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RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE ,KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1NAME OF THE CANDIDATE AND ADDRESS
Ms.NINU SOPHIA Ist YEAR M.Sc NURSING SRILAKSHMI COLLEGE OF NURSING SUNKADAKATTE BANGALORE-91.
2 NAME OF THE INSTITUTION
SRILAKSHMI COLLEGE OF NURSING.
3 COURSE OF THE STUDYAND 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.’
1
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 .
2
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 the rating. Conjoint analysis was used to judge the relative
contribution of 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 other side-effects, including extra payment (15–50 US$). Although
the interesting data have not yet been published as a full paper, numerous authors have
quoted the abstract to confirm the importance of antiemetic strategies 16
3
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
4
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
5
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
6
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, chandigarh
India , 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 relationship between inpatient bed rest and
functional outcomes. They examined how immobility is associated with function and
mortality in patients with hip fracture. Conducted a prospective cohort study of 532
patients 50 years and older, who were treated with surgery after hip fracture in 4 hospitals
7
in New York. We collected information from hospital visits, medical records, and
interviews. "Days of immobility" was defined as days until the patient moved out of bed
beyond a chair. Follow-up was obtained on function (using the Functional Independence
Measure) at 2 and 6 months and on survival at 6 months. Result was Patients with hip
fracture experienced an average of 5.2 days of immobility. Compared with patients with a
longer duration of immobility (ie, at the 90th percentile) in adjusted analyses, patients at
the 10th percentile of immobility had lower 6-month mortality (–5.4%; 95% confidence
interval [CI], –10.9% to –1.0%) and better Functional Independence Measure score for
locomotion (0.99 points; 95% CI, 0.3 to 1.7 points, with higher values indicating better
function), but there was no significant difference in locomotion by 6 months (0.58 points;
95% CI, –0.3 to 1.4 points). The adverse association of immobility was strongest in
patients using personal assistance or supervision with locomotion at baseline (difference
in 6-month mortality between the 90th and 10th percentile of immobility was –17.1%
[P = .004] for this group and only 1.2% [P = .38] for patients independent in locomotion
at baseline). In patients with hip fracture, delay in getting the patient out of bed is
associated with poor function at 2 months and worsened 6-month survival. 13
7. . Kim MS An Experimental Study on the Effects of Structured Preoperative
Teaching on Postoperative Recovery. 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
8
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.
9
6.4 OBJECTIVES OF THE STUDY
1. 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 .
6.5 OPERATIONAL 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 .
10
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
11
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 .
VARIABLES
Research variables are the concepts of various level of obstruction that are entered
manipulated and collected in a study .
Independent variable : Early ambulation
Dependent variable : Post operative recovery
12
7.0 MATERIALS AND METHODS
[METHODOLOGY]
This study is designed to evaluate the effectiveness of early ambulation and post
operative recovery of patients who undergone abdominal surgery in selected Hospitals ,
Bangalore, karnataka.
7.1` SOURCE OF DATA :
Data will be collected from patients under gone abdominal surgery in selected
Hospitals, Bangalore , Karnataka
7.1.1 RESEARCH DESIGN
Quasi experimental design .
7.1.2 RESEARCH APPROACH
A evaluative research approach .
7.1.3 SETTING OF THE STUDY
The study will be conducted in selected Hospitals Bangalore, karnataka
.
7.2 METHODS OF DATA COLLECTION [INCLUDING SAMPLING
PROCEDURE
Methods of data collections are interviewing technique, Observation schedule,
questionnaire ,
13
7.2.1 SAMPLING TECHNIQUE
Convenient sampling.
7.2.2 SAMPLE SIZE
The sample of the study consist of 60 patients undergone abdominal
surgery .
SAMPLING CRITERIA
INCLUSION CRITERIA
1. Patients undergone abdominal surgery
2. Patients willing to participate in the study .
3. Patients who can understand English and kannada.
4. Patients who are present during the time of data collection.
EXCLUSIVE CRITERIA
1. People who are not willing to participate in the study .
2. People who are unable to response to questions
3. People who are not present at the time of data collection
4. People who has undergone laprotomy and systemic diseases .
7.2.3 TOOL FOR DATA COLLECTION
Observation and interviewing will be used for data collection
14
PROCEDURE FOR DATA COLLECTION :
The investigator collect the data from patients who undergone abdominal surgery
using observations , interviewing ,structured questionnaire to assess post operative
recovery after obtaining prior permission from the participant .
