Preoperative Nursing Intervention - Book Report/Review Example

INTRODUCTION The following essay is a critical review of a research based on preoperative nursing intervention in abdominal surgeries and its role in alleviating anxiety and pain perception of the patient and thus minimizing his suffering. The review basically includes the literature review and theoretical work on which the research is based, the methodology that includes the methods of sampling, data collection, experiment procedure and instruments or methods, observation and inference. It also includes review of the results, analysis and conclusion of the research paper. The article chosen for the review is Li-Ving L & Reuy-Hsia.W 2005 Abdominal surgery. Pain and anxiety: preoperative nursing intervention from the Journal of Advanced Nursing 51(3) 252-260. This article was chosen because it presented a typical example of research article with an experimental design, a single hypothesis with variables and direction, simple random method of sample collection and use of statistics for the analysis. The framework used for the critical review of this article was adopted from LoBiondo-Wood. G. & J. Haber. 19QS. Cursing research: methods, critical appraisal and itti!i:arion. 4'1' ed. St Louis: Mosbv. Before going further on the review a brief knowledge of the concept of research i.e. preoperative nursing intervention is necessary. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain can be better understood with the help of Venn diagram Figure 1: Venn diagram The inference we derive from it is that pain experienced by different persons, differs from person to person as they differ in 1. Physical health and fitness e.g. the mild pain experienced by a normal person by a blow may be excruciating to a weak individual. 2. State of mental health. E.g. a psychic patient may feel more pain or no pain to a stimulus causing mild pain in a normal person. 3. The rational part is different in every person depending upon his previous experience with similar kind of pain or motivation. E.g. a multi gravida experiences less labor pain than a primi gravida. Patients come across two types of pain during abdominal surgery 1. A continuous dull aching pain which gives a good response to morphine. 2. An acute sharp pain due to coughing or sneezing, which is not alleviated with morphine. Pain in abdominal surgery varies according with 1. Site of surgery: pain experienced during upper abdominal surgery is greater than that during lower abdominal surgery. 2. Type of abdominal surgery: minimally invasive techniques like laproscopy cause little pain than routine surgeries like exploratory laprotomy. 3. Age: as the age increases the pain threshold increases and experience of severity of pain reduces. 4. Personality: a person who is mentally strong or a person whose anxiety is alleviated with psychotherapy or drugs experiences less pain. The amount of analgesics required varies from person to person depending on 1. Pharmacokinetic variations: drug absorption, first pass metabolism and peak plasma concentration is different in different people. Therefore analgesic requirement varies which may sufficiently affect the postoperative pain. 2. Pharmacodynamic variations: the sensitivity of opioid receptors is different in different persons, which also determines the analgesic requirement. Pre operative medication 1. Relief from anxiety - anxiety is a major problem pre operatively and hampers the smooth induction of anaesthesia. It is alleviated by preoperative psychotherapy by which the surgeon or the nurse creates a rapport with the patient and explains him about the events during surgery and postoperative recovery and reassurance regarding his fears. If the patient is very anxious benzodiazepines can be given either one night before or 2 hours before surgery. 2. Analgesics - if patients are in pain pre operatively opioids are drugs of choice when analgesia without antipyretic action is desired, but should be used with caution in patients with impaired hepatic function. Opioids are contraindicated in acute disease states in which the pattern and degree of pain are important diagnostic signs (head injury, abdominal pain). They are also contraindicated in head injury as they raise the intra-cranial tension. Constant pain - requires continuous analgesia round the clock with supplementary doses for break through pains. Lowest dosage that provides adequate analgesia is the aim. Oral medication should be used whenever possible. The lowest initial dose should be given with a graded increase in the amount of drug until adequate analgesia is obtained. Opioid analgesics given along with benzodiazepines are helpful in managing preoperative pain and anxiety. An opioid with a long half-life if given pre operatively may provide some analgesia in postoperative period. Continuous intravenous administration provides steady blood level. Morphine is ideal. Patient controlled analgesia (PCA) is often used to control pain in post operative or terminally ill patients. PCA often improves pain relief, decreases anxiety and allows less amount of drug to be given. Immediate and sustained release morphine preparations are elixirs useful in patients with dysphagia. As tolerance develops, larger doses are required. Slow release drug systems- continuous infusion of low dose opioids into either subcutaneous or epidural or intrathecal or intraventricular space is employed in those with malignant pain. Postoperative medication The preoperative assessment and psychotherapy play a significant role in postoperative pain management. 1. Intra muscular opioids on a pro- renata basis - unsatisfactory and should not be given after major surgery because intramuscular absorption can be affected by hypothermia, hypotension or hypovolemia. Adverse effects like nausea and vomiting are common. 