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“EFFECTIVENESS OF PLANNED PERIOPERATIVE

NURSING INFORMATION ON POSTOPERATIVE


OUTCOME AMONG THE PATIENTS UNDERGOING
SELECTED SURGERIES AT SELECTED HOSPITAL
OF KOLAR, KARNATAKA”.

Thesis submitted in partial fulfillment for the award of


Degree of DOCTOR OF PHILOSOPHY IN NURSING

By
ZEANATH CARIENA JOSEPH

Under The Guidance of

Prof. Dr. B.A PATALIAH

VINAYAKA MISSION UNIVERSITY

SALEM, TAMILNADU, INDIA

DECEMBER - 2014

I
II
III
ACKNOWLEDGEMENT
I am grateful to God Almighty for his guidance, strength,

and wisdom throughout the endeavor.

I, the investigator of the research work owe my sincere

thanks and gratitude to all those who have contributed to the

successful accomplishment of this piece of research work.

I extend my sincere thanks to the Vice- Chancellor and the

Educational Board Members of The Vinayaka Mission’s


Research Foundation, Deemed University –Salem for their
excellent efforts in imparting quality education to all the

aspirants and for the opportunity given to me to conduct this

study as a requirement for the degree of Ph. D (Nursing).

I am deeply indebted expressing the deepest sense of

gratitude to my esteemed research guide and teacher,

Prof. Dr. B. A Pataliah, Principal, Sushruthi CON, Bangalore,

for his expert guidance, valuable suggestions unconditional

support and encouragement which has motivated me for the

successful completion of this research work.

It is my privilege to indebt my sincere and special thanks

to Prof. Dr. Rajendran Dean of Research for his encouragement,

timely suggestion, and support, without whom this research

would be incomplete.

It is my privilege to indebt my sincere thanks to Principal,

& Heads of Various Departments, SDUCON, Kolar for timely

encouragement and support.

IV
I am extremely thankful to the Medical Superintendent,

surgeons and Peri-operative team of R. L. Jalappa Hospital and

Research Centre- Kolar for their kind cooperation, support and

permission for smooth conduct of this research study.

I express my sincere thanks to all the subject experts for

having their time for valuable judgment, constructive

recommendations and enlightening suggestions while validating

the content of the tool and teaching plan.

My sincere thanks and appreciation to Dr. Ravishanker,

Bio-statistician for his expert guidance and tireless help.

I am thankful to all the librarians and technical experts

for enabling me to reach to the Evidence Based Literature and

help rendered in the overall alignment of the dissertation.

My heartfelt thanks to all the study participants who

formed the core and basis for this study and for whole hearted

co-operation.

Finally, I owe and acknowledge with gratitude and respect

to my dear parents, family and friends for their prayers and

unfailing support, which cannot be put into words throughout

this endeavor.

Date: 02-12-2014

Place: Kolar Mrs. Zeanath Cariena J

V
TABLE OF CONTENTS

Chapter Page
Content
No. No.

I INTRODUCTION 01 - 05

II REVIEW OF LITERATURE 06 – 51

III METHODOLOGY 52 – 70

IV RESULTS AND DISCUSSION 71 – 116

SUMMARY, CONCLUSION,
V
IMPLICATIONS, AND 117 – 140
RECOMMENDATIONS.

BIBLIOGRAPHY 141 - 157

ANNEXURES I - LXVIII

VI
LIST OF TABLES
Table Page
Title
No. No.
Frequency and Percentage distribution of sample according
1 74
to socio-demographic variables.
Distribution of Sample according to information specific to
2 76
surgical history in both Experimental and control group
Distribution of sample according to the overall level of
3 78
perioperative Knowledge before and after intervention.
Distribution of sample according to the overall level of
4 80
perioperative Practice before and after intervention.
Area wise Distribution of perioperative Knowledge of sample
5 82
before and after intervention
Area wise Distribution of perioperative Practice of sample
6 84
before and after intervention
Comparison of perioperative Knowledge level before and
7 86
after intervention among both Experimental and control group
Comparison of perioperative Practice before and after
8 87
intervention among both Experimental and control group.
Comparison of perioperative knowledge, practice and level of
9 satisfaction among Experimental and control groups after 88
intervention.
The distribution of the sample based on the occurrence of
10 89
complication in experimental and control group.
Distribution of sample according to the overall level of
11 satisfaction of Experimental and Control groups after 90
intervention
Area wise distribution of level of satisfaction of Experimental
12 91
and Control groups after intervention
Association of perioperative knowledge with selected socio
13 demographic variables in both experimental and control 92-93
groups after intervention
Association of perioperative Practice with selected socio
14 95
demographic variables after intervention
Association of level of satisfaction with selected socio -
15 demographic variables with level of satisfaction after 97
intervention

VII
LIST OF FIGURES

Figure Page
Title
No. No.

Modified Conceptual framework based on Pender‟s


1 50
Health Promotion Model

2 Schematic representation of the study design 54


Distribution of sample according to the overall level of
3. 79
perioperative Knowledge before and after intervention.

Distribution of sample according to the overall level of


3 81
perioperative Practice before and after intervention.

Area wise Distribution perioperative Knowledge of


4 83
sample before and after intervention
Area wise Distribution perioperative Practice of sample
5 85
before and after intervention
Distribution of sample according to the overall level of
6 satisfaction of Experimental and Control groups after 90
intervention

VIII
LIST OF ANNEXURES

ANNEXURE
CONTENTS
No.

A letter seeking permission to conduct the research


1.
study

Structured interview schedule (English &


2.
Kannada version).

Planned perioperative teaching information


3.
lesson plan (English version)

IX
ABSTRACT
Perioperative nursing is a specialized area of nursing

practice. As a fundamental member of the surgical team, the nurse

works in collaboration with other health care professionals in

providing care to the patient preoperatively, intraoperatively, and

postoperatively. Currently, substantive inconsistencies are

apparent in perioperative teaching for surgical patients. This lapse

has resulted in a lack of knowledge and preparedness that

prevents patients from immediately engaging successfully in

postoperative self-care activities.

Based on the limited literature and personal experience of

the investigator, the study was designed to “Assess the

Effectiveness of Planned Perioperative Nursing Information on

Postoperative Outcome among the Patients Undergoing Selected

Surgeries at Selected Hospital of Kolar, Karnataka”.

The study aimed at assessing the perioperative knowledge,

practice, level of satisfaction, effectiveness of planned teaching

program and association of the socio-demographic variables with

perioperative knowledge, practice and level of satisfaction after

implementation of intervention.

X
By using an Experimental Two Group before and after

intervention design, the study was conducted at R. L. Jalappa

Hospital and Research Centre, Kolar. The sample of the study

consisted of 400 surgical patients (200 for each experimental and

control groups). The random sampling technique was adapted by

using the lottery method to select the sample of the study. The

data were collected from patients who were admitted for surgical

procedures of Gastrointestinal and Genitourinary system who

fulfilled the inclusion criteria by using structured interview

schedule, i.e. Structured Knowledge questionnaire, observational

checklist for practice along with a three point Likert scale for

assessment of level of satisfaction.

The major findings of the study revealed that before the

intervention majority of the sample had inadequate perioperative

knowledge in both experimental (88.5%) and control (73.5%)

groups, whereas after intervention majority (86.5%) of the sample

in the experimental group showed improved knowledge level i.e.

moderate knowledge and only (1%) had inadequate

knowledge,whereas in the control group (57.5%) majority of the

sample had moderate level of preoperative knowledge and (41%)

of them belonged to inadequate knowledge.

XI
With regard to the overall perioperative practice level

majority (96%) of the sample in the experimental group had poor

perioperative practice level and none of them belonged to an

adequate level before intervention. But after intervention the in

experimental group perioperative practice had significantly

improved as majority (90%) of them belonged to adequate

perioperative practice level, (10%) of them to moderate and none

of them had inadequate perioperative practice level. In the control

group the entire (100%) sample belonged to inadequate

perioperative practice level.

With regard to the effectiveness of planned perioperative

teaching program the study, findings revealed that there was a

significant difference between mean perioperative knowledge

(18.33) practice (14.32) and level of satisfaction (95.70) of

experimental group when compared with the knowledge (16.16)

practice (6.84) and satisfaction (57.65) level of the control group

after the intervention. The calculated „t‟, value (t‟ 399=3.290,

P<.0001) was greater than the table value, hence the stated

hypotheses H1 & H2 was accepted.

The level of satisfaction with perioperative care aspects was

higher in experimental (84.5%) group when compared with the

control (15.5%) group.

XII
With regard to the findings on the association between

perioperative knowledge and socio-demographic variables the

findings revealed that there was a significant association between

perioperative knowledge with marital status as the obtained 2

value was higher than the table value in both experimental

(210.623, df =2, p=.010) and control (26.291, df=4, p=.222)

groups, hence the stated hypothesis H3 is accepted.

In the control group, the calculated value was higher only in

terms of educational status (2 6.197, df =2, p=.185), hence stated

hypothesis H3 is accepted. The findings also revealed that there

was no association between perioperative knowledge with age,

gender, educational status, type of occupation, religion, income,

and exposure to mass media in both experimental and control

groups, as the obtained 2 value was less than the table value,

hence the stated hypothesis H3 is rejected.

Regarding the association between practice and socio-

demographic variables in the experimental group, the findings of

the study revealed that the obtained 2 value was greater than

the table value with regard to gender (23.908, df =1, p=0.052) ,

educational status (26.193, df =2, p=0.008 ) type of occupation

(26.088, df =2, p=0.031) and exposure to mass media


XIII
(2 4.745, df=1, p=0.038) respectively, hence the stated hypothesis

H4 was accepted. As the obtained 2 value was less than the table

value in age, marital status, religion, and family income in the

experimental group, hence the stated hypothesis H3 was rejected.

In the control group findings revealed that there was

association between perioperative practice with exposure to mass

media (2 11.462, df =2, p=.003) as the obtained 2 value was

greater than the table value, thus the stated hypothesis H4 is

accepted. With regard to age, gender, educational status, Type of

occupation, marital status, religion, and family income the obtained

2 value was less than the table values, hence the stated

hypothesis H3 is rejected.

Regarding the association between socio-demographic

variables and satisfaction level on perioperative care aspect, that

the obtained 2 value was greater than the table value only in

sample of experimental group with regard to age (2 6.911, df= 2,

p=0.013 ), gender (2.4.148, df- 1,p=0.057), education (26.455,

df -2, p=0.055), occupation (24.023, df -2, p=0.056) and exposure

to mass media (24.138, df -1, p=0.057), hence the stated

hypothesis H5 is accepted.

XIV
Whereas with regard to marital status, religion, and family

income the obtained 2 value was less than the table value, thus

the stated hypothesis H5 is rejected.

In control group none of the variables as age, gender,

educational status, type of occupation, marital status, religion,

income, exposure to mass media the obtained 2 value was less

than the table value, thus the stated hypothesis H5 is rejected.

The study findings have implication for nursing education,

practice, administration and research as a whole as it emphasizes

on acquiring knowledge, developing skill and enhancing the level

of satisfaction for all patients by ensuring quality nursing care and

outcomes which is a key for Evidence Based Practice.

The investigator strongly recommends for a similar study to

be conducted at various settings on a large sample for

generalization of the study findings. Finally from the findings of the

study it can be highlighted and concluded that, planned

perioperative teaching program was effective in reducing post-

operative discomforts and complications. Thus, preoperative

teaching forms a basis for attaining a better quality of life among

surgical patients.

XV
CHAPTER - I

INTRODUCTION

Health is both personal and an economical asset. Optimal

health is the best physiological and psychological condition which

an individual can experience. Disease is an inability to adequately

counteract physiological stresses that can cause disruption of the

body‟s homeostasis. Additional influences such as congenital

anomalies, infection or trauma, interfere with optimal human health

and quality of life.

The treatment of a wide variety of illnesses, injuries and

human conditions includes some type of surgical or procedural

interventions. Surgery gave physician the means to treat the

conditions that were difficult or impossible to manage purely by

medicine.

Surgery is almost always viewed as life crises and evokes

anxiety and fear. Today‟s nurses enter a realm of opportunities

and challenges in providing high-quality evidence based care in

health care setting. More than ever today‟s nurses‟ need to think

critically, creatively and compassionately. Surgery is a planned

alteration of physiological process within the body in an attempt to

reduce or eliminate disease or illness.

1
Modern surgery helped to alleviate many diseases that have

crippled or killed people in the past generation. The abdominal

cavity is the largest cavity in the body.

Perioperative nursing is a specialized area of nursing

practice. As a fundamental member of the surgical team, the nurse

works in collaboration with other health care professionals. The

perioperative nurse provides nursing care to the patient

preoperatively, intraoperatively, and postoperatively.

The overall goal of perioperative nursing practice is to assist

the patients and their significant others throughout the surgical

episodes (preoperative, intraoperative and postoperative) to help,

promote positive outcomes, and achieve their optimal level of

function, well being and satisfaction after surgery.

The perioperative nurse plans, directs and works in

collaboration with other health care professionals and possesses

unique, highly developed set of knowledge, skill and attitude in

providing quality care. A conceptual model for perioperative

nursing care describes that; patient is at the center of all care

activities.

2
Surgical patient has the right to know what to expect, and

how to participate effectively during surgical experiences.

Preoperative teaching increases patient satisfaction, and also it

reduces postoperative pain, fear, anxiety, nausea, and stress. It

can also reduce complications during hospitalization and recovery

time following the surgical procedures.

The actual and potential problems faced by the surgical

patients may be acute pain, risk for infection, ineffective breathing

pattern, pneumonia, atelectasis, pulmonary embolism,

hypovolemia, hemorrhage, thrombo-phlebitis, urinary retention,

nausea and vomiting, constipation, wound infection, and post-

operative depression etc.

Globally, each year, 234 million surgeries are performed. At

least half a million deaths per year would be preventable with

effective implementation of the Surgical Safety Checklist (WHO).

Worldwide distribution of surgical interventions is unequal.

A retrospective cohort study that investigated the time

window from 1995 to 2007, has collected information from

DATASUS, a National Public Health System Database and

investigated on the variables like: number of surgeries, cost, blood

transfusion related costs, length of the stay and case fatality rates.

3
The trend analysis was performed by a linear regression

model which revealed that there have been 32,659,513 non-

cardiac surgeries performed in Brazil in thirteen years with an

increment of 20.42% in the number of surgeries. Nearly 3 million

operations are performed annually.

Nurses are in a key position to provide preoperative teaching

and responding to patients questions and concerns. New demands

and new expectations of patients are armed with the information

from media as well as the guidelines developed by the health

planners and by the health care team, especially the nursing

personnel with expectations of quality of care with the highest

standards. With technological innovations in the medical field,

patients have become so much obsessed and dependent on the

technology that understanding the patient‟s feelings and his

emotions have become the priority of the past. Advancements in

technology have provided nurses with the opportunity to improve

and intensify the preoperative educational strategies.

Preoperative teaching serves as a standard of nursing

practice within the surgical settings.

4
Providing patients with the supportive preoperative teaching

that incorporates the most useful information about postoperative

activities within a confined time frame has been a challenge.

Patient satisfaction is a subjective and complex concept

involving physical, emotional, mental, social and cultural factors.

Dissatisfaction arises, if the patient experiences a discrepancy

between expected and provided care and information.

The effectiveness of the preoperative teaching depends on

the learning needs, style, and preference of the patient.

