitis or phlebothrombosis occurs less frequently because early ambulation prevents stasis of blood by increasing the rate of circulation in the extremities . Pain is often reduced when early ambulation is possible . The hospital stay is shorter and less costly , further advantage to the patient and hospital. Nursing interventions are planned to suit each individual patient , his problem and his needs . Nursing measures are started shortly after surgery to meet the basic needs of the patient . They include mobility , personal hygiene , toilet management ,dressing ,eating etc. 2
Every hospitals should be aware of the important of early ambulation on post operative to prevent complication .According to the hospital protocol the nurse and the physiotherapist initiates and assist at the time of ambulation .It facilitate the patient to meet the activity of daily living , restoration of physiological activity and psychological well being .4
Bonnard ,etal [1978] : the assessment on the effect of abdominal surgery incisions on ventilatory function on 40 post operative patients found that the reduction relative to preoperative values on the 1st day after surgery was of the order of 60% for high abdominal incision ,35% for lower abdominal incision . A return to post operative value was obtained on the 5th ,6th post operative days in which the changes are due to limitations of diaphragmatic movement is high .These indicate the stone fast evidence for initiating early mobilization which include turning ,deep breathing exercises 6 .
Hall book etal [1984] : concluded that early mobilization and breathing exercises were as effective as other prophylactic treatment against pulmonary complications . In those patients under going gallbladder surgery with or without bronchodilators as evidenced by absence of any changes in pulmonary status and ABG analysis and pulmonary x ray which does not show any difference between two groups .Oflio [1989] invented that 31 Nigerians with uncomplicated acute appendicitis , who were discharged within 48 hrs of operation no patient returned to hospital with any complications before removal of sutures and was no re admissions . So early ambulation and discharge were safe and have socioeconomic benefits and should be more readily practiced in the developing countries .
Brandjes [1990] stated that major surgery without prophylaxis encomposes a high risk for thrombosis [ortho surgery 50% ,abdominal surgery 20% ] the problem is the development of proximal vein thrombosis despite the best possible thrombosis prophylaxis [10%] .So the pre surgical identification of a patient in risk of developing venous thromboembolism post operative is the major issue , where several investigation have developed complicated the risk prediction that is body weight. But the need for single screening test is emphasized by the research .
Nancy .L.N ,studied the prevention of pulmonary complication associated with prolonged bed rest during post operative include a decreased functional activity ,increased airway closure in the supine position, dependent leg edema ,a predisposition to thrombosis formation . Preventive stratergies include frequent turning , passive exercises and early ambulation . So early ambulation is one of the most important factor in preventing the complications of immobility.7
Exercises of the lower extremities are particularly important in the prevention of venous stasis and should be performed until patient the patient sits up and walking about several hours of the day .
6.3 REVIEW OF LITERATURE
1. Caliskan E , Turkoz A, Sener M ,etal 2008 march , Baskent university Turkey conducted a prospective randomized double –bind study to determine the effect of thorasic epidural neostigmine on postoperative ileus after abdominal aortic surgery , on 45 patients concluded that thorasic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of post operative ileus after abdominal aortic surgery.8
2. Leung J.M, Dzankics .S ,2001 august at department of anaesthesia and perioperative care ,university of California ,U.S.A , conducted study on relative importance of preoperative health status versus intraoperative factors in predicting adverse outcomes in geriatric surgical patients , a prospective cohort study of consequative patients undergoing noncardiac surgery of patients above 70 years of age the study demonstrates that the postoperative mortality rate in geriatric surgical patients undergoing noncardiac surgery is low . despite the prevelance of preoperative chronic medical conditions , most patients do well postoperatively .9
3. Pearse .R , Dawson .D. , etal , 2005 , November , St George’s hospital , London , early goal directed therapy after major surgery reduces complications and duration of hospital stay . a randomized ,controlled trial . 122 samples were selected and they concluded that post operative GDT is associated with reductions in post operative complications and duration of hospital stay .the beneficial effects of GDT may be achieved while avoiding the difficulties of pre operative ICU admissions. 10
4. Kirkeby –Garstad 1, Sellevold of, 2005 july ,at St Olav hospital ,university hospital of Trondhim ,Norway . related articles , links mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery . 31 CABG patients were included in an open observational study . concluded that patients with CABG exhibit a marked desaturation during early post operative mobilization . preoperative ejection fraction did not effect s[v] 0(2) during exercise . the clinical consequences and underlying mechanism require further investigations .11
5. Pramila Chari , Neerja Bhardwaj , Angom Russia Singh , 2006, chandigarhIndia , frequency of immediate postoperative complications in patients undergoing neurosurgical procedures , 101 samples were selected and divided in to 4 groups and complications referable to the various system was identified . They concluded that tachycardia and hypertension due to pain are common in younger patients undergoing elective spine surgery .12
6. Albert L .Siu ,MD ,MSPH ,Joan D Penrod, Phd ,Keneth S ,
conducted studies which examined the relationshipbetween inpatient bed rest and functional outcomes. They examinedhow immobility is associated with function and mortality inpatients with hip fracture. Conducted a prospective cohort study of 532patients 50 years and older, who were treated with surgery afterhip fracture in 4 hospitals in New York. We collected informationfrom hospital visits, medical records, and interviews. "Daysof immobility" was defined as days until the patient moved outof bed beyond a chair. Follow-up was obtained on function (usingthe Functional Independence Measure) at 2 and 6 months and onsurvival at 6 months.Result wasPatients with hip fracture experienced an averageof 5.2 days of immobility. Compared with patients with a longerduration of immobility (ie, at the 90th percentile) in adjustedanalyses, patients at the 10th percentile of immobility hadlower 6-month mortality (–5.4%; 95% confidence interval[CI], –10.9% to –1.0%) and better Functional IndependenceMeasure score for locomotion (0.99 points; 95% CI, 0.3 to 1.7points, with higher values indicating better function), butthere was no significant difference in locomotion by 6 months(0.58 points; 95% CI, –0.3 to 1.4 points). The adverseassociation of immobility was strongest in patients using personalassistance or supervision with locomotion at baseline (differencein 6-month mortality between the 90th and 10th percentile ofimmobility was –17.1% [P=.004] for this groupand only 1.2% [P=.38] for patients independent inlocomotion at baseline). In patients with hip fracture, delay in gettingthe patient out of bed is associated with poor function at 2months and worsened 6-month survival. 13
