Effect of Preoperative Education on Short term Postoperative Outcomes in Hysterectomy

 

Dr. Thilagavathi Krishnaswamy

Lecturer, College of Nursing and Allied Health Sciences, Jazan University, Ministry of Education, 

Kingdom of Saudi Arabia.

 

ABSTRACT:

Objectives: To evaluate the effectiveness of preoperative education on improving short term postoperative outcomes in hysterectomy. Short term postoperative outcomes include physiological vital parameters (Temperature, Pulse, Respiration, Blood pressure and Inspiratory capacity) and other parameters (Ambulation, Demand for additional analgesics, Total amount of analgesics received and Length of stay) in this study. Methods: A quasi experimental study was conducted among 300 women admitted in gynaecology ward for elective hysterectomy in District Tertiary care hospital in Salem, Tamilnadu from September 2012 to January 2014. Subjects were selected by convenience sampling technique allotted into experimental group (n₁=200) and control group (n₂=100) based on eligibility criteria. Tools used were: Demographic Performa and flow chart to note down physiological vital parameters and other parameters. The experimental group received comprehensive preoperative education including postoperative exercises before surgery and control group had routine hospital care. Collected data was analysed with descriptive and inferential statistics. Results: There was no significant difference revealed on physiological vital parameters (p˃0.05) except for inspiratory capacity. Experimental group ambulated earlier (30.33±8.594) as compared to control group (41.56± 6.960) and these differences were statistically significant (p<0.001). There was no significant difference found between groups on demand for analgesic and total amount of parenteral analgesics received. Mean length of stay was more in experimental group (17.65±3.587) as compared to control group (14.31±3.349). Conclusion: The present findings revealed providing preoperative education was effective to improve inspiratory capacity and to initiate early ambulation in women after hysterectomy.

 

 

 

INTRODUCTION:

Hysterectomy is one of the oldest surgeries performed in gynecology. It is common operation carried out in women for problems associated with reproductive organs.

 

Global statistics reveals that around 50,000 hysterectomies are done in the United Kingdom every year. One in five women will undergo this surgery by the age of 65 years¹; whereas in United States around 60,000 hysterectomies are undertaken annually. For every 10 minutes, 12 hysterectomies are performed. Of these 75% surgeries are done among women between the ages of 20 and 49 years and remaining 25% will undergo by the time they are 60 years². In Australia, the incidence is 4.8 per 1000 women³. In India, there is no national registry maintained to report hysterectomies, so majority of it go unreported. Studies in limited geographical areas have indicated prevalence rates of hysterectomy ranging from 4 % to 10 %^4-5. The National Family Health Survey carried out in 2005-2006 reported that 12.7% women in the age group of 30 to 45 years attained early menopause due to hysterectomy⁶. Preoperative teaching serves as a standard of nursing practice within the surgical setting⁷. In general, preoperative teaching includes significant information about the surgery and issues that patients are anticipated to face in the preoperative and postoperative periods. Preoperative teaching readily and effectively enables patients to cope with their surgery, reduces the duration of hospitalization, elevates satisfaction, minimizes postsurgical complications, and augments patients’ psychological well-being⁸. Effective preoperative teaching has a positive impact in the postoperative period especially on the first 24 hours.  Several literatures have reported preoperative teaching promoted early ambulation, decreased demand of additional analgesics and total analgesics administered in general surgical patients. The present study aimed to evaluate the effectiveness of preoperative education in improving short term postoperative outcomes in hysterectomy women.

 

METHODS AND MATERIALS:

A quasi-experimental study was conducted in the District Tertiary Care Hospital in Salem, Tamilnadu, India. Subjects were selected with convenience sampling technique for experimental group (n₁=200) and control group (n₂=100) respectively.  Women between the age group of 30-60 years; those living with partner; premenopausal/postmenopausal age; who undergo abdominal/vaginal hysterectomy with or without salphingo oophorectomy for nonmalignant reason, were included for the study. Informed written consent was obtained from each subject after explaining objectives of the study. Demographic Performa used to collect the socio-demographic data of subjects. Physiological vital parameters (Temperature, Pulse, Respiration, Blood pressure and Inspiratory capacity) was measured once in the preoperative period for baseline data(Pretest) followed by at 5 points in the postoperative period namely at 12 hours(Posttest-1), 24 hours(Posttest-2), Second postoperative day(Posttest-3), Fifth postoperative day(Posttest-4) and at discharge(Posttest-5). Hours after surgery (Ambulation) the subjects initiated first walk was noted by observation. Rest of the parameters like demand for additional analgesics, total amount of analgesics received and length of stay were taken from the medical records and noted in the flow chart. Experimental group received perioperative information which includes general information about surgery, preoperative preparations, preparations on the day of surgery, intraoperative care, immediate postoperative care and late postoperative care until discharge. Postoperative exercises mainly respiratory exercises, mobilizing exercises and muscle strengthening exercises were taught and demonstrated to the subjects by the investigator in the preoperative period. Subjects showed the return demonstration followed by time was allotted to clarify their doubts. Incentive spirometry was given to each subjects and instructed to practice it. Control group received routine hospital care. Collected data was coded and analyzed using SPSS software 17.0 based on the objectives of the study. After attrition, total subject size became 279 in which, 184 belonged to experimental group and 95 in control group.

 

RESULTS:

Demographic characteristics of subjects showed more than one quarter of subjects, 33.7% belong to 36-40 years in experimental group and 34.7% of them fall between 41-45 years in control group. Most of them were illiterate (53.3% in experimental group and 46.3% in control group). Majority were coolie workers in both groups (56% in experimental group and 71.6% in control group). 53.8% earned below Rs.2000 in both groups as family monthly income. Majority of them had 2 children in both groups (52.7% in experimental group and 40% in control group) respectively. Regarding duration of complaints, most of them, 46.2% in experimental group and 29.5% in control group, had their complaints in less than 3 months. Majority of them diagnosed with fibroid uterus and undergone Total Abdominal Hysterectomy and Bilateral Salphingo Oophorectomy.

 

DISCUSSION:

Measurement on physiological vital parameters revealed majority had normal vital signs among subjects in both groups. There was no significant difference found between subjects except for inspiratory capacity. There was drastic improvement on inspiratory capacity in the postoperative period seen among subjects in experimental group as compared to control group. Effective practice of deep breathing, controlled coughing exercises and use of incentive spirometer in the postoperative period helped the experimental group to achieve positive results. Above findings were supported in a study conducted by Naz, Siddiqui, Ikram (2014) among patients who underwent laparotomy. The experimental group that received incentive spirometry and breathing exercises had an improved BORG scale and FEV1/FVC ratio significantly (P=0.0001, p=0.0001) as compared to the control group which practiced only deep breathing exercises⁹. Similar study conducted by Sanjeev Kumar (2013) also revealed that the patients in incentive spirometry group had better pulmonary functions as compared to deep breathing exercise group after three days and five days of surgery¹⁰. The experimental group ambulated earlier (30.33± 8.594) as compared to control group (41.56± 6.960) which had statistical significance (p˂0.001). These findings were consistent with other studies^11-12. Oetker-black, Jones, Estok, Ryan, Gale, Parker (2003) reported in their study that efficacy enhancing group ambulated for a mean of 330 seconds (SD=615) than usual care group ambulated for a mean of 156 seconds (SD=97) and these differences were statistically significant (p<0.05)¹³.

 

Table 1:  Description of Physiological vital parameters in Experimental group and Control group (N= 279)