Preoperative teaching includes situational information and the

psychosocial support, the role of the patient throughout the

perioperative period, expected sensation and discomfort, and

training for the postoperative period.

5
CHAPTER - II

REVIEW OF LITERATURE

This chapter presents a review of literature related to the

research topic. The review helped the investigator in developing a

deeper insight into the concept of perioperative teaching, surgical

patient satisfaction and in gaining information on the trends in

various related studies in this area.

Review of literature is defined as a broad, comprehensive, in

depth, systematic and critical review of scholarly publications, print

materials, audiovisual materials and personal communication.

Review of literature helps and guides the investigator to design the

study in a systematic manner so as to achieve the desired

outcome.

The literature reviewed for the present study has been

organized under the following headings:

1. Literature related to the effectiveness of perioperative teaching

on postoperative outcome.

2. Literature related to patient satisfaction with perioperative

nursing care information.

6
1. Review of literature related to effectiveness of

perioperative teaching on post-operative outcome.

Mc Carran. B. (2004), conducted studies to investigate the

effects of early ambulation on respiratory and hemodynamic

variables in the intubated, ventilated abdominal surgical patients.

Ambulation was designed as the progression of activity from

supine to sitting over the edge of the bed, standing, walking on the

spot for one minute, sitting on the bed initially and sitting out of the

bed for 20 minutes. 17 patients who fulfilled the inclusion criteria

were selected as a sample. Respiratory and hemodynamic

parameters were measured in each of the above positions and

compared with supine. The investigator concluded that changes in

the tidal volume, respiratory rate and minute volume were largely

due to positional changes when moving from sleeping to standing.

Mackay MR, Ellis Johnston. C. (2005), conducted a

randomized clinical trial to determine that deep breathing exercises

and secretion clearing technique used by standardized

physiotherapist directed program which improved clinical

outcomes in patients who underwent open abdominal surgery.

Fifty six patients were randomized before operation to an early

mobilization only group or an early mobilization plus deep

7
breathing and coughing group. Mobility duration, frequency and

intensity of breathing interventions were quantified for both groups.

All outcomes were assessed by using a standardized outcomes

measurement tool developed specifically for this population.

Outcome includes incidence of clinically significant postoperative

pulmonary complications, fever, and length of stay and restoration

of mobility. The results indicated that the incidence of

postoperative pulmonary complications in the non-deep breathing

and coughing group was 17%, the study conducted that in a

particular clinical setting, in addition to deep breathing and

coughing exercises to physiotherapist directed program of early

ambulation aid significantly reduce the incidence of clinically

significant postoperative pulmonary complications in high-risk open

abdominal surgery subjects.

Hossco, (2004), conducted a prospective study to examine

a new preoperative treatment plan for accelerating postoperative

recovery and evaluated the results. This is so called fast-track

program for employees underwent thoracic peridural analgesia,

forced early ambulation and rapid renourishment. A total of 64

consecutive patients with benign and malignant disease of the

large intestine aged an average of 66 years (range 54-71) were

8
operated. Thirty received conventional resection and 34 of them

were treated laproscopically preoperatively by using a fast-track

program. The hospital diet was given to all the patients on the 1st

postoperative day. The results showed that the first bowel

movements occurred in all cases on the 2nd day (range 2-3). The

study concludes that in colonic surgery the fast-track method

accelerated the convalescence, lowered the number of general

complications and reduced the duration of hospital stay. Therefore,

evaluation of fast-track concept is warranted in other types of

elective abdominal surgery.

Hardy SE. et. al. (2005), conducted a study on factors

associated with recovery of independence among older persons

undergoing major abdominal surgery. The aim of the study was to

identify independence predictors of time and the duration of

recovery of independent activities of daily living (ADL) function

among community dwelling older persons who had a major

abdominal surgery. The study was cohort used 754 persons under

the age of 70 years old were included, the investigator studied the

420 participants who experienced at least 1 episode of disability

involving one or more key activities of daily living (ADLs) bathing,

dressing, walking or transferring during a median follow-up of 53

9
months. The results showed that habitual physical activity is

important predictors of time and duration of recovery of

independent ADL function among community-dwelling older

persons who had a major abdominal surgery.

Stern and Lockwood. (2005), conducted a systematic

review of randomized controlled trials investigating preoperative

instruction of patients and the effect of such instruction on patients‟

understanding of knowledge and ability to perform postoperative

activities. On the basis of limited rigorous studies, these

researchers concluded that preoperative teaching before

admission and the use of preoperative videos improved patients‟

knowledge and skill.

Evrard and colleagues. (2005), surveyed 108 postsurgical

patients who had watched a preoperative DVD. The survey asked

patients to evaluate the following DVD content areas: (1) access to

the information, (2) presentation, (3) patients‟ perception, and (4)

global satisfaction. Seventy-one percent of the patients reported

that the DVD provided a positive and encouraging experience, and

83% recommended its use as a pre-operative teaching tool.

Interestingly, among the 14 patients who experienced

complications, only 21% thought that they had received thorough

10
information from the DVD and only 12% believed that they were

well prepared to handle postoperative complications.

Basse L, Thorbol JE, Lossl K, Kehlet H. (2005), carried

out accelerated rehabilitation and conventional care for patient‟s

undergone colonic surgery. The aim of the study was to evaluate the

postoperative outcome after colonic resection with conventional

care compared with fast track multimodal rehabilitation. One

hundred thirty consecutive patients receiving conventional care

(group 1) in one hospital were compared with 130 consecutive

patients receiving multimodal, fast-track rehabilitation (group 2) in

another hospital. Outcomes were timed to first defecation after

surgery, postoperative hospital stay and morbidity during the first

postoperative month. Median age was 74 years (group 1) and 72

years (group-2). American society of anesthesiologists (ASA)

score was significantly higher in group 2 (p < 0.05). Defecation

occurred on day 4.5 in group 1 and day 2 in group 2 (p < 0.05).

The median hospital stay was 8 days in group 1 and 2 days in

group 2 (p <0.05). The use of a nasogastic tube was longer in

group 1 (p < 0.05). The overall complication rate (35 patients) was

lower in group 2 (p<0.05), especially cardiopulmonary

complications (5 patients p<0.01). Readmission was necessary in

12% of cases for group 1 and 20% in group 2 (p <0.05). The


11
researchers concluded that the fast-track rehabilitation programme

was effective in giving positive outcome.

Sirkku Rankinen, Sanna Salanterä, et.al.(2006), conducted

a descriptive and comparative study to compare surgical patients'

knowledge expectations at admission with the knowledge they

received during their hospital stay. The study was conducted on

surgical wards at one randomly selected university hospital in

Finland. The sample (n = 237) consisted of surgical patients

(traumatological, gastroenterological, urological and heart and

thorax surgery) admitted to hospital during a 2-month period in

2003. The data were collected from two specially developed,

parallel questionnaires: Hospital Patients' Knowledge Expectations

and Hospital Patients' Received Knowledge. These 40-item

instruments used a four-tier response scale and made a distinction

between the bio-physiological, functional, experiential, ethical,

social and financial dimensions of knowledge.

The data were analyzed statistically. Surgical patients

received less knowledge than they felt they expected on the bio-

physiological, functional, experiential, ethical, social and financial

dimensions. Their knowledge expectations and the knowledge

they received were related to age, gender and level of basic

12
education. The results highlighted the need for improved patient

education. Surgical patients expect to receive more knowledge

than they actually receive on all dimensions. The most problematic

areas in the education of surgical patients were the experiential,

ethical, social and financial dimensions of knowledge. In particular,

younger patients, female patients and patients with a higher level

of education require more attention. The most important finding

revealed that patients do not seem to receive as much knowledge

as they expect to. This clearly attests to the need to further

develop and improve patient education.

Deepa M. (2007), studied the effectiveness of early

ambulation on postoperative recovery of patients who underwent

abdominal surgery at railway hospital, Chennai. Quasi

experimental, nonequivalent control group post-test only design

was adopted. The study was conducted in postoperative ICU,

surgical wards (male and female), on 60 patients who had

undergone abdominal surgery out of which 30 patients were

assigned to each experiment and control group. The investigator

ambulated the patients in the experimental group from 24 hours

after surgery, till his/her ability to do independently. For the control

group Hospital regular regimen was followed.

13
The level of dependency in performing activities of daily

living was assisted using an observational checklist; the level of

comfort was assisted by structured interview. The patient in the

experimental group showed a highly significant decrease in the

level of dependency in performing activities of discomfort following

early ambulation (P< 0.001), when compared with the patients in

the control group.

Nirmal Kaur, Prem Verma, Rana, Sandip Singh. (2007),

conducted a study to assess the effect of planned pre-operative

teaching on self-care activities for patients undergoing cardiac

surgery. A quasi-experimental design was used based on

convenient sampling technique. There were total 40 subjects and

20 each in the experimental (Group I) and control group (Group II).

In each group an equal number of subjects 10 each were included

undergoing two types of cardiac surgery i.e. open (Group A) &

closed (group B) heart surgery. A checklist with 40 items was

framed to assess the level of performance during pre-operative

period, before the implementation of teaching on self-care

activities and as well as on the 4th and the 7th postoperative day.

The control group did not receive any preoperative teaching. Data

analysis showed that statistically there was no significant (P>0.05)

14
difference of pretest performance scores between the two groups.

A comparison of post test performance scores between both

groups showed that the experimental group had statistically

significant (P<0.001) increase in performance of total scores as

well as each variable of self-care activities. The findings of the

study reflected that the preoperative teaching was extremely

effective medium to increase the level of performance and

enhance the early recovery of the subjects.

Khoo CK, Vickery CJ, Forsyth N, Vinail NS, Eyre-Brook

T.(2007), conducted a prospective randomized controlled trial of

multimodal perioperative management protocol in patients

undergoing elective colorectal resection for cancer. This study

evaluates the use of a multimodal package in colorectal cancer

surgery in the context of a Randomized Controlled Trials. Patients

for elective resection for colorectal cancer was offered trial entry.

Participants were stratified by sex and the requirement for a total

mesorectal excision and centrally randomized. Multimodal patients

received intravenous fluid restriction, unrestricted oral intake with

prokinetic agents, early ambulation, and fixed regimen epidural

analgesia. Control patients received intravenous fluids to prevent

oliguria, restricted oral intake until the return of bowel motility, and

15
weaning regimen epidural analgesia. Adherence to both regimens

was reinforced using a daily checklist and protocol guidance

sheets. Discharge decision was made using pre-agreed criteria.

The primary endpoint was postoperative staying, and the

achievement of independence milestones. Secondary endpoints

were postoperative complications, re-admission rates, and

mortality. Analysis was by intention to treat. Seventy patients were

recruited. Approximately one fourth underwent TME. Median ages

were similar (69.3 vs. 73.0 years).

The median stay was significantly reduced in the multimodal

group (5 vs. 7 days; P < 0.001, Mann-Whitney U test). Patients in

the control arm were 2.5 times as likely to require a postoperative

stay of more than 5 days. Patients in the multimodal group had

less cardio respiratory and anastomotic complications but more

readmissions. There were 2 deaths, both controls. This

Randomized Control Trials provide level evidence that a

multimodal management protocol can significantly reduce

postoperative stay following colorectal cancer surgery.

Browning. L. Denehy. L., Scholes RL. (2007), conducted

prospective observational study to evaluate the quality of upright

mobilization following upper abdominal surgery. Fifty patients who

16
had undergone upper abdominal surgery after receiving

standardized preoperative education and physiotherapy

intervention on the first postoperative day. An activity logger

recorded uptime continuously for the first four postoperative days.

Postoperative factors such as postoperative pulmonary

complications, surgical attachments, pain relief, duration of

anesthesia and intensive care admission were collected daily. The

median uptime was 3.0 (IQR 8.2), 7.6 (IQR 11.5), 13.2 (IQR 26.6)

and 34.4 (IQR 65.6) minutes for the first four postoperative days

respectively. Morning uptime was greater than both afternoon

uptime (p =0.0001) and evening uptime (p < 0.001). Uptime over

the first four postoperative days predicted length of stay ( r2 =

0.05, p <0.001). Uptime was not significantly less in those who

developed postoperative pulmonary complications (p = 0.08 to

0.17). The results show that the quality upright mobilization had a

positive effect on reducing length of stay and pulmonary

complications following upper abdominal surgery.

As reported by Joe Ong, et. al. (2007), in a quasi

experimental research study conducted to explore the impact of

preoperative instruction in patients undergoing surgery. After a

review of the DVD, patients were surveyed for their knowledge and

17
perceived ability to participate in postoperative care activities.

Patients (n =15) who participated in this project were

predominantly older than 60 years of age (n=12 [80%]) and

English-speaking (n =14 [93%]). Fifty-three percent were female (n

=8), and 47% were male (n =7). Based on the Likert scale (1 =I do

not understand to 4 = I understand very well), on the post

intervention survey, patients‟ response to the question „„How much

do you understand about each of the following after viewing the

preoperative DVD?‟‟ Study findings indicated that high mean score

for all areas of postoperative care. When asked about their ability

to participate in postoperative care after viewing the preoperative

DVD, study scores indicated patients were able to participate or

able to participate a great deal in all areas. Patients reported that

the pre-operative DVD was effective overall in preparing them and

their family members for postoperative care activities.

Thus study findings concluded that preoperative teaching

has a positive impact on patient coping skills postoperatively.

Study also recommended that preoperative information provides

an effective and efficient method of distributing important

postoperative care information and may enhance patients‟ ability to

recall key aspects of their preoperative instruction.

18
Kaur, Nirmal. (2007), conducted a study to assess the

effectiveness of planned preoperative teaching on early

ambulation for patients undergoing abdominal surgery. A quasi-

experimental design was adopted using a convenient sample of 30

subjects, 15 in each of experimental and control group.

Preoperative teaching plan on early ambulation was developed

after an extensive review of literature and expert opinion. It

includes the steps on deep breathing exercises, extremity

exercises, up and down walking, maintenance of daily routine

activities and progressive ambulation. A checklist with 40 items

was used the level of performance preoperatively, before the

implementation of teaching on early ambulation as well as on the

3rd and the 5th postoperative day. The Control group did not

receive any pre-operative teaching. Data were analyzed using both

descriptive and inferential statistics. The major findings of the

study revealed a nonsignificant difference of pretest performance

scores between the two groups (p>0.05) before the

implementation of planned pre-operative teaching on early

ambulation. There was a strong, statistically significant difference

(p < 0.001) found between the posttest performance scores of

experimental and control group when analyzed by unpaired „t‟ test.

In conclusion the patient who received pre-operative teaching had

less pain, early wound healing and recovery than the patients who

did not receive.

19
A study conducted by Richard D. Kuylen,. Lallie

Kemp.(2008), at Medical Center, Independence Louisiana, on

assessing the efficacy of a surgical orientation video in decreasing

pre-operative anxiety and surgical related discomforts. Two -

group, pretest / posttest research design was adopted. A total of

30 samples was selected by simple random sampling technique.

The intervention group had 13, patients who had watched a pre-

operative surgical orientation video and received surgery-specific

pre-operative education. Control group (n=17) – received standard

pre-operative education without viewing the orientation video.

Surgery and anesthesia-related anxiety evaluated by using a

quantitative scale of pre-operative anxiety before and after

implementing pre-operative education and viewing the pre-

operative video. Participation in a pre-operative teaching clinic, on

a day prior to the scheduled surgery, showed significantly

decreased pre-operative anxiety and facilitated a smooth transition

through the surgical process for patients, family members and

operating room staff. The study also revealed no significant

reduction in mean anesthesia-related anxiety (p=0.227). Thus the

investigator concluded that the video assisted teaching influences

anxiety reduction. Thus the research is indicated to assess the

Preoperative Surgical Orientation Video‟s effects on surgical

outcome with anxiety reduction.