7. .Kim MS An Experimental Study on the Effects of Structured Preoperative Teaching on PostoperativeRecovery. The purpose of this study was to test the effect of the structured preoperative teaching on postoperative recovery and to observe the effects of an structured preoperative teaching on the adult surgical patient's ventilatory function ability, the length of hospital stay, the number of analgesics within a 72 hour postoperative period, the length of early ambulation The research question investigated in the study was: What would be the effects of a structured preoperative teaching upon the adult surgical patients postoperative recovery? This study was based on a sample of 40 patients who were scheduled for abdominal surgery. They were
assigned alternately to experimental and control group. Among 40 subjects, 20 were placed in the experimental group and 20 in the control group. Preoperative ventilation function testing of control and experimental subjects was done the evening before surgery and before the patient received the structured preoperative teaching. A structured preoperative teaching was given to the subjects in the experimental group only by writer. postoperative testing was done the 5th postoperative day. The data were collected over a
period of two months, from Aug. 8 to Oct. 31, 1983. For the analysis of the data and test for the hypotheses, the t-test with mean difference was used. The results of this study regarding the four-hypotheses were as follows: 1. Experimental group which received structured preoperative teaching will have more increase to-cough and deep breathe as measured by his forced vital capacity(FVC), forced expiratory volume 1 (FEV1), maximal voluntary volume 15 (MVV15) than control group without structured preoperative teaching. The ventilation function ability was more increase in experimental group than in control group, the mean difference was statistically significant at 0.01 level. hypotheses 1 was supported. 2. Experimental group with structured preoperative teaching will have more reduced the length of hospital stay than control group without structured preoperative teaching. The length of hospital stay of the experimental group and control group were 11.90 days and 16.05 days respectively. However, the difference was not statistically significant at 0.05 level. Therefore the hypotheses 2 was not supported. 3. Experimental group with structured preoperative teaching will have more reduce the number of analgesics within a 72 hour postoperative period than control group. The number of analgesics within a 72 hour postoperative period of experimental group and control group were 1.65 times and 2.4 times. The difference was not statically significant at 0.05 level. Therefore, the hypotheses 3 was not supported. 4. Experimental group with structured preoperative teaching will have more reduce the length of early ambulation than control group without structured preoperative teaching. The length of early ambulation of experimental group and control group were 2.2 days and 3.6 days respectively. The difference was statistically significant at 0.05 level. The hypotheses 4 was supported.14
STATEMENT OF THE PROBLEM
A study to evaluate the effectiveness of early ambulation and post operative recovery of patients who had undergone abdominal surgery in selected Hospitals , Bangalore, Karnataka.
6.4 OBJECTIVES OF THE STUDY
- To determine the effectiveness of early ambulation on post operative patients who had undergone abdominal surgery in the experimental group and control group .
2. To ascertain the difference among selected variable and
post operative recovery of patients who had undergone abdominal
surgery in the experimental group .
6.5OPERATIONAL DEFINITIONS
1. EFFECTIVENESS :
Refers to the outcome of the early ambulation in terms of patient able to walk 16-24 hrs after the abdominal surgery .
2. EARLY AMBULATION :
Early ambulation is a procedure done 16-24 hrs after an abdominal surgery . The patient helped to place his legs over the edge of the cot and to move first to a sitting than to a standing position with the feet flat on the floor and to walk as tolerated before returning to the horizontal position on the bed . this procedure is repeated till he is able to do independently .
3. POST OPERATIVE RECOVERY :
Refers to the restoration of the patients who had undergone abdominal surgery to their normal or near normal conditions .
4. ABDOMINAL SURGERY :
The following surgical procedures are included in this category
Gastro jejunostomy
Gastro jejunostomy with vagotomy
Vagotomy
Partial gastrectomy
Gastrectomy
Small intestinal resection
Hemi coloectomy
Cholecystectomy
Laparostomy which includes any one from the above
5. PATIENT :
Refers to a person with abdominal surgery
6.6 HYPOTHESIS OF THE STUDY :
H1- There will be significant difference in the functional activity scores in relation to early ambulation among patients who had undergone abdominal surgery in the experimental group and control group .
H2- There will be significant difference in the sense of well being scores in relation to early ambulation patients who had undergone abdominal surgery in the experimental group and the control group
H 3- There will be significant difference among selected variables of activity of the daily scores in relation to early ambulation among patient who had undergone abdominal surgery in the experimental group and control group
6.7 ASSUMPTIONS :
1. The patient would cooperate with the researcher and would be willing to participate effective in nursing care steps on early ambulations .
2. The item included in the tool would be adequate and sufficient and represent the measures of activity of daily living , functional activity and sense of well being .
6.8 DELIMITATIONS
1)The study was limited to patient who have undergone abdominal
Surgery.
2)The study was limited to those who are able to understand English/
kannada
3) Sample size was limited to 60 patients
6.9 PILOT STUDY
The pilot study will be conducted with 8-10 samples .The purpose of pilot study is to find out the feasibility of conducting study and design on plan out statistical analysis .