2. Intravenous infusions - pump driven controls pain better (pulse oxymetry monitoring). 3. Patient controlled analgesia (PCA) - pulse oxymeter is essential for monitoring. 4. Rectal opioids - best for children. 5. Spinal opioids - into CSF (may cause vomiting, respiratory depression and urinary retention). 6. Transdermal opioids - fentanyl patch (fat soluble preperation) gives same analgesia as infusion. 7. Local anaesthesia by infiltration, nerve block, epidural (best pain relief but hypotension and general paralysis are complications) 8. Cryo analgesia- freezing of sensory nerves during surgery with a liquid nitrogen probe. BACKGROUND LITERATURE REVIEW The research study was carried out to know whether or not preoprative-nursing intervention has any effect on management of pain, anxiety outcome related to surgeries so that it can be implemented routinely in all hospitals. The research includes independent variables like preoperative nursing intervention and dependent variables like anxiety and positive pain attitude, which are related directly to each other and can be tested individually. The population of research has been selected randomly between January and august 2001 by permitted block randomization and was divided into four subgroups according to gender and site of surgery. This study provides significant evidence for the implementation of preoperative intervention for major abdominal surgeries so that it benefits people and decrease their suffering. The literature review includes concepts of pain, anxiety, methods of controlling pain, positive pain attitude, and preoperative nursing intervention. Pain is defined as a unique and personal experience (i.e. it varies from person to person) and is result of interaction between physiologic, sensory, affective, cognitive, behavioral, and socio cultural dimension. The concept of methods of pain control includes 1. Explanations and causes of pain 2. Importance of pain management 3. Early out of bed activities 4. Expression of feeling and concerns 5. Anxiety reduction 6. Medicinal and non-medicinal pain relief methods. The literature review makes the variables explicit and has also described how pain and anxiety are related to the perception pf pain, which he has attributed to neuropsychological functions and is also dependent on feelings and emotions of a person. The anxiety and the pain are directly related to the perception of the pain but pain perception is inversely related to the positive attitude towards pain therefore pain perception can be decreased by decreasing anxiety and increasing positive pain attitude similarly pain perception is directly related to negative pain attitude which in turn is related negative pain experiences The author has mostly used primary references like Cupples (1991) and Divine (etal) The operational definitions for Postoperative pain is a subjective perception of discomfort caused by surgical wound, which is different from its conceptional definition. Anxiety is defined as degree of perception of worry and nervousness and defined pain attitude as beliefs in thoughts about postoperative pain and management. The hypothesis is that " patient who receives pre operative nursing intervention for pain will have lower levels of preoperative anxiety, a more positive preoperative pain attitude, and lower levels of post operative pain than those who do not receive such intervention". The above statement in appropriate but a bit generalized. It should have included subjective differences like people of same age or same body mass index or similar gender, which would give a precise idea of what is happening exactly. The hypothesis is more of a research as it has not mentioned any numerical value e.g. the postoperative pain will come down to above 30% or so The independent variable is preoperative nursing intervention and the dependent variables are anxiety positive pain attitude and postoperative pain. The hypothesis is very much testable but taking into account the same aged patient or of similar gender makes it easier. The hypothesis can be defined as multivariable directional hypothesis as it has multiple dependent variables and exhibits changes in dependent variable depending on changes in the independent variable. It moves in a positive direction where the pressure of preoperative pain is helping the people and the research. METHODOLOGY The sample was from a group understanding abdominal surgery and who had the specified criterion for the research like 1. 20-70 years of age 2. Were not transferred to ICU after surgery 3. Could speak Chinese or Taiwanese 4. Gave consent for study 5. Had been suffering pain from other conditions. 6. Could not do any out of bet activities prior to surgery The sample size was taken by power analysis. Large effect size = 0.05 (significance) And power = 0.80 r (100 - r) + (100 -5) = 8 x ------------------------------- (r -5) raised to 2 Therefore sample size is appropriate for the kind of research going on. As the patients in sample have passed the criterion and the sampling done randomly they represent the normal average group of people going for surgery and not just any special cases The finding can be generalized to normal population except that it is not valid for children and adolescents or geriatric age groups also the findings cannot be generalized to people who have abnormal mental conditions or those who are in stress. An experimental design is used for the study because the purpose of the study because the effect of one variable on another. It includes an independent variable (the preoperative nursing intervention) dependent variables (positive pain attitude and anxiety) and the experiment includes two groups 1. Experimental group 2. Sample group In experimental group there is manipulation of independent variable i.e. preoperative nursing intervention was not applied to it. Internal validity is the ability of a study to determine if a causal relationship exits between one or more independent variables and one or more dependent variables. The following are the threats to the internal validity in this study. 