20
Lin JH, Whelan RL, Sakellarios NE, Cekic V, Forde K.A,

Bank J, Feingold DL. (2009), conducted prospective study of

ambulation after open and laparoscopic colorectal resection. This

study compared the ambulation, hospital length of stay (LOS), and

incision length after open and laparoscopic colorectal resection.

Equivalent open and laproscopic group were comparable in terms

of gender, age, body mass index, ASA class, indication of

operation and resection performed. Seventy open colectomy

patients were compared with 99 laparoscopic-assisted colectomy

patients. On average, patients in the open and laparoscopic-

assisted groups ambulated 67 and 390 feet, respectively, on Post-

operative day 1 (P < .001), 290 and 752 feet on day 2 (P < .001),

and 495 and 965 feet on day 3 (P < .001). The average LOS in the

open group was 9.3 days compared with 5.9 days in the

laparoscopic group (P < .001). The average incision length in the

open group was 19.7 cm compared with 5.3 cm in the laparoscopic

group (P < .001). Seventeen open LAR patients were compared

with 30 hybrid LAR patients. On average, patients in the open and

hybrid groups ambulated 22 and 150 feet, respectively, on Post-

operative day 1 (P = .003), 105 and 433 feet on day 2 (P = .003),

and 369 and 488 feet on day 3 (P = .43).

21
The average LOS in the open group was 10 days compared

with 8.5 days in the hybrid group (P = .46). The average incision

length in the open group was 19.8 cm compared with 10.8 cm in

the hybrid group (P < .001). When all 216 patients were

considered, the 91 patients with incisions shorter than 8 cm

(average 4.6 cm) ambulated 396, 752, and 956 feet on

consecutive days, whereas the 125 patients with incisions 8 cm or

longer (average 16.9 cm, P < .001) ambulated 101, 334, and 521

feet on consecutive days (all P values <.001). Average LOS in the

<8-cm group was 6 days compared with 8.9 days in the> or =8-cm

group (P < .001). Patients undergoing minimal-access colorectal

surgery ambulated significantly farther than equivalent open

patients in the early Postoperative period and had a shorter LOS.

Karin Valkenet., et.al. (2010), conducted a study to assess

the effects of pre-operative exercise therapy on post-operative

outcome: a systematic review, to summarize the current evidence

on the effects of pre-operative exercise therapy in patients

awaiting invasive surgery on post-operative complication rates and

length of hospital stay. Studies were included if they were

controlled trials evaluating the effects of pre-operative exercise

therapy on post-operative complication rate and length of hospital

22
stay. The methodological quality studies were independently

assessed by two reviewers using the Pedro scale. Statistical

pooling was performed when studies were comparable in terms of

patient population and outcome measures. The results were

separately described if pooling was not possible. The result

revealed that twelve studies of patients undergoing joint

replacement, cardiac or abdominal surgery were included. The

PEDro scores ranged from 4 to 8 points. Preoperative exercise

therapy consisting of inspiratory muscle training or exercise

training prior to cardiac or abdominal surgery led to a shorter

hospital stay and reduced Postoperative complication rates. By

contrast, length of hospital stay and complication rates of patients

after joint replacement surgery was not significantly affected by

pre-operative exercise therapy consisting of strength and/or

mobility training. Thus, investigators concluded that pre-operative

exercise therapy can be effective for reducing Postoperative

complication rates and length of hospital stay after cardiac or

abdominal surgery. More research on the utility of pre-operative

exercise therapy and its long-term effects is needed as well as

insight on the benefits of using risk models.

23
Chang, Chia Hue. (2011), conducted study on factors

influencing abdominal surgical patients at their first postoperative

ambulation. The purpose of this study to explore the factors, which

influences the duration of the patient getting out of bed those who

underwent surgery. An instrument was modified by the researcher

entitled to interview the patients who get out of the bed at the first

time after a general surgery. The instrument has been revised by a

panel of expert for its content validity and conducted a pre-test

among the patients for its reliability. Totally 58 subjects were

recruited from a surgical ward of a medical center of nursing, using

the convenience sampling technique. Observation, interviewing

and reviewing medical records was used by two research

assistants who are the students of the department of health

management. SPSS 10.0 package was facilitated for analysis of

data. The finding revealed that the period taken by the patient to

get out of the bed for the first time after surgery was 79.2 hours.

Based on the demographic data, the patients who are younger,

well-educated and female are more likely to experience a shorter

period of time to get out of the beds. However, after a surgery the

patients whose bodies had inserted some tubes than those who

have no tube inserted would be more likely to take an increase in

the period of time to get out of the beds.


24
Approximately, there are 50% of the participants with his /her

first time to get out of bed after a surgery being encouraged by the

health professionals, and the barriers include fear of pain and

wound split, 55.2%, 32.8%, respectively. The discomforts

experienced by the patients who are at the moment of the first time

of getting out of the beds are pain, fainters and lower leg

weakness, 67.2%, 58.6%, 34.5% respectively.

Wang G, Jiang ZW, Xu J, Gong JF, Bao Y, Xie LF, Li JS.

(2011), conducted Fast-track rehabilitation program Vs

conventional care after colorectal resection a randomized clinical

trial. One hundred and six consecutive patients who underwent the

fast-track rehabilitation program were encouraged to have early

oral feeding and movement for early discharge, while 104

consecutive patients underwent conventional care after resection

of colorectal cancer. Their gastrointestinal functions, Post-

operative complications and hospital stay time were recorded. The

restoration time of gastrointestinal functions in the patients was

significantly faster after fast-track rehabilitation program than after

conventional care (2.1 d Vs 3.2 d, P<0.01). The percentage of

patients who developed complications was significantly lower 30 d

after fast-track rehabilitation program than after conventional care

25
(13.2% Vs 26.9%, P<0.05). Also, the percentage of patients who

had general complications was significantly lower 30 d after fast-

track rehabilitation program than after conventional care (6.6% vs

l5.4%, P<0.05). The Post-operative hospital stay time of the

patients was shorter after fast-track rehabilitation program than

after conventional care (5 d vs 7 d, P<0.01). No significant

difference was observed in the re-admission rate 30 d after fast-

track rehabilitation program and conventional care (3.8% Vs

8.7%). The fast-track rehabilitation program can significantly

decrease the complications and shorten the time of postoperative

hospital stay of patients after resection colorectal cancer.

Christine Fink., et.al. (2013), designed a cluster-

randomized controlled pilot study to assess the impact of pre-

operative patient education on prevention of postoperative

complications after major visceral surgery. The aim of the trial was

to evaluate the feasibility and the impact of pre-operative patient

education on postoperative morbidity, mortality and quality of life in

patients scheduled for elective major visceral surgery. The

experimental group was exposed to a standardized pre-operative

seminar to learn how best to behave after surgery in addition to

being given a standard information brochure, whereas the control

26
group received only the information brochure. Outcome measures

such as postoperative morbidity, postoperative pain, postoperative

anxiety and depression, patient satisfaction, quality of life, length of

hospital stay and postoperative mortality was evaluated. Statistical

analysis based on the intention-to-treat population, analysis of

covariance was applied for the intervention group comparison,

adjusting for age, center and quality of life before surgery.

2. Review of literature related to patient satisfaction on peri-

operative nursing care information

Amina T. Ghulam, Margrit Kessler, Lucas M. Bachmann.

(2006), conducted a study to assess the Patients' Satisfaction with

the preoperative Informed Consent Procedure at Switzerland. A

Multicenter Questionnaire Survey was used. The study was

conducted between March 2001 and April 2002, patients from 11

Swiss hospitals, representing 3 linguistic areas of Switzerland,

were given a questionnaire and a standardized operation-specific

leaflet and engaged in a structured conversation. The

questionnaire and operation-specific leaflet were designed in

collaboration with the Swiss Patient Organization, the judicial

service of the Swiss Medical Association, and the Swiss Society of

Obstetrics and Gynecology. The findings revealed that a total of

27
3888 (56%) of 6970 women received the questionnaire and were

enrolled in the study. Most of the patients considered the written

and oral information to be good or excellent, and more than 80%

did not desire further written information. Forty-five percent (45%)

would have preferred to receive this structured information the

same day the decision to undergo an invasive procedure was

made, and more than half of the patients were reassured by the

information provided. However, in 7% anxiety increased. In the

multivariate analysis, Turkish (odds ratio [OR], 6.7; 95%

confidence interval [CI], 2.0-22.4; P=.002) and Serbo-Croat (OR,

8.0; 95% CI, 2.4-27.4; P=.001) language and a poor rating of the

written description of the planned operation (OR, 3.1; 95% CI, 1.1-

9.0; P=.03) were the only variables significantly associated with

discontent. The researcher concluded that ,the combined written

and oral pre-operative information presented is well adapted to the

patients' informative wishes and needs; it allows for a structured

conversation, facilitates documentation, and offers valid legal proof

that adequate information has been provided. Therefore, close

collaboration between the national patient organization and the

expert judiciary and medical societies of the corresponding country

is strongly recommended to improve the informed consent

procedure which is a key source of increased patient satisfaction.


28
C. Baumann, et.al. (2006), conducted a multicentre cohort

study of 228 patients with osteoarthritis followed up after total hip

or knee replacement. Quality of life and patient satisfaction were

assessed by self-administered questionnaires. Patient satisfaction

was the dependent variable in a multivariate linear regression

model. Independent variables included socio-demographic factors,

pre- and post-operative clinical characteristics and the pre-

operative and post-discharge health-related quality of life. The

mean age of the patients was 69 years (SD 9), and 43.8% were

male. Pre- and postoperative clinical characteristics were not

associated with satisfaction with health care. Only pre-operative

bodily pain (p < 0.01) and pre-operative social functioning (p <

0.05) influenced patient satisfaction with care. The preoperative

health-related quality of life and patient characteristics have little

effect on inpatient satisfaction with care. This suggests that the

impact of the care process on satisfaction may be independent of

observed and perceived initial patient-related characteristics. Thus

the study concluded that changing the process of such care may

have a direct impact on satisfaction, independent of observed and

perceived initial patient characteristics.

29
Jennie April Walker. (2007), conducted a literature review is

to examine the relationship between the provision of written

information given to patients‟ preoperatively and their

postoperative recovery in terms of physiological adaptation and

satisfaction following elective surgery. It is not currently apparent

which is the most effective method of delivering pre-operative

information, or at what stage of the pre-operative phase is the

optimum time to deliver such important information. The purpose

of this review is to briefly outline the affiliation between anxiety

experienced by surgical patients and the information received

preoperatively and to examine the relationship between the

provision of written information given to patients preoperatively

and their Post-operative recovery following elective surgery.

However, research does indicate that the provision of good-quality

pre-operative information facilitates patients‟ active involvement in

their care, and therefore may contribute to an overall increase in

satisfaction. There remains a need for rigorous research that

identifies the optimum timing and method of delivering pre-

operative information to maximize their positive effect on patients

undergoing elective surgery.

30
Jaime Ortiz, et.al. (2010), conducted a survey on pre-

operative patient education: can we improve satisfaction and

reduce anxiety? With an aim to develop anesthesia patient

education materials that would help improve patient's satisfaction

regarding their knowledge of the peri-operative process and

decrease anxiety in a community hospital with a large Spanish-

speaking population. After approval by the Baylor College of

Medicine IRB in February 2010. The survey was administered to

patients presenting to the Ben Taub General Hospital

anesthesiology pre-operative clinic during a 4-week period in April

2010. The survey was anonymous and optional, and it included a

statement of the purpose of the survey and that the information

collected anonymously would be used for research purposes only.

By completing the survey and returning it to their

anesthesiologist, the patients were provided consent for the study.

All patients aged 18 years and older were given this survey upon

arrival to the pre-operative clinic and before meeting with a

member of the anesthesiology team. There were both English and

Spanish versions of the survey to accommodate the large

Spanish-speaking population in the hospital, which is around 40%

of the patient population. Patients were given a choice as to which

version to complete if they spoke both languages. Results,


31
revealed that patients who received the handout, showed

statistically significant improvement in questions that were asked

about satisfaction with regard to understanding of the type of

anesthesia, options for pain control, what patients are supposed to

do on the day of surgery, and the amount of information given with

regard to anesthetic plan.

Thus researcher concluded that a patient education handout

written at the appropriate reading level and available in their

primary language resulted in a significant improvement in patient

satisfaction concerning their understanding of the

anesthesiologist's role, types of anesthesia, options for pain

control, and instructions for the day of surgery. Future studies are

needed to explore the impact of improving patient's knowledge of

the perioperative process in the community hospital setting.

Additionally, future studies are needed to further understand how

to best communicate with patients.

Colin Howie. (2010), conducted a study by the University‟s

Department of Orthopedics and Trauma, has found that patients‟

satisfaction with their operation depends not only on the surgeon‟s

ability to treat them safely, but on the hospital environment. More

than 4,700 joint replacement surgery patients were involved in the

study. Other factors identified to influence patient experience and

32
satisfaction includes the meeting of preoperative expectations and

good pain relief. The five-year study is the first to measure and

show how important the hospital environment and care pathway is

to levels of satisfaction among patients. The researchers also

found that levels of patient satisfaction had dropped at the same

time as clinical performance had improved. Researchers say that

the study highlights the complexity of meeting and measuring

patients‟ expectations and satisfaction with the surgery. The

Edinburgh team concludes that patient satisfaction is determined

by different factors to those which influence patients' overall health

outcome, such as age, gender and other medical conditions.

Paul Licina. (2012), conducted a prospective case series

study of patients undergoing lumbar spine surgery, with an

Objective of finding the correlation between patients' expectations

before lumbar surgery, postoperative outcomes, and satisfaction

levels. A total of 145 patients undergoing primary, single-level

surgery for degenerative lumbar conditions were included and

study adopted Oswestry Disability Index, back Visual Analog

Scale (VAS), and leg VAS were assessed pre-operatively and at 6

weeks and 6 months after surgery. Patients' expectations were

measured pre-operatively by asking them to score the level of pain

and disability that would be least acceptable for them to undergo

surgery and be satisfied.

33
Satisfaction was assessed 6 weeks postoperatively with a 5-

point Likert scale. Differences in patient expectations between

actual and expected improvements were quantified. Results

revealed that most patients had a clinically relevant improvement,

but only about half achieved their expectations. Satisfaction did not

correlate with pre-operative pain or disability, or with patient

expectation of improvement. Instead, satisfaction correlated with

positive outcomes. Thus, researchers concluded by stating that

patient expectations have little bearing on the final outcome and

satisfaction.

According to research reported in the Journal of Healthcare

Quality, the peer reviewed publication in (2013) of the National

Association for Healthcare Quality, (NAHQ). in a retrospective

comparative study of patients undergoing hemorrhoidectomy

procedures, satisfaction levels for an initial group of 60 patients

were measured at UK St, Peters NHS Foundation Trust, and a

second group undergoing the same operation was surveyed after

being offered improved patient information, such as normal

recovery time, suggestions for optimal pain management, and

what to do if normal bleeding occurs. Comparisons between the

groups were determined to assess whether good patient

information could enhance satisfaction after recovery and reduce

the incidence of post-operative medical attention sought.