S. No	Physiological vital parameters	Pre-test %		Post-test 1 %		Post-test 2 %		Post-test 3 %		Post-test 4 %		Post-test 5%
		EG	CG	EG	CG	EG	CG	EG	CG	EG	CG	EG	CG
1.	Temperature a. 98.1-99 degree F b. 99.1-100 degree F c. 100.1-101 degree F d. 101.1-102 degree F	100 0 0 0	100 0 0 0	56.0 36.4 07.6 0	57.9 31.6 10.5 0	66.3 23.9 09.8 0	80 12.6 5.3 2.1	72.2 23.4 03.3 01.1	83.1 11.6 1.1 4.2	90.8 09.2 0 0	94.7 4.2 1.1 0	100 0 0 0	100 0 0 0
2.	Pulse a. 61-70/minute b. 71-80/minute c. 81-90/ minute d. 91-100/minute	08.7 84.2 07.1 0	05.3 87.3 07.4 0	01.1 82.1 16.8 0	02.1 73.7 24.2 0	01.6 78.3 16.3 03.8	0 70.5 21.0 08.5	14.1 71.3 13.0 01.6	12.6 74.8 09.5 03.1	06.0 87.5 06.5 0	11.6 77.9 10.5 0	09.8 87.5 02.7 0	13.7 86.3 0 0
3.	Respiration a. 16-20 breaths/minute b. 21-24 breaths/minute c. 25-28 breaths/minute	71.7 28.3 0	66.3 33.7 0	50.6 46.7 02.7	45.3 51.6 03.1	50.0 46.2 03.8	35.8 62.1 02.1	63.0 37.0 0	63.2 36.8 0	72.8 27.2 0	64.2 35.8 0	82.6 17.4 0	73.7 26.3 0
4.	Systolic BP a. 90-100 mm of Hg b. 110-120mm of Hg c. 130-140mm of Hg d. 150-160mm 0f Hg	17.4 66.3 16.3 0	19.0 73.6 07.4 0	17.9 63.6 15.2 03.3	14.7 76.9 05.3 03.1	17.4 63.0 16.8 02.7	22.1 67.3 05.3 05.3	20.1 62.0 16.3 01.6	21.1 67.3 07.4 04.2	24.4 62.5 13.1 0	29.5 52.6 17.9 0	38.0 50.6 11.4 0	52.7 44.2 03.1 0
5.	Diastolic BP a. 70 mm of Hg b. 80mm of Hg c. 90mm of Hg d. 100mm of Hg	51.1 32.6 16.3 0	58.9 33.7 07.4 0	53.2 28.3 15.2 03.3	56.9 34.7 05.3 03.1	52.2 28.3 16.8 02.7	60.0 29.4 05.3 05.3	55.4 26.6 16.4 01.6	44.2 37.9 15.8 02.1	70.1 16.3 13.6 0	74.7 18.9 06.3 0	70.1 28.3 01.6 0	62.1 34.8 03.1 0
6.	Inspiratory  capacity a. 600ml b. 900ml c. 1200ml	11.9 40.8 47.3	14.7 46.4 38.9	82.1 17.9 0	84.2 15.8 0	77.2 22.8 0	82.1 17.9 0	61.9 38.1 0	81.1 18.9 0	08.1 28.3 63.6	54.7 34.7 10.6	03.8 29.9 66.3	30.5 50.5 19.0

Table 1 describes the distribution of physiological vital parameters in experimental group and control group measured at different points.

 

Table 2: Comparison of physiological vital parameters between experimental group and control group. (N=279)

S. No	Physiological vital parameters	Pre-test		Post-test 1		Post-test 2
		EG Mean ±  SD	CG Mean ± SD	EG Mean ±  SD	CG Mean ± SD	EG Mean ± SD	CG Mean ± SD
1.	Temperature	98.57 0.137	98.56 0.137	99.21 0.589	99.19 0.643	99.13 0.601	99.06 0.615
	t-test	0.183NS		0.182NS		0.824NS
2.	Pulse	75.26 4.323	75.73 3.888	76.91 5.151	77.60 5.669	77.65 6.479	79.33 7.793
	t-test	0.881NS		1.020NS		1.906NS
3.	Respiration	19.30 2.652	19.87 2.590	20.66 2.824	21.20 2.758	20.79 2.758	21.37 2.514
	t-test	1.713NS		1.517NS		1.699NS
4.	Systolic BP	113.97 11.163	111.58 8.910	114.57 12.537	112.95 11.000	114.89 12.631	113.05 12.722
	t-test	1.809NS		1.064NS		1.149NS
5.	Diastolic BP	76.52 7.456	74.84 6.335	76.85 8.484	75.47 7.404	77.01 8.447	75.58 8.215
	t-test	1.874NS		1.337NS		1.354NS
6.	Inspiratory capacity	1005.98 205.703	972.63 208.563	653.80 115.407	647.37 109.973	668.48 126.257	653.68 115.603
	t-test	1.277NS		0.448NS		0.954NS

NS – Not Significant.         ***p<0.001.    ** p<0.01.

 

Table 2: Continue......

