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