34
Results showed that the average satisfaction score (scale

1-5) in the group receiving better information was 4.2 vs. 2.95 in

the original group. Further, only three patients from the well-

informed group sought post-operative medical attention vs. 34

from the original group. Although hemorrhoidectomy is a short

procedure, it causes prolonged post-operative pain with mild

bleeding and requires regular analgesia, laxatives and antibiotics.

If patients are not well informed about their recovery, the

symptoms can foster anxiety and the need for medical attention to

provide reassurances. "These findings demonstrate that good pre-

operative communication with patients can alter behavior upon

discharge, improve success in managing procedures in a day-care

setting, and possibly improve cost-effectiveness and satisfaction

levels”.

Upul Senarath, et.al. (2013), studied on "Patient satisfaction

with nursing care and related hospital services at the National

Hospital of Sri Lanka", This study aims to assess patient

satisfaction with nursing care and related hospital services, and

the association between satisfaction and patient characteristics at

the National Hospital of Sri Lanka (NHSL). A systematically

selected sample of 380 patients admitted for three to 90 days in


35
general surgical/medical units was interviewed on discharge. Data

were collected using a satisfaction instrument previously

developed and validated for the same setting that contained 36

items under five sub-scales. Multiple logistic regression analyses

were used to identify factors associated with satisfaction in each

sub-scale. The findings – revealed that the majority of respondents

were males (61 percent), aged 35-64 years (70 percent), educated

to GCE (O/L) and above (61 percent), and previously hospitalized

(66 percent). The proportion satisfied with “interpersonal care” was

81.8 percent, “efficiency and competency”, 89.7 percent, “comfort

and environment”, 59.2 percent, “cleanliness and sanitation”, 48.7

percent, and “personalized and general information”, 37.4 percent.

Males reported higher satisfaction (OR varied from 2.29-2.87, p <

0.001) than females. Patients with GCE (A/L) were less satisfied

with “comfort and environment” (OR=0.45, p < 0.05) and

“cleanliness and sanitation” (OR=0.45, p < 0.05) compared with

those educated below grade 5. Satisfaction with “comfort and

environment” was lower among patients from medical (OR=0.51, p

< 0.01) rather than from surgical units.

36
The review of literature on effectiveness of planned

perioperative nursing information on postoperative outcome

revealed that only few studies were conducted in different settings

on different surgical procedures. In sum, the literature review

helped the investigator become aware of the various

methodologies used in studies pertaining to positive postoperative

outcomes. It further helped the investigator to understand that thus

far very few studies have been conducted on perioperative aspect

as a whole, most of the studies highlighted only on preoperative

teaching on specific postoperative outcome.

Thus a review of literature clearly gives evidence that there is

a need for conducting study on perioperative care aspects on

assessing the knowledge, practice, and level of satisfaction in

achieving positive postoperative outcome and increased level of

satisfaction.

37
NEED FOR THE STUDY

Health care delivery systems have been restructured in

recent years to focus on achieving high-quality outcomes for

patients by using the most cost-effective methods. Optimizing

outcome for the patients undergoing surgery requires the

collaborative and coordinated efforts of physicians, nurses, and

allied health personnel.

Surgery is a unique experience of planned physical alteration

encompassing of three phases, namely pre-operative, intra-

operative and post-operative care these phases are together

referred as the peri-operative period.

Patient satisfaction is a multidimensional construct that

includes humanness of the staff, availability of care convenience,

financial accessibility, quality of care, and condition of facilities. It

represents the recipient„s assessment of the salient aspects of

their experience.

Perioperative nursing is a fast-paced, changing and

challenging field to work. preoperative teaching is a vital part of

nursing care. Studies have shown that pre-operative teaching

readily and effectively enables patients to cope with their surgery,

38
and in reducing their duration of hospitalization, and to elevate

patient satisfaction, and resulting in minimizing postsurgical

complications, and augment patients‟ psychological well-being.

Preoperative teaching has been defined as an „„interactive

process of providing information and explanations about surgical

processes, expected patient behaviors, and anticipated sensations

and providing appropriate reassurance to the patients who are

about to undergo surgery. „Postoperative care refers to the nursing

activities performed during the patient‟s postoperative phase.

Preoperative teaching not only provides patient-specific

information about what to expect during the postoperative period,

but also influences the attitudes and behaviors of the patients with

respect to their postoperative care.

As reported by WHO (2010), that globally, data monitor

estimates that there were 7.4 million major abdominal surgeries,

expected to grow or increase by 8.1 million surgeries in 2020. Over

that 20,000 patients die in a year following complications of the

surgery. The numbers of abdominal surgeries are expected to

increase from around 7,436,000 surgeries in 2010 to 8,109,000

surgeries in 2020. In seven major countries, there will be

approximately 166,400 surgeries done under the age group of

39
15 years, 5,125,000 in those between 14 and 44, 1,194,000 in

those between 45 and 64, and 950, 300 surgeries in those over

age of 65 respectively.

The world wide ratio of hernias is over 1 million abdominal

wall hernia repairs as performed each year, with inguinal hernia

repairs constituting nearly 770,000 of these cases. Good pre-

operative teaching also facilitates the patient‟s return to work and

other activities of his daily living.

As reported by Thomas G Weiser, Scott E Regenbogen.

et. al. (2009), an estimation of the global volume of surgery: a

modeling strategy based on available data, in the Netherlands

from October 2007 to March 2009 shows that with the use of a

surgical safety checklist, complications were reduced by more than

one-third and deaths are reduced by almost half (from 1.5% to

0.8%) in test hospitals compared to control hospitals. Almost 70%

of surgeries performed in the hospitals are related to the abdomen.

Many developed complications after surgery and nurses are at the

highest priority care giver to the patients after surgery.

The most common problem arising after surgery performed

under general anesthesia are, circulatory complications, problems

of consciousness, discomfort and respiratory tract complications.

40
When the patient develops the postoperative complications, it will

result in increase in hospital stay as well as economic loss.

The hospitals selected for study have the increased rate of

complications as 60-70% per month, either minor or major

complications in immediate or late postoperative period, and are

found to have decreased levels of knowledge of anesthesia, the

common procedures carried out, and satisfaction with the care

received by the surgical patients and their family members

Currently, substantive inconsistencies are apparent in pre-

operative teaching for surgical patients. This lapse has resulted in

a lack of knowledge and preparedness that prevents patients from

immediately engaging successfully in postoperative self-care

activities.

Based on the limited literature, researcher‟s experience, and

observations made during clinical work in the surgical units, found

that most of the patients as well as the family members (care

givers) expressed anxiety and fear related to Post-operative

outcomes, like fear on after effects of anesthesia, severity of pain,

impairment in the body, and return to normal activities of daily

living, and it was also found that most of the surgical patients‟

were found to have post-operative discomforts like pain, nausea,

vomiting, and complications as wound infection, respiratory and


41
cardiac complications which resulted in decreased level of

satisfaction among surgical patients‟ and their significant others.

Thus, the challenge was to develop structures and

processes that would enable the surgical patients to receive

thorough perioperative teaching consistently. This study in specific

was designed to explore the effect of pre-operative teaching on

post-operative outcome, and make significant contributions to the

surgical patients and for the nursing profession as a whole.

42
STATEMENT OF THE PROBLEM

“Effectiveness of Planned Perioperative Nursing Information

on Postoperative Outcome among the Patients undergoing

Selected Surgeries at Selected Hospital of Kolar, Karnataka”.

OBJECTIVES OF THE STUDY:

1. To assess the knowledge and practice regarding perioperative

nursing care information among the surgical patients before and

after intervention.

2. To determine the effectiveness of planned perioperative

nursing care and the information among the surgical patients

before and after intervention.

3. To determine the level of patients‟ satisfaction on perioperative

nursing care information among the patients before and after

intervention

4. To find the association between selected socio-demographic

variables with perioperative knowledge, practice and level of

satisfaction among surgical patients after intervention.

43
HYPOTHESES:

H1 - There will be a significant difference between perioperative

knowledge and Practice among the surgical patients before

and after intervention.

H2 - There will be a significant difference between levels of

satisfaction among surgical patients of both experimental

and control groups before and after intervention

H3 - There will be a significant association between the socio-

demographic variables with perioperative knowledge among

surgical patients after intervention.

H4 - There will be a significant association between the socio-

demographic variables with perioperative practice among

surgical patients‟ after intervention.

H5 - There will be a significant association between the socio-

demographic variables with the level of satisfaction among

surgical patients after intervention.

44
LIMITATIONS OF THE STUDY:

The following limitations were recognized:

1. The study was limited by describing the effectiveness of the

planned teaching program on postoperative outcomes and

satisfaction level only.

2. The study was limited to 400 surgical procedures performed on

problems related to gastrointestinal and genitourinary surgeries

only.

3. The study was limited to the experimental two groups before

and after intervention design only.

4. The study was limited to surgical patients admitted in a selected

hospital of Kolar, Karnataka.

OPERATIONAL DEFINATIONS:

1. Effectiveness refers to the extent to which the planned peri

operative nursing information will achieve the desired

change/positive postoperative outcome as measured by the

difference between before and after intervention scores.

2. Patients are referred to the individuals who are admitted for

selected surgical procedures like gastrointestinal, and

genitourinary surgeries in selected hospital, Kolar, Karnataka.

45
3. Planned Perioperative Nursing Information refers to a

systematically developed multimedia teaching regarding

planned perioperative nursing care information, which is

designed to achieve the positive post-operative outcome

among the patients‟ undergoing selected surgeries,

4. Postoperative Outcome, refers to the extent of which the

surgical patients‟ are free from the Postoperative complications

related to CVS, Respiratory, Musculoskeletal CNS,

Integumentory, Gastrointestinal, Genitourinary, Renal and

psychological system complications as measured by the

observational checklist and Satisfaction Scale.

5. Selected Surgeries refer to the surgical procedures performed

on the problems related to the gastrointestinal and genitourinary

surgeries

6. Patient Satisfaction Level refers to the quantification of

patients‟ expression of their level of satisfaction with

perioperative nursing, teaching information on the positive

postoperative outcome as measured by their responses to the

items on the three points Likerts Patient Satisfaction Scale.

(Fully Satisfied, Moderately Satisfied, and Not Satisfied.)

46
CONCEPTUAL FRAMEWORK OF THE STUDY:

A concept is an abstract idea or mental image of a

phenomenon or reality. Conceptualization is a process of forming

ideas, which utilizes and forms the conceptual framework for the

development of research design. A framework is a basic structure

supporting anything. It gives a clear picture for logical thinking, for

systematic observation and interpreting the observed data.

The conceptual framework deals with abstractions that are

assembled by the virtue of their relevance to a common theme.

The most important purpose of theoretical framework is to

communicate clearly the relationship of various concepts.

Conceptual framework facilitates the communication and provides

the basis for a systematic approach to nursing, research,

education, administration and practice.

The conceptual framework selected for this study is the

Health Promotion Model. This model was proposed by Nola

Pender (2002) and it is designed to be a “complimentary

counterpart to models of health protection. HPM is a

competence/approach oriented model. Health Promotion Model is

directed at increasing a patient‟s level of well being.

47
The HPM describes the multi-dimensional nature of persons

as they interact within their environment to pursue health. The

model focuses on the following three areas;

1) Individual characteristics and experiences,

2) Behavioral specific cognition and affect,

3) Behavioral outcomes.

The HPM notes that each person has unique personal

characteristics and experience that affects subsequent actions.

The set of variables for behavioral-specific knowledge and affect

have important motivational significance. These variables can be

modified through nursing actions. Health promoting behavior is the

desired outcome and is the end point in the HPM.

Health-promoting behavior should result in improved health,

enhanced functional ability, and better quality of life at all stages of

development. This model is selected for this study, as it measures

the effectiveness of perioperative information on selected positive

post-operative outcomes.

48
In this study the Individual Characteristics and

Experiences are depicted by the personal background of selected

variables like age, sex, occupation, income, educational

qualification, type of surgery, type of anesthesia, duration of

surgery, experience and exposure to any kind of mass media,

patients and staff nurses.

The Behavior Specific Cognition and Affect in this study

refers to the implementation of pre-test and post-test for both the

Experimental and Control groups, and it also includes the

implementation of planned perioperative video-teaching nursing

care information to the patients of the experimental group. The

behavior specific cognition is represented as the change in the

level of knowledge and behavior specific modification.

The Behavioral Outcome in this study is represented by

positive postoperative outcomes, i e, improved health status,

enhanced functional ability, and better quality of life as measured

by observational checklist and patient satisfaction scale as

manifested by decreased levels of pain, anxiety, nausea,

vomiting, urinary retention, constipation, hypostatic pneumonia,

and wound infection.

49
CONCEPTUAL FRAMEWORK OF THE STUDY

Individual Characteristics and Behavior Specific Cognition and Behavioral Outcome


Personal Experiences Affect

P Increase in
P  Knowledge
Experimental O  Practice
Group INTERVENTION
Socio - R  Satisfaction
S
Demographic  Decreased post
E
Variables T operative
T Complication
Surgical
specific E
T
personal Control Group S
experience. E No change in,
NO INTERVENTION  Knowledge
T
S  Practice
 Satisfaction
T
 Minimal Post
operative
complication

Fig: 1 Modified Conceptual Framework Based on NOLA Health Promotion Model (2002- Revised).

50
SUMMARY

This chapter highlighted on the review of literature, the need

for the study, a statement of the problem, objectives, hypotheses,

limitations, assumptions, operational definitions, conceptual

framework adopted based on the Health Promotion Model, which

kept the researcher in a research milieu.

51
CHAPTER - III

METHODOLOGY

This chapter deals with the methodology selected for the study. It

includes research approach, design, setting, sample and sampling

technique, development and description of the tools for data collection,

method of administration of planned perioperative nursing care

information on achieving positive post-operative outcome, along with

the procedure of data collection and plan for data analysis. The

methodology of the research indicates the general pattern of organizing

the procedure for empirical study together with the method of obtaining

valid and reliable data for problem under investigation.

RESEARCH APPROACH:

In the present study, the investigator aims to assess the knowledge

of patients undergoing selected surgical procedures before and after the

administration of planned perioperative nursing care information in both

experimental and control groups. Hence the research approach adopted

for this study is an evaluative approach. This helps to explain the effect

of the independent variable on the dependent variable.

52
RESEARCH DESIGN:

The research design adopted in this study was Experimental Two

Group pretest posttest design aiming to evaluate the effectiveness of

planned perioperative nursing care information on achieving positive

postoperative outcome.

True –Experimental two groups before and after intervention

design

Pre-
Group Intervention Post -test
test

E O1 X O2

C O1 _ O2

Key:

E: Experimental group.

C: Control group.

O1: Pre-intervention Observation.

X: Intervention

O2: Post-intervention Observation

53
RESEARCH DESIGN

Title and Purpose of Study:


Effectiveness of planned perioperative nursing.

Research Design:
Experimental two groups before and after intervention design

Effectiveness of planned peri-operative nursing information.


Target population: Surgical patients

Accessible Population:

Gastro-intestinal & genito urinary surgical patients who fulfilled the criteria.

Sample and sampling technique:

400 surgical patients Random Sampling technique by adopting lottery


method.

Pre-Test by the following tools

1. Structured knowledge
Experimental group-200 questionnaire Control group.-200
2. Observational checklist.
3. Satisfaction scale.
Implementation of intervention No intervention

Post test

Data analysis by using descriptive and inferential


tyuuuustatistics statistics

Interpretation and dissemination of study findings

Fig.2: SCHEMATIC REPRESENTATION OF THE STUDY DESIGN

54
VARIABLES OF THE STUDY:

Three types of variables are identified in this study. They are

independent, dependent and attribute variable.