S. No	Physiological vital parameters	Post-test 3		Post-test 4		Post-test 5
		EG Mean ±  SD	CG Mean ± SD	EG Mean ± SD	CG Mean ±  SD	EG Mean ± SD	CG Mean ± SD
1.	Temperature	98.96 0.568	98.88 0.673	98.69 0.352	98.64 0.33	98.56 0.137	98.56 0.136
	t-test	1.084NS		1.268NS		0.183NS
2.	Pulse	75.79 6.080	76.23 6.548	75.97 4.363	75.18 5.438	74.64 3.693	73.77 3.824
	t-test	0.555NS		1.312NS		1.848NS
3.	Respiration	20.09 2.757	20.11 2.742	19.55 2.636	19.96 2.783	18.88 2.435	19.28 2.575
	t-test	0.053NS		1.189NS		1.287NS
4.	Systolic BP	113.91 11.684	112.53 10.102	110.98 9.181	112.11 10.609	110.00 9.973	107.89 9.553
	t-test	0.982NS		0.921NS		1.695NS
5.	Diastolic BP	76.41 8.109	77.58 7.951	74.35 7.213	73.16 5.882	75.16 7.316	74.11 5.553
	t-test	1.146NS		1.387NS		1.237NS
6.	Inspiratory capacity	714.13 146.046	656.84 118.189	1066.30 192.639	767.37 203.920	1095.65 149.982	865.2 209.2
	t-test	3.304/0.001**		12.039/0.000***		10.578/0.000***

 

Table 2 describes there was a significant difference (p˂0.05) noted in inspiratory capacity during post-test 3,   post-test 4 and post-test 5 between experimental group and control group. Rest of the parameters it was not significant.

 

Table 3:  Distribution of other parameters in experimental group and control group. (N=279)

 

Table 4: Comparison of other parameters between experimental group and control group.  (N=279)

S . No	Other parameters	Experimental (n1=184)		Control (n2=95)		t-test	p value
		Mean	SD	Mean	SD
1.	Ambulation	30.33	8.594	41.56	6.960	11.007	0.000***
2.	Demand for additional analgesic	0.15	0.366	0.21	0.410	1.349	0.179NS
3.	Total amount of parenteral analgesics received	3.81	1.132	3.91	1.509	0.594	0.796NS
4.	Length of stay	17.65	3.587	14.31	3.349	7.540	0.000***

***p<0.001.                          NS-Not Significant.

 

Most of the subjects in both groups did not demand for additional analgesic and received only 3-4 doses of parenteral analgesic in the postoperative period. Similar findings were seen in other studies conducted by Chumbley GM, Ward I, Hall GM, Salmon P(2004)¹⁴, Sjoling M, Nordahi G, Olofossan N, Asplund K(2003)¹⁵ and Patrick Callaghan, Ho Cheung Li(2002)¹⁶. Length of stay was more in the experimental group that is 17 days as compared to control group which stayed only for 14 days. In government settings, it was noted that, there was a lack of policy on total length of stay after gynecological surgery. Many times it was left to the women’s preferences. Once they felt physically better they decided to go home. However, most of them preferred to stay in the hospital for a longer duration in order to take more rest than in home settings. These factors contributed to the increase in length of stay for the present study. These findings are also supported by another study conducted by Shuldham C.M, Fleming Goodman H (2002) among three hundred and fifty-six patients to assess the preoperative education on postoperative pain, anxiety, depression and wellbeing following coronary artery bypass surgery¹⁷. These findings contradicted with other studies ^18-20 as all of them revealed the intervention group had a lesser LOS as compared to usual group.

 

CONCLUSION:

Administering preoperative education was found to be effective in improving short term postoperative outcomes mainly inspiratory capacity and ambulation among women undergone hysterectomy. Providing education about perioperative care and postoperative exercises in the preoperative period in a structured manner will guide women to understand about postoperative care after hysterectomy and facilitate participation in postoperative activities and help to prevent potential complications.

 

ACKNOWLEDGEMENT:

Author is grateful to the Research guide Dr Rajeswari Vaidyanathan, Biostatistician Dr Porchelvan, Saveetha Dental College, Chennai, Nodal officer Dr Reddemma, and Core Committee members of National Consortium in Ph.D. Nursing, Bangalore, India for their constructive suggestions and guidance provided during study period.

 

CONFLICT OF INTEREST:

Author does not have any conflict of interest.

 

FUNDING FOR THE STUDY:

None.

 

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Received on 06.12.2016          Modified on 19.12.2016

Accepted on 20.01.2017         © A&V Publications all right reserved