1. History: it is any event or accident outside of a research that can alter or effect the subjects behavior or reaction to pain like any stress or trauma etc. this threat has been minimized by selecting the sample by sample randomization considering that the outside events that occur in one group are also likely to occur in another. 2. Testing: when people are subjected to similar certainty again and again they show a better performance. Using a control group along with the test group decreases this. 3. Instrumentation: the modes of measurement of effect was consistent through out the study and there were no changes in retest and post test methods. 4. Selection of the subject was done based on randomization and were divided into four sub groups depending on their site of surgery (whether upper or lower) and according to their gender so their will be no bias in result due to selection. 5. Experimental bias: to support the hypothesis the research may be found towards the result. To minimize this a double blinded study was used. For this two nurses from another unit of the hospital were trained as data collectors and the interclass correlation coefficient between the two nurses in measuring the five patients anxiety, pain attitude, pain intensity and interface of pain in daily activities were 0.98, 0.97, 0.97 and 0.99. 6. Mortality and the subject dropout may drastically affect the results. To prevent this a total of 80 patients were initially recruited of whom 18 fulfilling exclusion criteria were excluded. And a total of 32 were included in test group and 30 in the controlled group. External validity refers to the generalizability of the study i.e., whether the results of the research or study represents the entire population. The study has certain limitations because 1. It represents population between ages of 20 and 70. Therefore it does not apply to children or geriatric age group. 2. It includes patients with one surgery and doesn't hold good for patients with multiple surgeries, emergencies or patient with associated disease conditions like cancer etc. 3. it does not include patients with altered mental state or those on drug dependence. The study designed a questionnaire, which was implemented in both pretest, and posttest and was similar for all subjects. It included 1. Basic data: like Personal data: age, weight, height, gender, marital status, employment, associated diseases (hypertension, diabetes or other cardio vascular diseases), and previous surgical experience. Surgical data: surgery area, duration of surgery, length and direction of incised wound, use of PCA, dose of analgesics etc. 2. Anxiety scale: the visual analogue scale for anxiety (VASA) was used. 3. Pain attitude scale: this included seven items adopted from American pain society patient outcome questionnaire and the researchers formed eight items. Of which each item was rated from 0 (strongly disagree) to 5(strongly agree). 4. Brief pain inventory: BPI Chinese version is adopted which has a pain intensity subscale to measure pain intensity and pain interference subscale to measure the degree of interference of pain with daily activities. The study includes only subjects who gave an informed consent to the research. They were made aware of the research objectives, process, data collection, procedure and their right for refusal. The study was started only after the ethical approval was taken from various ethical comities and also the data was collected in accordance with the hospital policies for human experimentation. In the study the use of various methods is to ensure that any little effect or change in the result can be efficiently detected and can be analyzed. The anxiety scale, which uses VASA, is used because it is very sensitive and can detect minor changes in behavior. The study uses five experts who evaluate all the scales for relevance of the content and the accuracy of the methods used .the methods were reviewed by them and few necessary changes were made by them in the methods .the interview of five patients was taken to assess the clarity of different points in the data collection methods and those unclear were changed according to the patients understanding. The study also uses two nurses as observers from another department of the same hospital as there was a chance of bias due to internal validity. These two nurses were trained as data collectors. The presence of observers had influence on the patient's response as evidenced by the interclass correlation coefficients, which vary from 0.97 to 0.99. The study has used data records which help the researcher to divide the sample into sub group according to site of surgery and gender, also the data provides relevant information about the effect of the surgery on patients mind and body. Basically the data is used to describe the sample. For Brief Pain Inventory The test-retest reliability was given as 0.79 for pain intensity subscale and 0.81 for pain interference subscale. Cronbach's alpha for internal reliability was 0.81 fr pain intensity subscale and 0.89 for pain interference subscale. For Pain Attitude Scale the Cronbach's alpha is 0.92. As the reliabilities are positively correlated they are considered acceptable. Concurrent validity has been used for each method. For BPI which is adopted from Chinese version and proved to be effective in a previous study on cancer patients in Taiwan .the Pain Attitude Scale was mostly taken from American pain society quality of care committee 1995, for the Anxiety scale VASA was used which is proved to be reliable(Price etal 1994). FINDINGS Analysis of the data: to analyze the data mean (M), standard deviation (SD) and frequency were calculated. To test the differences between test and control Chi square test and 't' tests were done. To measure the effects of intervention Two Way ANOVA was used. The descriptive statistics used mean standard deviation and frequency where as inferential 't' tests and Two Way ANOVA obtained statistics. The following statistics were obtained after analysis. 