Independent variable:

An independent variable is the variable that stands alone and it is

not dependent on any other. It is the cause of the action.

In this study planned teaching program on perioperative nursing

care information is the independent variable.

Dependent variable:

A dependent variable is the effect of the action of the independent

variable and cannot exist by itself. In this study, knowledge and positive

postoperative outcome and level of satisfaction are the dependent

variables.

Attribute Variable

Attribute variables are those variables that are present in

research environment which may interfere with the research findings by

acting as unwanted independent variables. In the present study it refers

to the selected socio- demographic variables like age in years, gender,

educational status, type of occupation, marital status, religion, family

income per month , exposure to mass media within 6 months period

and also includes information specific to surgical history like, previous

55
history of hospitalization for any surgical procedure, duration of present

illness, type of surgical procedure proposed, type of anesthesia

proposed for present surgical procedure, body system where the

surgical procedure is involved, body mass index, history of pre existing

surgical risk factors and duration of present stay in the hospital after

surgery:

SETTING OF THE STUDY:

The study was conducted in the surgical wards of R. L. Jalappa

Hospital and Research Centre, a private multi-specialty Medical

Teaching tertiary level, 1100 bedded nonprofit charitable organization

dedicated to establishing a center of health care of excellence and

improving the well being of the community through quality programs of

preventive medicine, medical education and research. It is dedicated to

establishing a patient friendly approach and is committed to reach out to

the community. Being 89-92%occupied, each day. Out of the total beds,

300-315 beds are exclusively allotted for surgical patients. The bed

occupancy rate of surgical wards on an average every day, it is found to

be 80-90% with 1:6 nurse patient ratio.

56
The hospital has well equipped laboratories for early diagnosis

and facilitation of prompt treatment. High-tech Operation Theater with

sixteen operating tables for major surgeries and two tables are allotted

for minor surgical procedures.

The pre and post-operative units along with recovery room are

well equipped with life saving equipments. Further, the radio-diagnostic

departments along with endoscopic investigation facilities attract the

number of patients for surgical procedures for both gastrointestinal and

genitourinary system.

The number of both major and minor surgeries conducted per day

ranged between 46-50 out of which more than 30-35 number of surgical

procedures belongs to gastrointestinal and genitourinary system. Thus

the investigator felt the need to select this hospital because of the

availability of samples, feasibility of the study, and geographical

proximity.

POPULATION:

Population is the entire aggregation of cases that meet a

designated set of criteria. In this study population refers to all the

patients‟ undergoing surgery.

57
SAMPLE AND SAMPLING TECHNIQUE:

The sample of the study consisted of patients‟ undergoing

selected surgeries, at selected hospital of Kolar. The random sampling

technique was used by adopting the lottery method to select the sample

of the study.

The procedure followed in adopted random sampling technique

by using the lottery method was;

 The list of clients who attended surgical OPD was short listed by

obtaining details from the OPD register.

 The list of clients who required surgical intervention of

gastrointestinal and genitourinary related system was further

shortlisted based on inclusion criteria of the study.

 Adopting lottery technique the slips were picked from a container

and assigned to both experimental and control group randomly, i.e.

every odd number to experiment and even number to control group

respectively.

CRITERIA FOR SELECTION OF SAMPLE:


Inclusion criteria: refers to the individuals who are;

1. Admitted for selected surgical procedures like Gastrointestinal

and Genitourinary surgeries in selected hospital,

2. Within the age group of 19-75 years,

3. Willing to participate in the study,

4. Able to understand Kannada and English language.

58
Exclusion Criteria; refers to the individuals who are;

1. Chronically ill at the time of admission,

2. Develop complications during the perioperative phases.

3. Having a psychiatric illness,

4. Undergoing surgery within four hours of admission,

5. Above the age of 75 years.

SELECTION AND DEVELOPMENT OF TOOL:

Data collection tools are the procedures of instruments used by

the researcher to observe, measure the key variables in the research

problem. For the present study structured knowledge questionnaire and

other outcome related tools were used.

Development of the tool:

The main purpose of developing this tool was to enhance the

knowledge and practice of patients undergoing surgical procedure with

a view to achieve positive post-operative outcome and enhanced level

of satisfaction.

For development of the tool, research and non research

literature is reviewed and suggestions of experts and present statistical

approaches are taken to determine the concepts to be included in the

tool.

59
The following steps are undertaken to prepare the final tool:

 Preparation of blue print.

 Development of the tool.

 Development of criteria rating scale.

 Content validity of the tool.

 Pretesting of the tool

 Reliability of the tool.

Preparation of Blue Print:

The investigator prepared the blueprint before constructing the

questions. The items are distributed according to the content areas in

three domains and shown with a number of question and percentage. In

these domains, knowledge domain contains 62% of questions,

comprehension 20% and application (problem solving) 18 %.

Development of the tool:

The developed tool was organized under the following headings:

TOOL – 1

Consisted of the following sections;

Sec. A - Socio Demographic Data- Eight Items

Sec. B - Information Specific to Surgical History- Eight Items

Sec. C - Structured Knowledge Questionnaire on perioperative

Nursing care Information.

60
The Structured interview schedule on Knowledge Questionnaire

initially had 45 questions later based on Validation of the tool the

questions were organized and a total of 40 questions.

TOOL- II

Sec. A - Observational Checklist on re-demonstration of postoperative

exercises preoperatively consisted of twenty two items.

Sec. B - Observational Checklist on analyzing Complication before and

after intervention consisted of eight items.

TOOL –III

Sec. A- Modified Aldrete‟ scale consisted of three parameters as

activity, respiration and level of satisfaction with a total of 15 as

maximum score. (Checklist to determine the patient‟s readiness for

transfer from the PACU to surgical ward).

Sec. B- Observational Checklist on assessment of post-operative

outcome consisted of ten items.

TOOL –IV

Patient satisfaction scale on perioperative nursing care

information. This section consisted of 35 items which emphasized on

the patient Satisfaction level in all the three phases of peri-operative

nursing.

61
SCORING OF THE TOOL:

The total knowledge, practice and satisfaction score obtained by

the subject are arbitrarily graded as;

Knowledge Score Percentage (%) Grade

(Max. Score 40)

<19 49 Inadequate

20-28 50-70 Moderate

29 -40 71-100 Adequate

Practice score

(Max. Score 22)

<9 41 Poor

10-16 42-72 Moderate

17-22 73-100 Adequate

Level of Satisfaction Percentage (%) Grade

(Max. Score 140)

<71 50 Not satisfied

72-105 51-74 Moderately Satisfied

106-140 75-100 Fully Satisfied

62
Development of Criteria Rating Scale.

A criteria checklist for the validation of the tool was developed.

The criteria for Structured Knowledge Questionnaire had Very Relevant,

Relevant, Needs Modification, Not Relevant and Remarks Columns.

Content Validity of the Tool

The prepared data collection tool along with a problem statement,

hypothesis, operational definitions, blue print and criteria raring scale

designed for validation was submitted to ten experts. The experts

consisted of five Nursing and five Surgeons, who were experts in

Gastro and Genitourinary related surgeries. There was 100%

agreement on all the items of each tool except for modification in certain

distracters in the Structured Knowledge Questionnaire. Based on the

subject experts‟ suggestions and opinions the tool was modified with

consultation of the guide.

Pretesting of the Tool

Pretesting of the tool was done on ten subjects. The clarity of

items and time taken to complete the tool was assessed. All the items

were clearly understood with appropriate responses by the subjects.

The subjects have taken about 45-50 minutes to answer the questions.

63
Reliability of the Tool

Reliability of the instrument was inferred by administering the tool

to ten subjects, admitted in selected surgical wards. The internal

consistency reliability of the tool was established by the split half

method along with reliability for stability by using test re-test method by

using Karl Pearson‟s correlation formula with the Spearman Brown

Prophecy formula.

The reliability for internal consistency was 0.99 and for stability,

0.81 which is highly reliable. Hence the tool was found to be is reliable.

Development of Teaching on Planned Perioperative Nursing

Information

Teaching information on perioperative nursing care was

developed to educate all selected surgical patients undergoing

Gastrointestinal and Genitourinary system related surgeries based on

the review of literature and discussion with the Guide.

The steps involved in the development of the planned perioperative

teaching program is

a. Preparation of draft/ script with general and specific objectives for

planned perioperative teaching program.

b. Preparation of lesson plan.

c. Development of criteria checklist.

d. Content validity of planned perioperative teaching program

e. Preparation of final planned perioperative teaching program.

f. Translation of planned perioperative teaching program.


64
Preparation of draft/ script with general and specific objectives for

planned perioperative teaching program

The script of teaching was prepared after reviewing the literature,

organized as per the sequence based on the suggestion and opinions

given by the subject experts and research guide. The factors such as

time and level of understanding and needs of the learner were

considered while preparing planned peri-operative teaching program.

Preparation of lesson plan

The lesson plan was prepared after reviewing the literature. The

final content was organized with adequate Audio-Visual Aids as per the

sequence based on the suggestion and opinions given by the subject

experts and research guide.

Development of Criteria Checklist

A criteria checklist for the validation of the planned perioperative

teaching program was developed. The aspects evaluated were grouped

under the headings as formulation of objectives, selection of content,

and organization of content, language and audio- visual aids. The

criteria check list for the planned perioperative teaching program was

very Relevant, Relevant Needs Modification, Not Relevant and

Remarks Columns.

65
Content Validity of teaching information

The prepared planned perioperative teaching program information

along with a problem statement, hypotheses, operational definitions,

blue print and criteria raring scale designed for validation was submitted

to ten experts. The experts consisted of five Nursing and five Surgeons,

who were experts in Gastro and Genitourinary related surgeries. There

was 100% agreement on all the content of teaching information.

A further degree of consistency was obtained by giving the

planned perioperative teaching program information to two raters who

independently assigned score. The information of teaching was found

relevant as the scores of two raters were found to be equivalent.

Preparation of final planned perioperative teaching

programme information.

Based on the expert‟s suggestion and guides correction the

planned perioperative teaching program information was

organized under the following headings:

 Information related to surgery, its types, common positions, and

surgical team and perioperative nursing care phases with their

purposes

 Preoperative preparation procedures and their importance.

 Intra-operative period related procedures and their importance

 Postoperative period related procedures and their importance along

with post-operative complications and its prevention

66
Translation of planned perioperative teaching programme

The English version of the planned perioperative teaching

program information was translated into Kannada version and later

validated by the language expert.

Pilot study

A pilot study is a small preliminary investigation of the same

general character as the major study. A pilot study was conducted in

selected surgical wards at Kolar from 11-04-2012 to 25-04-2012.

The investigator obtained written permission from the concerned

authority prior to the study. The purpose of the study was explained to

the study subjects and confidentiality was assured.

The data were collected by adopting structured interview

schedule using a knowledge questionnaire, observational checklist, and

Likert three point scale for satisfaction assessment. The data were

collected from 40 samples (10% of the total sample) i.e. 20 for

experimental and 20 for control group respectively, who fulfilled the

inclusion criteria for sample selection. Both the group's knowledge,

practice was assessed on the first visit.

The selected sample of experimental group only had teaching

program on planned perioperative nursing care information, on the

same day of pre-test. On the 5th or 7th day, i.e. on the day of discharge

post test was conducted with the same tool in order to assess the gain

67
in knowledge, skill on performance of post-operative exercises and level

of satisfaction. The data were analyzed by using both descriptive and

inferential statistics. Based on the pilot study findings, the objectives of

the study could be achieved. Thus investigator felt the study could be

conducted as it was feasible and practicable.

Data Collection procedure

The data were collected from 26 -04-2012 to 30-08- 2012 as per

the availability of the sample. Formal written permission was obtained

from concerned authorities. The study was done on four hundred

subjects (200 experimental group 200 control group) in selected

surgical wards. The purpose of the study was explained to the study

subjects and confidentiality was assured. The data were collected by

using a structured interview schedule for assessing knowledge,

practice, level of satisfaction and post-operative outcomes. The data

collection procedure consisted of three phases.

First phase deals with the selection of the sample based on specified

inclusion criteria, development of structured, planned perioperative

nursing information teaching program along with the tools of data

collection, pretesting of the tool and content of teaching program,

testing the reliability of the tool and teaching content along with the Pilot

study.

68
The second phase deals with administration of planned perioperative

nursing information teaching program to the selected sample of the

study, which will be followed on the first day after the pre-test.

The third phase consists of evaluation of the effectiveness of the

teaching program with the same Structured Knowledge Questionnaire

and other outcome observational and three points Likert satisfaction

scale which was carried out on 5th or 7th day in both groups of

experimental and control group after the intervention.

Plan for Data Analysis

Data analysis is a systematic organization and synthesis of the

research data and testing of research hypotheses using data.

The data obtained was planned to analyze by using both descriptive

and inferential statistics on the basis of study objectives and null

hypotheses of the study. Demographic data containing sample

characteristics were analyzed by using the frequency and percentage.

The association between knowledge with selected socio demographic

variables, post-operative outcomes along with the level of satisfaction

was being analyzed by using chi-square test. The level of perioperative

knowledge, practice and level of satisfaction of the sample before and

after administration of planned perioperative teaching program was

determined by using frequency, mean, median, range, paired t-test,

unpaired t-test, percentage, standard deviation.

69
Ethical Considerations

This study was planned and implemented based on the ethical

principles of the research. All respondents were given written

information about the study and informed that participation was

voluntary. All respondents gave their informed consent and were

guaranteed confidentiality. The study was reviewed and approved by

the Ethical Committee at Sri Devaraj Urs College of Nursing attached to

R.L, Jalappa Hospital and Research Centre, Kolar, Karnataka.

Summary

The research methodology is the blueprint or overall plan of the

entire process of tackling the research problem in a systematic and

scientific manner. This chapter has dealt with research approach,

research design, and variables under study, the setting of the study,

population, sample, sampling, sampling technique, research setting,

study instrument or tool, pilot study and method of data collection plan

for data analysis.

70
CHAPTER – IV

RESULTS AND DISCUSSION

RESULTS
This chapter presents the results of study conducted to find out

the “Effectiveness of Planned Perioperative Nursing Information on

Postoperative Outcome among the Patients Undergoing Selected

Surgeries at Selected Hospital of Kolar, Karnataka”.

The data were collected through a structured interview schedule,

observational checklist and Likerts‟ rating scale. The sample consisted

of 400 surgical patients (200 experimental and 200 control groups). The

analysis was made by adopting both descriptive and inferential

statistical methods. The analysis and interpretation of data were based

on the objectives and hypotheses of the study:

Organization of Findings
The analyzed data is organized and presented under the following
sections:

Section I: This section deals with the data pertaining to,

1. Distribution of sample according to socio-demographic variables of

both experimental and Control groups.

2. Distribution of sample according to information specific to surgical


history in both experimental and Control groups.

71
Section II: Deals with the data pertaining to the first objective of the

study, which was to assess the perioperative knowledge and practice of

sample among Experimental and Control groups before and after

Intervention

1. Distribution of sample according to level of perioperative knowledge,

among Experimental and Control groups before and after

Intervention.

2. Distribution of sample according to perioperative practice among

Experimental and Control groups before and after Intervention.

3. Area wise Distribution perioperative Knowledge of sample before

and after intervention.