7.2.4 DATA ANALYSIS METHOD :
The investigator will use descriptive inferential statistics
Descriptive statistics : mean , median , mode , and standard deviation of described
demographic variables .
Inferential statistics : it is like chi –square and relevant statistical techniques . the
data analysed will be in the form of tables ,diagram and graphs .
7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE
CONDUCTED ON PATIENTS OR OTHER HUMANS AND ANIMALS .
Yes, the early ambulations will be conducted on patients undergone abdominal
surgery .
7.4 ETHICAL CLEARANCE
Yes, copy enclosed the main study will be conducted after the approval of
research committee .Permission will be obtained from the concerned head of the
institution. The purpose and after details of the study will be explained to the
study subjects and an informed consent will be obtained from there . Assurance
15
will be given to the study subjects on the confidentiality of the data collection
from them . Informed consent will also be taken from the staff nurses who are
willing to participate in the study .
8. LIST OF REFERANCES
1. R.J.F.H.Pinsent proceedings of royal society of medicine jan 20, 1960 E; /
JSTOR the American journal of nursing vol-50 ,no 12 ,(dec1950) .htm.
2. Smelter –C-Suzane etal ,medical surgical nursing 9th edition published by
Lippincott Williams and Wikins
3. Joyce .M.Black etal ,medical surgical nursing 6th edition 2001 published by
haricurt (India)pvt limited Philadelphia .
4. Mrs Nirmala Kaur, Indian journal of holistic nursing, sept 2007 vol3.
5. Phipps .long. woods. Shafers medical surgical nursing 7th edition 2002 B.I.
publications newDelhi.
6. Bonnard ,etal: the assessment on the effect of abdominal surgery incisions on
ventilatory function on 40 post operative patients
http;//www.ncbi.nlm.gov/sites/entrez
7. http;//www.ncbi.nlm.gov/sites/entrez
8. Chaliskan E, Turkoz A, Sener M etal 2008 ,march, baskent
university.http;//www.ncbi.nlm.gov/sites/entrez
16
9. Leung J.M, Dzankics .S ,2001 august at department of anaesthesia and
perioperative care ,university of California ,U.S.A
http;//www.ncbi.nlm.gov/sites/entrez
10. Pearse .R , Dawson .D. , etal , 2005 , November , St George’s hospital ,
London .http;//www.ncbi.nlm.gov/sites/entrez
11. Kirkeby –Garstad 1, Sellevold of, 2005 july ,at St Olav hospital ,university
hospital of Trondhim ,Norway http;//www.ncbi.nlm.gov/sites/entrez
12. Pramila Chari , Neerja Bhardwaj , Angom Russia Singh , 2006, chandigarh
India . http;//www.ncbi.nlm.gov/sites/entrez
13. Albert L. Siu,M.D.,Joan d. Penrod,Keneth S,etal studied the relation ship
between inpatient bed rest and functional outcomes in Newyork
Arch intrern med-2006 vol166 no 7 ,april 10 ,2006
14. Kims M.S. An experimental study on the effects of structured preoperative
teaching on post operative recovery , 1983. E:/korea med –basicJ .P. Broth
techniques 2nd edition (2004) published by new age international private limited
15 . http://www.find-health-articles.com/
16 . E:\Patient preferences for immediate postoperative recovery
-- Eberhart et al_ 89 (5) 760 -- British.htm
17
9 SIGNATURE OF THE CANDIDATE
10 REMARKS OF THE GUIDE
11 NAME AND DESIGNATION OF 11.1 GUIDE Mr. I CLEMENT
ASSO – PROFESSORMEDICAL SURGICAL NURSINGSRI LAKSHMI COLLEGE OF NURSINGBANGALORE
11.2 SIGNATURE
11.3 CO GUIDE
11.4 SIGNATURE
12 HEAD OF THE DEPARTMENT
Mr. I CLEMENTASSO – PROFESSORMEDICAL SURGICAL NURSINGSRI LAKSHMI COLLEGE OF NURSINGBANGALORE
12.1 SIGNATURE
13 REMARKS OF THE CHAIRMAN/PRINCIPAL
13.1 SIGNATURE
18