1. The mean preoperative, pre intervention anxiety score for Experimental group = 5.00(2.99) Control group = 4.60(2.59) 2. The mean preoperative, pre intervention pain attitude score for Experimental group = 35.73(8.10) Control group = 35.70(7.42) 3. The mean postoperative, post intervention anxiety score for Experimental group = 3.03(2.46) Control group = 4.67(2.53) 4. The mean postoperative, post intervention pain attitude score for Experimental group = 62.56(8.22) Control group = 35.45(7.18) 5. Anxiety scores at pretest for both groups are similar t = 0.56 , p = 0.58 6. Pain attitude scores at pretest for both groups are similar t = 0.02 , p = 0.99 7. Repeated measure two ways ANOVA gave a statistically significant difference in anxiety scores between the groups. F = 174.03; p < 0.001 8. Repeated measure two way ANOVA gave a statistically significant difference in Pain attitude scores between the groups. F = 2253.78; p < 0.001 9. The statistical difference between pretest and post test anxiety scores was noted as f = 35.63 ; p < 0.001 10. The statistical difference between pretest and post test pain attitude scores was noted as f = 251.04 ; p < 0.001 Based on the above statistical data it can be said that the preoperative nursing intervention for pain had a statistically significant effect on decreasing anxiety levels and increasing pain attitude levels. As various variables could be analyzed with Two Way ANOVA it was appropriate method used for the level of measurement of the variable and are relevant for hypothesis. The study has not described any level of error (significance) and has made point estimations rather than interval or confidence interval estimations. the tables used in the paper have precise titles and headings, supplement the text but do not economize it as it repeats the text. Conclusion The results support the hypothesis i.e. preoperative nursing intervention was found to be beneficial in decreasing the pin and anxiety .the results are interpreted in context of hypothesis" our results support the assumption that preoperative nursing intervention for pain has a positive effect on the preoperative anxiety, pain attitude and pain perception of patients undergoing abdominal surgery". The study has few limitations, one of which is that the non medical methods of pain relief which were taught to the experimental group and may have contributed to the relief of pain was not recorded so the effect of non medical methods to control pain cannot be supported. Another limitation is that the participants in the study were patients undergoing abdominal surgery in one hospital therefore the results couldn't be applied to patients undergoing other surgeries or from other hospitals. As the sample size was limited, the researcher couldn't examine the effect of nursing intervention depending on gender type or site of surgery. According to the researcher the results of this study could be applied as a standard guideline for nurses to improve the pain care of surgical patients. The investigator has generalized his findings in the discussion as preoperative nursing care can lower anxiety levels and has a positive pain attitude of all kinds of patients which is way beyond the scope of the results. The author recommends the following for future research. 1. The practice of non-medical pain relief methods on perception of pain and anxiety. 2. Effects of preoperative nursing intervention on early discharge of patients. 3. Effects of preoperative nursing interventions by gender type or site of surgery. As the study has applied acceptable methods of examination, design, data collection, observation and analysis it can be considered valid but only for a limited group of people i.e. Taiwanese people between 20 to 70 years of age undergoing abdominal surgery. This study supports similar studies by Cupples(1991) and Chiou(1993). This study can be applied to nursing practice as it is feasible in terms of ethics, time, effort and money when compared to the suffering of the patient which is more important for a man of medicine as it relieves the patient of the agony and mental suffering. Though it may take a little time and a little extra money but it is worth implementing keeping the following in mind 1. Age of the patient 2. Kind of surgery and site of surgery. A similar kind of study can be considered in patients going for orthopedic surgery or patients with burns so that we can make one more step towards the benefit of mankind. BIBLIOGRAPHY 1. Prys- Robert Brown. International Practice of Anaesthesia, vol 1. Butterworth Heinmann, Oxford, 1996. 2. Aitkenhead, Rowbotham, Smith. Textbook of Anaesthesia. 4th ed. Churchill Livingstone . Harcourt Publishers Limited. London, 2001. 3. Surgical Clinics. Perioperative Issues For Surgeons: Improving Patient Safety And Outcomes; Dec 2005, Vol 85,Page 1252-4. 4. Dennis L Kasper [etal]. Harrison's Principles On Internal Medicine .16th Ed .Mc Graw-Hill Publishers. London 2005. 5. Russell Williams Bulstrode. Bailey and love's short practice of surgery. 24th ed. Oxford university press. New York. 2004. Read More