4. Area wise Distribution perioperative Practice of sample before and

after intervention

Section III: Deals with the data pertaining to the second objective of the
study, that was to assess the Effectiveness of planned perioperative
nursing information on postoperative Outcome among experimental and
control groups.

1. Comparison of perioperative Knowledge level before and after

intervention among both Experimental and control group.

2. Comparison of perioperative Practice before and after intervention

among both Experimental and control group.

72
3. Comparison of perioperative knowledge, practice and level of

satisfaction among Experimental and control groups after

intervention.

4. Distribution of the sample based on the occurrence of

complication in experimental and control group.

Section IV: Deals with the data pertaining to the third objective of the

study, which was to assess the level of satisfaction among Experimental

and Control groups after Intervention

1. Distribution of sample according to level of Satisfaction among

Experimental and Control groups after Intervention.

2. Area wise distribution of level of satisfaction of Experimental and

Control groups after intervention.

Section V: Deals with the data pertaining to the fourth objective of the

study, which was to find out the association between the perioperative

knowledge, practice and level of satisfaction with selected socio-

demographic Variables in both Experimental and Control group.

1. Association of perioperative knowledge with socio demographic

variables after intervention.

2. Association of perioperative Practice with selected socio

demographic variables after intervention

3. Association of satisfaction with selected socio demographic variables

after intervention

73
SECTION – I : Distribution of sample according to socio-

demographic variables
Table -1: Frequency and Percentage distribution of sample
according to socio-demographic variables.

N=400
Experimental Group Control Group
SI. (n1=200) (n2=200)
Demographic Variables
NO
f % f %
1 Age in years
a. 19-30 years 28 14.0 31 15.5
b. 31-40 years 63 31.5 79 39.5
c. 41-50 years 75 37.5 44 9.5
d. 51-60 years 24 12.0 26 13.0
e. >61 years 10 5.0 20 10.0
2 Gender
a. Male 136 68.0 134 67.0
b. Female 64 32.0 66 33.0
3 Educational Status
a. Illiterate 123 61.5 83 41.5
b. Primary education 53 26.5 65 32.5
c Others specify ------ 24 12.0 52 26.0
4 Type of occupation
a. Government employee 19 9.5 31 15.5
b. Self-employed 130 65.0 116 58.5
c. Unemployed 51 25.5 53 26.0
5 Marital status
a. Married 162 81.0 160 80.0
b. Unmarried 31 15.5 29 14.5
c. Divorced 7 3.5 11 5.5
6 Religion:
a. Hindu 150 75.0 153 76.5
b. Muslim 29 14.5 29 14.5
c. Christian 21 10.5 15 7.5
d. Any other------- - - 3 1.5
7 Family income per month
a. Rs.< 2000 35 17.5 13 6.5
b. Rs. 2001-5000 98 49.0 57 28.5
c. Rs. 5001-7000 36 1.0 81 40.5
d. Rs.7001 and above 31 15.5 49 24.5
8 Exposure to mass media
a. exposed 28 14.0 19 9.5
b. not expose 172 86.0 181 90.5

74
Table-1 reveals the Socio-demographic variables of the sample.

Regarding age, majority 37.5% (75) of the sample in experimental

group were between the age of 41-50, years and only 5% (10) of them

were in the age group of 61 years and above, whereas in control group

majority 39 % (79) of the sample were between the age of 31-40 years.

With regard to sex, the majority of the sample were males in both

experimental 136 (68%) control 67 % (134) groups and 32% (64) were

female in experimental and control 33 %( 66) groups.

Regarding Educational Status, the majority of the sample were

illiterates, in both experimental 61.5 % (123) and in control 41.5 % (83)

groups. With regard to type of occupation, majority130 (65%) of the

sample in the experimental group were self employed, 25 % (51) of

them were unemployed and only 9.5 % (19) them were government

employees. In the control group majority 58% (116) of them were self

employed and 53(26%) of them belonged to self employment and

15.5 %( 31) of them belonged to government employment.

In terms of Marital status, the majority of the sample in both

experimental 81% (165) and control 80 % (160) groups were married.

Regarding religion, the majority of the sample in both experimental 75%

(150) and control 76.5% (153) groups were Hindus. With regard to

family income, majority 49 % (98) of the sample in the experimental

group belonged to the income of Rs.2001-5000, whereas in the control

group majority 41.5% (81) of them belonged to the income of Rs. 5001-

7000. Regarding Exposure to Mass Media, the majority of the sample

was not exposed to any kind of mass media on information related to

perioperative care aspects within six months period in both

experimental 86% (172) and control 90%(181) groups.


75
Table 2: Distribution of Sample according to information specific
to surgical history in both Experimental and control group
N=400
Experimental Group Control Group
SI. Surgical Specific History
(n1=200) (n2=200)
NO Variables
f % f %
1 Previous history of surgical
exposure:
a. Yes 37 18.5 28 14.5
b. No 163 81.5 172 86.0
2 Duration of present illness
a. 6 months to 1 year 183 91.5 177 88.5
b. >1 year 17 8.5 23 11.5
3 Type of surgery
a. Major surgery 135 67.5 135 67.5
b. Minor surgery 65 32.5 65 32.5
4 Type of anesthesia used
a. General anesthesia 147 73.5 140 70.0
b. Spinal anesthesia 53 26.5 60 30.0
5 System of surgical procedure
a. Gastrointestinal 135 67.5 158 79.0
b. Genito- urinary 65 32.5 42 21.0
6 Body mass index:
a. Normal weight 85 42.5 114 57.0
b. Underweight 52 26.0 48 24.0
c. Overweight 30 15.0 19 9.5
d. Very obese 33 16.5 19 9.5
7 History of pre existing risk
factors
a. Yes 57 28.5 113 56.5
b. No 143 71.5 87 43.5
8 Duration of present
hospitalization:
a. 5 days – 8 days 133 66.5 157 78.5
b. 9 days and above 67 33.5 43 21.5

The Table-2 explains on information specific to surgical history.

With regard to previous history of the surgical procedure, majority of the

sample in both experimental 163 (81.5%) and control 86 % (172)

groups had no surgical exposure.

76
Regarding, duration of illness, the majority of the sample in both

experimental 79% (158) and control 71% (142) groups presented illness

symptoms less than 6 months. In terms of the type of surgical

procedure, majority 67% (135) of the sample belonged to major surgical

procedure in both experimental and control groups. With Regard to the

type of anesthesia used, study findings revealed that majority of

samples in both experimental 73.5% (147) and control 70% (140)

groups had undergone a surgical procedure under general anesthesia.

Regarding the body system of surgical procedure, findings

revealed that majority of the sample in both experimental 67.5% (135)

and control 79% (158) groups had undergone surgeries related to the

gastrointestinal system. Whereas 32.5% (65) of sample in experimental

and 21% (42) in the control group had surgeries related to Genitourinary

system.

In terms of Body Mass Index, majority of sample in both

experimental 85 (42.5%) and control 57% (114) groups had normal

body weight. In experimental group, 16.5% (33) and control9. 5% (19)

groups were very obese.

Regarding history of pre existing surgical risk factors, in

experimental group majority 71.5% (143) of the sample had no history

of pre-surgical risk factor and only 28.5% (57) of them presented with

risk prior to surgery. In control group majority 56% (113) of the sample

had preexisting risk factors and only 43.5%) (87) of them did not have

any pre-existing risk factor.

77
With regard to hospitalization after surgery, majority of the sample

in both experimental 66.5 % (133) and control 78.5% (157) groups

sample were hospitalized for less than 8 days.

SECTION – II: Overall and area wise level of perioperative


Knowledge, practice among Experimental and

Control groups.

Table-3 Distribution of the sample according to the overall level of


perioperative Knowledge before and after intervention.

N=400
Experimental group Control group
(n1=200) (n2=200)
Variables Grade
Before After Before After

No. % No % No % No %
Inadequate
176 88.5 2 1.0 147 73.5 83 41.5
(<49%)

Perioperative Moderate
24 12 173 86.5 52 26.5 115 57.5
Knowledge (50-70% )

Adequate-
- - 25 12.5 1 0.5 2 1.0
(71-100%)

Table-3 presents the findings regarding the overall level of

knowledge. The majority of the sample had inadequate perioperative

knowledge in both experimental 88.5% (176), and control 73.5 (147)

group before intervention.

78
After intervention the perioperative knowledge of the

experimental group had improved from inadequate to moderate 86.5%

(173) and 12.5% (25) of them had adequate knowledge, and only

1% (2) showed an inadequate level of knowledge. Whereas in control

group majority 57.5% (115) of them had moderate knowledge with only

1% (2) of them presented with adequate knowledge, remaining 41.5%

(83) belonged to the inadequate knowledge level (Figure-3).

Knowledge level Inadequate- Knowledge level Moderate Knowledge level Adequate

100
88.5
90
80 73.5
70
Percentage

60
50 41.5
40
30
20
10
1
0
% % % %

Before After Before After

Experimental Control group

Knowledge level

Fig- 3 Distribution of sample according to the overall level of peri-


operative Knowledge before and after intervention.

79
Table - 4 Distribution of sample according to the overall level
of perioperative Practice before and after
Intervention.
N=400
Experimental Control group
group(n1=200) (n2=200)

Variables Grade Before After Before After

No. % No % No % No %
Poor
192 96 - - 200 100 189 94.5
(<41%)

Moderate
Perioperative 8 4 20 10 - - 10 5.0
Practice (42-72% )

Adequate
- - 180 90 - - 1 0.5
(73-100%)

The data presented in Table-4 reveal the findings regarding the

overall level of perioperative practice. In the experimental group,

majority 96% (192) of the sample had a poor level of perioperative

practice and none of them belonged to an adequate practice category

before intervention. But after the intervention the perioperative practice

level was significantly higher, as majority 90% (180) of them belonged

to adequate, 10% (20) to moderate and none of them had inadequate

perioperative practice level.

80
In the control group the entire sample belonged to 100% (200) poor

performance. The findings further revealed that without the intervention

the sample had showed some change in performance level, i.e. 5% (10)

had moderate and 0.5% (1) adequate perioperative practice level,

and majority 94.5% (189) of them belonged to poor levels of

perioperative practice (Figure-4).

120
96 100
100 94.5
PERCENTAGE

80
Practice score
60 Poor

40

20 10
4 5
0 0 Practice score
0 Moderate
% % % %

Before After Before After


Practice score
Experimental group Control group Adequate

PRACTICE LEVEL

Fig-4 Distribution of sample according to the overall level of


perioperative Practice before and after intervention.

81
Table 5- Area-wise Distribution of perioperative Knowledge
of sample before and after intervention.

N=400

Experimental group Control group


(n1=200) (n2=200)
Variable Area
Max.
Range Mean Sd Range Mean Sd
Score
Surgical Before 5 0-3 1.60 .983 0-4 1.85 1.028
information After 5 2-4 3.11 .678 1-4 2.41 .696
Preoperative Before 23 7-18 11.13 2.144 1-21 12.70 2.878
Perioperative care After 23 11-21 16.33 2.141 7-21 13.26 2.613
Knowledge Intraoperative Before 4 0-4 1.72 .978 0-4 1.91 1.117
care After 4 2-5 3.27 .708 0-4 2.38 .836
Postoperative Before 8 0-4 1.71 .853 0-4 1.87 1.043
care After 8 2-4 3.20 .697 0-4 2.28 .803

The data in Table-5 depicts area-wise mean perioperative

knowledge of the study sample. The mean perioperative knowledge

level of experimental group before and after intervention with regard to

surgical information was (1.60 ± .983), (3.11±.678), pre-operative

area (11.13± 678), (16.33 ±2.141), intra-operative (1.72 ± .978 ), (3.27

± 708) and post-operative care(1.71+ .853 ), (3.20 + .697) respectively.

In the control group the mean perioperative knowledge level

before and after intervention with regard to surgical information it was

(1.85 ± 1.028) and (2.41 ± .696), pre-operative area (12.70 ± 2.878) and

(13.26 ±2.613), intra-operative (1.91±. 1.117) and (2.38 ± .836) and

post-operative care(1.87+ 1.043) and (2.28 ± .803) respectively.

82
Findings highlight that after an intervention, the mean perioperative

knowledge level improved significantly in all the areas of experimental

group, when compared to control group (Figure-5).

Area-wise knowledge
Experimental group Control group

16.33

12.7 13.26
11.13

3.11 3.27 3.2


2.41 2.38 2.28
1.61.85 1.721.91 1.711.87

Before After Before After Before After Before After

Surgical information Preoperative care Intra-operative care Post operative care

Knowledge

Fig: 5 Area-wise Distribution of perioperative Knowledge of


sample before and after intervention

83
Table 6 – Area-wise Distribution perioperative Practice of
sample before and after intervention
N=400

Experimental group Control group


(n1=200) (n2=200)
Variable
Area Max.
Range Mean Sd Range Mean Sd
Score
Breathing Before 6 0-3 1.77 .757 0-3 1.74 .816
exercise with
After 6 2-5 3.61 .838 1-4 2.04 .795
splinting
Coughing Before 8 0-3 1.68 .757 0-3 1.66 .689
Perioperative exercise with
After 8 2-6 4.18 .986 0-3 1.93 1.044
Practice splinting
Leg exercise with Before 4 0-3 1.32 .656 0-3 1.21 .706
splinting After 4 2-4 3.29 .624 0-3 1.53 .625
Turning and Before 4 0-2 1.17 .663 0-2 .93 .712
ambulation After 4 2-4 3.24 .716 0-3 1.34 .675

The data in Table 6 depict area-wise the mean perioperative

practice before and after intervention, on breathing with splinting

exercise, (1.77 ± .757), (3.61 ± 838) coughing with splinting, (1.68 ± .757)

(4.18 ± .986) leg exercise with splinting (1.32 ± .656) and turning

exercise with ambulation (1.17 ±.663), (3.24 ± .716) respectively.

In control group the mean perioperative practice before and after

intervention, on breathing with splinting exercise, (1.74 ± .816), (2.04 ±795)

coughing with splinting, (1.66 ± .689) (1.93 ± 1.044) leg exercise with

84
splinting (1.21 ± .706) and turning exercise with ambulation (.93 ± .712),

(1.34 ± .675) respectively. The sample of the experimental group

showed improvement in all types of exercise. Whereas the sample of

the control group showed slight change in all types of exercises

(Figure-6).

Experimental Group
Ряд1
Area-wise practice
Control Group
Ряд2
4.18

3.61
3.29 3.24

2.04 1.93
1.771.74 1.681.66
1.53
1.321.21 1.34
1.17
0.93

0 0

Before After Before After Before After Before After

Breathing with Coughing with Leg exercise with Turning and


exercise splinting exercise splinting splinting ambulation

Practice

Fig -6 Area-wise Distribution Practice of sample before and after


intervention

85
Section - III Effectiveness of planned perioperative nursing information
on Post-operative Outcome among experimental and
control groups.

Table-7 Comparison of perioperative Knowledge level before and


after intervention among both Experimental and control
group

N=400
Experimental Group Control Group
(n1=200) (n2=200)
Variable
„t‟ „t‟ value
Mean SD Mean SD
value (Unpaired)

Before-
16.16 2.634 18.33 3.054
intervention
37.511 13.777
Perioperative
After- *S *S
Knowledge 25.92 2.576 20.33 2.989
intervention

*S= Significant P<.0001 df=199 t- table value at 199 df 37.511

Table-7 presents the mean perioperative knowledge (25.92) was

higher in the experimental group after intervention than before

intervention (16.16). The calculated„t‟ value („t‟ 199=37.511, P<.0001)

was greater than the table value. Hence the stated hypothesis H1 is

accepted.

86
Table-8 Comparison of perioperative Practice before and after
intervention among both Experimental and control group.

N=400

Experimental Group Control Group


(n1=200) (n2=200)
Variable „t‟ value
Mean SD „t‟ value Mean SD
(unpaired)
Before-
5.93 1.888 5.54 1.992
Perioperative intervention 49.935 9.194
Practice After - *S *S
14.33 1.616 6.84 1.919
intervention

*S= Significant P<.0001 df=199 t- table value at 199 df 37.511

Table-8 depicts that the mean perioperative practice level (14.33)

was higher in experimental (14.33) group after intervention than the

mean practice level (5.93) before intervention. The calculated „t‟ value

(„t‟ 199=49.935, P<.0001) was greater than the table value. Hence the

stated hypothesis H1 is accepted.

87
Table - 9 : Comparison of perioperative knowledge, practice and
Level of satisfaction among Experimental and control
groups after intervention.

N=400
Experimental Group Control Group
t‟ Value
Variable (n1=200) (n2=200)
(Unpaired)
Mean SD Mean SD
Perioperative
18.33 3.606 16.16 2.628 7.602 *S
Knowledge
Perioperative
14.32 1.616 6.84 1.919 42.167 *S
Practice
Satisfaction
95.70 7.747 57.65 6.836 52.083 *S
*S = Significant P< 0.0001 df=399 t- table value at 399 =3.290

Table 9 indicates that there was a significant difference between

mean perioperative knowledge (18.33) practice (14.32) and level of

satisfaction (95.70) of experimental and control groups mean peri-

operative knowledge (16.16) practice (6.84) and level of satisfaction

(57.65) after intervention. The calculated „t‟, value (t‟ 399=3.290,

P<.0001) was greater than the table value. Hence the stated hypothesis

H1 & H2 was accepted

88
Table 10: Distribution of the sample based on occurrence of
Complication in experimental and control group.

N=400

Body system Experimental group Control group


SI.
related (n1=200) (n2=200)
No
complication f % f %
1 Cardiovascular 2 1 15 7.5
2 Coagulation - - - -
3 Respiratory 08 4 34 17
4 Central Nervous - - - -
5 Gastrointestinal 32 16 38 19
6 Genitourinary 2 1 34 17
7 Musculo- skeletal - - - -
8 Integumentary 7 3.5 27 13.5
Total 50 25 148 74

Table 10 presents that a majority, 148 (74%) of the sample in the

control group had more complications compared to experimental group

50 (25%). In both experimental 32 (16%) and control 38 (19%) group

majority of the sample presented with complication related to

gastrointestinal system. None of the sample presented with

complications associated with Central Nervous, coagulation and

musculo- skeletal system. The findings significantly highlights that

planned teaching program was effective in reducing the number of

complications in experimental group when compared to control group.

89
Section IV: Level of satisfaction among Experimental and Control

groups after Intervention

Table: 11 Distribution of sample according to the overall level of


Satisfaction of Experimental and Control groups after
intervention
N=400

Experimental Control group


Variable Grade group-(n1=200) (n2=200)
No. % No. %
Not satisfied
( <50% ) - - 193 96.5
Level of Moderately satisfied
satisfaction (51-74%) 169 84.5 7 3.5
Fully satisfied
(75-100%) 31 15.5 - -
Table 11 indicates that the level of satisfaction was higher in

experimental group when compared to control group. Majority 84.5%

(169) of the sample in the experimental group were moderately satisfied

and 15.5% (31) they were fully satisfied, whereas in the control group

majority, 96.5% (193) of the sample were not satisfied (Figure-7).

96.5
100 84.5
80
60
40 15.5
20 0 3.5 0
0
Not satisfied Moderately Fully
satisfied satisfied

Experimental group Control group

FIG-7 Distribution of sample according to the overall level of


satisfaction of Experimental and Control groups after intervention
90
Table - 12 Area-wise distribution of the level of satisfaction of
Experimental and Control groups after intervention
N=400
Experimental Group (n1=200) Control Group-(n2=200)
Area wise Level
of satisfaction Max.
Range Mean SD Range Mean SD
Score
General
20 11-18 15.02 1.519 6-15 10.12 1.965
information
Preoperative
48 18-46 30.87 4.957 12-35 22.36 5.413
information

Intraoperative
20 5-20 13.44 2.149 3-16 7.27 2.540
information

Postoperative
20 7-13 13.62 2.342 3-17 9.24 2.632
information

Facilities provided 32 13-32 22.75 3.819 10-28 18.78 3.869


Total 140

Table- 12 presents area-wise level of satisfaction. The mean


perioperative level of satisfaction of experimental group with regard to
general (15.02 +1.519), preoperative (30.87 ± 4.957 ), intraoperative
(13.44 + 2.149), postoperative information (13.62 + 2.342) and facilities
provided (22.75 + 3.819) was found to be higher when compared to
control groups.
In the control group the mean peri-operative level of satisfaction
in general (10.12+ 1.965), preoperative (22.36+ 5.413), intraperative
(7.27 + 2.540) postoperative information (9.24 + 2.632) and facilities
provided (18.78+ 3.869) was found to be less when compared to the
experimental group Further findings revealed that the mean satisfaction
with regard to preoperative information was higher in both experimental
(30.87 ± 4.957) and control (22.36 ± 5.413) groups, when compared
to other areas. These findings support that the teaching program was
effective in enhancing the level of satisfaction.

91
Section V: Association between the perioperative knowledge, practice and level of satisfaction with
Selected socio-demographic Variables in both Experimental and Control group.

Table: 13 Association of perioperative knowledge with selected socio demographic variables in both
experimental and control groups after intervention
N=400
Experimental group (n1=200) Control group(n2=200)
Level of knowledge Level of knowledge
Inference
Variable Mod. Inference Mod.
Inadequate Adequate Inadequate Adequate
Adequate Adequate
No. % No. % No. % No. % No % No. %
1. Age in years
a. 19-30 23 11.5 5 2.5 - - 2 20 10 11 5.5 0 2
 8.608  10.926
b. 31-40 60 30 3 1.5 - - df =4 66 33 12 6 1 0.5 df=8
c. 41-50 67 33.5 8 4 - - p=.069 28 14 16 8 0 p=.209
d. 51-60 18 9 6 3 - - NS 20 10 6 3 0 NS
e. 61and above 8 4 2 1 - - 13 6.5 7 3.5 0
2. Gender 2 2
 2.398  3.090
a. Male 123 61.5 13 6.5 - - df =1 96 48 38 19 0 0 df =1
b. Female 53 26.5 11 5.5 - - p=.056 51 25.5 14 7 1 0.5 p=.215
NS NS
3 Educational Status 2 2
 .447  6.197
a. Illiterate 107 53.5 16 8 - - df =2 66 33 16 8 1 0.5 df =2
b. Primary education 47 23.5 6 3 - - p=.800 48 24 17 8.5 0 0 p=.185
c higher than primary 22 11 2 1 - - NS 33 16.5 19 9.5 0 0 *S

92
4 Type of occupation 2 2
 3.013  1.173
a. Govt. employee 19 9.5 18 9 - - df =2 24 12 7 3.5 0 0 df =4
b. Self employee 112 56 60 30 - - p=.010 83 41.5 32 16 1 0.5 p=.903
c Unemployed 45 22.5 NS 40 20 13 6.5 0 0 NS
5 Marital status 2 2
 10.623  6.291
a. Married 147 73.5 15 7.5 - - df =2 117 58.5 43 21.5 0 0 df=4
b. Unmarried 22 11 9 4.5 - - p=.010 22 11 6 3 1 0.5 p=.222
c. Divorced 7 3.5 0 - - - *S 8 4 3 1.5 0 0 *S
2
6 Religion 2.179  .799
a. Hindu 132 66 18 9 - - df =2 111 55.5 41 20.5 1 0.5 df=6
b. Muslim 26 13 3 1.5 - - p=1.000 22 11 7 3.5 0 0 p=.962
c. Christian 18 9 3 1.5 - - NS 12 6 3 1.5 0 0 NS
d. others - - - - - - 2 1 1 0.5 0 0
7. Family income per
month 2 2
 .067  16.160
a. Rs< 2000 27 13.5 4 2 - - df =3 36 18 13 6.5 0 0 df =6
b. Rs 2001-5000 32 16 4 2 - - 62 31 19 9.5 0 0
p=.0001 p=.047
c. Rs.5001-7000 86 43 12 6 - - 39 19.5 18 9 0 0
NS NS
d. Rs 7000 & above
31 15.5 4 2 - - 10 5 2 1 1 0.5
2 2
8 Exposure to mass  .051  2.895
media df=1 11 5.5 8 4 0 0 df =2
a. Yes 25 12.5 3 1.5 - - p=.247 136 68 44 22 1 0.5 p=.193
b. No 151 75.5 21 10.5 - - NS NS
NS= Non Significant *S- Significant

93
Table 13 shows that there was a significant association between

perioperative knowledge and marital status as the obtained 2 value

was higher than the table value in both experimental (210.623, df =2,

p=.010) and control (26.291, df=4, p=.222) group, hence stated

hypothesis H3 is accepted. In control group the calculated value was

higher in terms of educational status (2 6.197, df =2, p=.185), hence

stated hypothesis H3 is accepted

The findings also revealed that there was no association between

perioperative knowledge with age ( 2 8.608, df =4, p=.069,

210.926, df=8, p=.209 ) gender, (22.398, df =1 , p=.05623.090, df

=1, p=.215 ) educational status (2.447, df =2, p=.800, 2 6.197, df =2,

p=.185) type of occupation (23.013, df =2 , p=.010, 21.173, df =4,

p=.903 ) religion (2.179, df =2, p=1.000, 2.799, df=6, p=.962)

income (2.067, df =3, p=.0001 216.160, df =6, p=.047) and

exposure to mass media (2 .051,df=1 , p=.247) in both experimental

and control groups, as the obtained 2 value was less than the table

value, thus the stated H3 is rejected.

94
Table 14: Association of perioperative Practice with selected socio

Demographic variables after intervention

N=400
Experimental group Control group
(n1=200) Inferenc (n2=200)
Variable Inference
Practice e Practice
Poor Moderate adequate Poor Moderate adequate
1. Age in years
a. <30 - 25 2 2 2.122 30 1 0 2 4.188
b. 31-40 - 56 5 df =4 75 4 0 df =8
c. 41-50 - 70 5 p=.713 40 3 1 p=.840
d. 51-60 - 21 2 NS 25 1 0 NS
e. 61and above - 8 2 19 1 0
2. Gender 23.908 2 0.543
a. Male - 121 12 df =1 126 7 1 df =2
b. Female - 59 4 p=0.052 63 3 0 p=.762
SS NS
3. Educational Status
a. Illiterate - 111 26.193 77 5 1 2 1.788
b. Primary - 48 9 df =2 62 3 0 df =4
c. Higher primary - 21 5 p=0.008 50 2 0 p=.775
2 SS NS
4.Type of occupation
a. Unemployed 26.088 2 1.759
b. Govt employee - 45 5 df =2 49 4 0 df =4
c..Private employee - 16 3 p=0.031 30 1 0 p=.780
- 119 8 SS 110 5 1 NS
5. Marital status 22.003 2 1.050
a. Married - 143 15 df =2 151 8 1 df =4
b. Unmarried - 30 1 p=.367 27 2 0 p=.902
c. Divorced - 7 0 NS 11 0 0 NS
6. Religion 2 0.723
a. Hindu - 133 14 21.490 144 8 1 df =6
b. Muslim - 28 1 df =2 28 1 0 p=.994
c. Christian - 19 1 p=.475 14 1 0 NS
d. others - - - NS 3 0 0
7. Family income per
month
a .Rs.>2000 - 30 1 23.508 46 3 0 2 5.852
b.Rs 2001-5000 - 32 4 df =3 79 1 1 df =6
c. Rs.5001-7000 - 84 10 p=.320 52 5 0 p=.440
d. Rs,7000 & above - 34 1 NS 12 1 0 NS

8. Exposure to mass 2 11.462


2
media  4.745 df =2
a. Exposed - 25 1 df=1 15 4 0 p=.003
b. Not exposed - 155 15 p=0.038 174 6 1 SS
SS
NS= Non Significant *SS Statistically significant df =1 ( 3.84), df=2 (5.99),
df=3 (7.82), df=4 (9.49),

95
Table 14 presents on association of perioperative practice with

socio-demographic variables. In experimental group, findings of the

study revealed that the obtained 2 value was greater than the table

value in terms of gender (23.908, df =1, p=0.052), educational status

(26.193, df =2, p=0.008) type of occupation (26.088, df =2, p=0.031)

and exposure to mass media (2 4.745, df=1, p=0.038) respectively,

hence the stated H4 was accepted.

As the obtained 2 value was less than the table value in age

(2 2.122, df =4, p=.713), marital status (22.003, df =2, p=.367),

religion (21.490, df =2, p=.475 ) and family income (23.508, df =3,

p=.320) in experimental group, hence the stated H3 was rejected.

In control group, findings revealed that the obtained 2 value

was greater than the table value only in exposure to mass media (2

11.462, df =2, p=.003), thus the stated H4 was accepted.

With regard to age (2 4.188, ,df =8, p=.840), gender (2 0.543,

df =2, p=.762), educational status (2 1.788, df =4, p=.775), Type of

occupation ( 2 1.759, df =4, p=.780), marital status (2 1.050, df =4,

p=.902), religion (2 0.723, df =6, p=.994) and family income (2 5.852,

df =6, p=.440) the obtained 2 value was less than the table value,

hence the stated H3 was rejected.

96
Table- 15 Association of level of satisfaction with selected socio

Demographic variables with level of satisfaction after


intervention

N=400

Experimental group Control group


(n1=200) (n2=200)
Variable Level of satisfaction Inference Level of satisfaction Inference
NOT MOD. FULLY NOT MOD. FULLY
SAT. SAT. SAT. SAT. SAT. SAT.
1. Age in years
a. <30 - - - 2 6.911 28 3 - 25.388
b. 31-40 - 76 15 df= 2 76 3 - df - 4
c. 41-50 - 66 9 p=0.013 43 1 - p=.242
d. 51-60 - 27 7 S* 26 0 - NS
e. 61and above - - - 20 0 -
2 2
2. Gender  .4.148  .319
a. Male - 114 22 df- 1 130 4 - df – 1
b. Female - 55 9 p=0.057 63 3 - p=.257
S* NS
2 2
3. Educational Status  6.455  4.035
a. Illiterate - 99 24 df -2 82 1 - df – 2
b. Primary - 50 3 p=0.055 63 2 - p=.119
c higher primary - 20 4 SS 48 4 - NS
2 2
4. Type of occupation  4.023  1.098
a. Govt employee - 17 2 df -2 29 2 - df – 2
b. Self-employee - 105 25 p=0.056 113 3 - p=.667
c Unemployed - 47 4 S* 51 2 - NS
2 2
5. Marital status  4.287  6.292
a. Married - 133 29 df -2 157 3 - df – 2
b. Unmarried - 30 1 p=.098 26 3 - p=.071
c. Divorced - 6 1 NS 10 1 - NS
2 2
6. Religion  2.391  0.734
a. Hindu - 130 20 df- 2 147 6 - df – 3
b. Muslim - 22 7 p=.292 28 1 - p=.876
c. Christian - 17 4 NS 15 0 - NS
d. others 3 0 -
7. Familyincome/mon.
2
a. Rs< 2000 - 27 4 χ 1.551 47 2 - 22.481
b. Rs 2001-5000 - 28 8 df- 3 80 1 - df – 3
c. Rs.5001-7000 - 84 14 p=.694 54 3 - p=.464
d. Rs 7000 & above - 30 5 NS 12 1 - NS
2 2
8. Exposure to mass  4.138  0.761
media df -1 df – 1
a. exposed - 23 5 p=0.057 19 0 - p=.492
b. Not exposed - 146 26 S* 174 7 - NS

NS= Non Significant S*= significant df =1 ( 3.84), df=2 (5.99), df=3 (7.82), df=4 (9.49),

97
Table 15 indicated that the obtained 2 value was greater than

the table value only in sample of experimental group with regard to age

(2 6.911, df= 2, p=0.013), gender (2.4.148, df- 1, p=0.057), education

(26.455, df -2, p=0.055), occupation ( 24.023, df -2, p=0.056) and

exposure to mass media (24.138, df -1, p=0.057) in experimental

group, hence the stated hypothesis H5 is accepted. Whereas in marital

status (24.287, df -2, p=.098), religion (22.391, df- 2, p=.292), and

family income (χ21.551, df- 3, p=.694), the obtained 2 value was less

than the table value, thus the stated H5 was rejected.

In control group none of the variables as age (25.388, df - 4,

p=.242), gender (2.319, df –1, p=.257 ), educational status (24.035, df

– 2, p=.119), type of occupation, (21.098, df – 2, p=.667), marital

status, religion (20.734, df – 3, p=.876 ) income (22.481, df – 3,

p=.464) and exposure to mass media (20.761, df – 1, p=.492)

presented association with satisfaction, as the obtained 2 value was

less than the table value, thus the stated H5 was rejected.

98
DISCUSSION

Optimizing outcome for patients undergoing surgery requires

the collaborative and coordinated efforts of physicians, nurses, and

allied health personnel. Surgery is always viewed as life crisis and

evokes anxiety and fear. Today‟s nurses enter a realm of

opportunities and challenges in providing high-quality evidence

based care in health care setting. More than ever, today‟s nurse‟s

need to think critically, creatively and compassionately.

Preoperative teaching serves as a standard of nursing

practice within the surgical setting. Providing patients with

supportive pre-operative teaching that incorporates the most useful

information about Post-operative activities within a confined time

frame has been a challenge.

The perspectives of the findings have been discussed with

reference to the research problem, conceptual framework,

objectives, hypothesis and assumptions of the study. The present

study aimed to evaluate the “Effectiveness of Planned

Perioperative Nursing Information on Post-operative Outcomes

among the Patients undergoing Selected Surgeries at Selected

Hospital of Kolar, Karnataka”.

99
This chapter discusses on the major findings of the study

based on objectives and hypotheses, which is reviewed in terms of

results obtained by other investigators.

Organization of Findings

The analysed data is organized and presented under the following

sections:

Section I: Socio-demographic variables and information

specific to surgical history of both experimental and

Control groups.

Section II: Overall and area wise perioperative knowledge and

practice of sample among Experimental and Control

groups before and after Intervention

Section III: Effectiveness of planned perioperative nursing

information on postoperative Outcome among

experimental and control groups.

Section IV: Overall and area wise level of satisfaction among

Experimental and Control groups after Intervention

Section V: Association between the perioperative knowledge,

practice and level of satisfaction with selected socio-

demographic Variables in both Experimental and

Control group.

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Section I - Socio-demographic variables and information

specific to surgical history of both experimental and Control

groups

The Socio-demographic variables of the sample presented

that, majority 37.5% (75) of the sample in the experimental group

were between the age of 41-50, years and only 5% (10) of them

were in the age group of 61 years and above, whereas in control

group majority 39 % (79) of the sample were between the age of

31-40 years. With regard to sex, the majority of them were males

in both experimental 136 (68%) control 67 % (134) groups and 32

%( 64) were female in experimental and control 33 %( 66) groups.

Regarding Educational Status, the majority of the sample

were illiterates, in both experimental 61.5 % (123) and in control

41.5 % (83) groups. With regard to type of occupation,

majority130 (65%) of the sample in the experimental group were

self employed, 25 % (51) of them were unemployed and only 9.5

% (19) they were government employees. In the control group

majority 58% (116) of them were self employed and 53(26%) of

them belonged to self employment and 15.5 % (31) of them

belonged to government employment.

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In terms of Marital status, the majority of the sample in both

experimental 81% (165) and control 80 % (160) groups were

married. Regarding religion, the majority of the sample in both

experimental 75% (150) and control 76.5% (153) groups were

Hindus. With regard to family income, majority 49 %( 98) of the

sample in the experimental group belonged to the income of

Rs.2001-5000, whereas in the control group majority 41.5% (81) of

them belonged to the income of Rs. 5001-7000.

Regarding Exposure to Mass Media, the majority of the

sample was not exposed to any kind of mass media on information

related to perioperative care aspects within a six month period in

both experimental 86% (172) and control 90%(181) groups. With

regard to the information specific to surgical history, the majority of

the sample in both experimental 163 (81.5%) and control 86 %

(172) groups had no surgical exposure. Regarding duration of

illness, the majority of the sample in both experimental 79% (158)

and control 71% (142) groups presented illness symptoms less

than 6 months.

In terms of the type of surgical procedure, majority 67%

(135) of the sample belonged to major surgical procedure in both

experimental and control groups. With Regard to the type of

anesthesia used, study findings revealed that majority of samples

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in both experimental 73.5% (147) and control 70% (140) groups

had under gone surgical procedure under general anesthesia.

Regarding the body system of surgical procedure, findings

revealed that majority of the sample in both experimental 67.5%

(135) and control 79% (158) groups had undergone surgeries

related to the gastrointestinal system. Whereas 32.5% (65) of

sample in experimental and 21% (42) in the control group had

surgeries related to genitourinary system.

In terms of Body Mass Index, majority of sample in both

experimental 85(42.5%) and control 57% (114) groups had normal

body weight. In experimental group, 16.5% (33) and control 9. 5%

(19) groups were very obese. Regarding the history of preexisting

surgical risk factors, in experimental group majority 71.5% (143) of

the sample had no history of pre-surgical risk factor and only

28.5% (57) of them presented with risk prior to surgery. In the

control group majority 56% (113) of the sample had preexisting

risk factors and only 43.5%) (87) of them did not have any pre-

existing risk factor. With regard to hospitalization after surgery,

the majority of the sample in both experimental 66.5 % (133) and

control 78.5% (157) groups sample were hospitalized for less than

8 days.

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The above findings are consistent with the findings of the

following studies conducted by various researchers:

Makary MA, Haynes AB, Dziekan G, Berry WR, Gawande

A A. (2009), who compared a group of patients who had attended

a preoperative education program with a control group who had

not. The results showed that the experimental group had a mean

of 4 days less hospitalization than the control group, with cost

savings of £10 640. Other important findings were increased

patient turnover and a shorter time on the waiting list in the

experimental group.

G, Palese (2012), in an experimental study conducted on

345 surgical patients highlighted that the majority (78%) of the

sample had undergone surgeries related to the gastrointestinal

system, majority (67%) of them were males, married,(72%) and

(86%) had no exposure to information regarding surgery. These

findings are very consistent with the present study findings.

Christine Fink, et al (2013), in a study conducted on 432

surgical patients with a view to measure the risk factors

contributing to poor postoperative outcome or prognosis,

highlighted that co-morbidity factors like increased body mass

index, hypertension, malnutrition prior to surgery increased the risk

104
for poor prognosis. These findings are consistent with present

study findings.

Section II- Overall and area-wise perioperative knowledge and

practice of sample among Experimental and Control groups

before and after Intervention

The findings regarding the overall level of knowledge,

Majority of the sample had inadequate preoperative knowledge in

both experimental 88.5% (176), and control 73.5 (147) group

before intervention. After intervention the perioperative knowledge

of the experimental group had improved from inadequate to

moderate 86.5% (173) and 12.5% (25) of them had adequate

knowledge, and only 1% (2) showed an inadequate level of

knowledge. Whereas in control group majority 57.5% (115) of

them had moderate knowledge with only 1% (2) of them presented

with adequate knowledge, remaining 41.5% (83) belonged to the

inadequate knowledge level.

Area-wise mean perioperative knowledge of study sample.

The mean perioperative knowledge level of experimental group

before and after intervention with regard to surgical information

was (1.60 ± .983), (3.11±.678), pre-operative area

(11.13± 678), (16.33 ±2.141), intra-operative (1.72 ± .978 ), (3.27

105
± 708) and postoperative care(1.71+ .853 ), (3.20 + .697)

respectively. In the control group the mean perioperative

knowledge level before and after intervention with regard to

surgical information it was (1.85 ± 1.028) and (2.41 ± .696), pre-

operative area (12.70 ± 2.878) and (13.26 ±2.613),

intraoperative (1.91± . 1.117) and (2.38 ± .836) and postoperative

care(1.87+ 1.043) and (2.28 ± .803) respectively. Findings

highlight that after an intervention area wise the mean

perioperative knowledge level improved significantly in all the

areas of experimental group, when compared to control group.

The findings regarding the overall level of perioperative

practice, in the experimental group, majority 96% (192) of the

sample had a poor level of perioperative practice and none of them

belonged to adequate practice category before intervention. But

after the intervention the perioperative practice level was

significantly higher, as majority 90% (180) of them belonged to

adequate, 10% (20) to moderate and none of them had inadequate

perioperative practice.

In the control group the entire sample belonged to 100%

(200) poor performance. The findings further revealed that without

the intervention the sample had showed some change in

performance level, i.e. 5% (10) had moderate and 0.5% (1)

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adequate perioperative practice level, and majority 94.5% (189) of

them belonged to poor levels of preoperative practice.

Area-wise mean perioperative practice of study sample. The

mean perioperative practice before and after intervention, on

breathing with splinting exercise, (1.77 ± .757), (3.61 ± 838)

coughing with splinting, (1.68 ± .757) (4.18 ± .986) leg exercise

with splinting (1.32 ± .656) and turning exercise with ambulation

(1.17 ±.663), (3.24 ± .716) respectively. In control group the mean

perioperative practice before and after intervention, on breathing

with splinting exercise, (1.74 ± .816), (2.04 ±795) coughing with

splinting, (1.66 ± .689) (1.93 ± 1.044) leg exercise with splinting

(1.21 ± .706) and turning exercise with ambulation (.93 ± .712),

(1.34 ± .675) respectively. The sample of the experimental group

showed improvement in all types of exercise, whereas the sample

of the control group showed slight change in all types of exercises.

The above findings are similar to the findings of the following

studies conducted by various researchers in different settings on

surgical patients as a sample:

107
Watt-Watson J, Stevens B, Katz J, Costello J, Reid GJ,

David T (2004) studied the Impact of preoperative education on

pain outcomes after coronary artery bypass graft surgery, revealed

positive results with by having pre-operative teaching.

Chumbley et. al (2004) found that benefit in providing

detailed preoperative information using either an information leaflet

or an interview. The results showed that following the use of

information leaflets, patients felt better informed and less

confused.

Section III- Effectiveness of planned perioperative nursing

information on Postoperative Outcome among experimental

and control groups

Preoperative education is a common feature of the

preparation for many surgical procedures. It is anticipated that this

education will result in beneficial outcomes for the patient. For

example, a meta-analysis found that patients who had received

pre-operative information spent 1.5 fewer days in hospital. Another

meta-analysis found that pre-operative education had a positive

effect on patient fear and anxiety. Single studies have identified

improvements in the level of psychological distress and pain

experienced by patients.

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The mean perioperative knowledge (25.92) was higher in the

experimental group after the intervention than before the

intervention (16.16). The calculated „t‟ value („t‟ 199=37.511,

P<.0001) was greater than the table value. Hence the stated

hypothesis H1 is accepted. The mean perioperative practice level

(14.33) was higher in experimental (14.33) group after intervention

than the mean perioperative practice level (5.93) before

intervention. The calculated „t‟ value („t‟ 199=49.935, P<.0001) was

greater than the table value, hence the stated hypothesis H1 is

accepted.

Further findings revealed that there was a significant

difference between mean perioperative knowledge (18.33) practice

(14.32) and level of satisfaction (95.70) of experimental and control

groups mean perioperative knowledge (16.16) practice (6.84) and

level of satisfaction (57.65) after intervention. The calculated „t‟,

value (t‟ 399=3.290, P<.0001) was greater than the table value,

hence the stated hypothesis H1 & H2 is accepted. The above

findings are consistent with the findings of studies conducted by

the following researchers in various settings:

109
Stern and Lockwood (2005) conducted a systematic review

of randomized controlled trials investigating preoperative

instruction of patients and the effect of such instruction on patients‟

understanding of, knowledge of, and ability to perform

Postoperative activities. On the basis of limited rigorous studies,

these researchers concluded that pre-operative teaching before

admission and the use of preoperative videos improved patients‟

knowledge and skill.

Oshodi (2007), the impact of preoperative education on

Post-operative pain. Sample of experimental group experienced

less pain compared to the control group.

Joe Ong,, et. Al,.( 2007) in a quasi experimental research

study conducted to explore the impact of preoperative instruction

in patients undergoing surgery. The study findings revealed that

surgical Patients‟ outcomes were improved consistently by

changing the system of surgical care by providing with a pre-

operative instructional material or DVD.

Ronco M, Iona L, Fabbro C, Bulfone G, Palese (2012), in

an experimental study conducted to identify the factors influencing

the knowledge and socio-demographic variables among 345

surgical patients revealed that education and family history of

110
surgical exposure strongly influences the knowledge and practice

of the surgical patient.

Section IV- Overall and area-wise level of satisfaction among

Experimental and Control groups after Intervention.

Level of satisfaction was higher in experimental group when

compared to control group. Majority169 (84.5%) of the sample in

the experimental group were moderately satisfied and 31 (15.5%)

they were fully satisfied, whereas in the control group majority, 193

(96.5%) of the sample were not satisfied. This finding reveals that

the planned teaching program was found to be effective in

improving the satisfaction levels.

Regarding area-wise level of satisfaction, the mean level of

satisfaction of experimental group with regard to general

(15.02),pre-operative (30.87 ), intra-operative(13.44 ), post-

operative information (13.62 ) and facilities provided (22.75) was

found to be higher when compared to control group.

In the control group the mean level of satisfaction in

general (10.12), pre-operative (22.36), intra-operative (7.27), post-

operative information (9.24) and facilities provided (18.78) was

found to be less when compared to the experimental group.

Further findings revealed that the mean score with regard to

111
preoperative information was higher in both experimental (30.87 ±

4.957) and control (22.36 ± 5.413) groups, when compared to

other areas. These findings supports that the indicated teaching

program was effective in enhancing the level of satisfaction.

The above findings are consistent with the findings of

studies conducted by the different researchers in various settings:

Caljouls, M. Van Beuzekom and Boer (2008), identified in

a study conducted to develop a valid and reliable self reported

multidimensional questionnaire assessing patient satisfaction with

perioperative care information revealed that the majority (80.4%) of

the of the sample who received information were satisfied. Further

study also supported that patients who had undergone major

surgery were comparatively satisfied higher than the group who

had minor surgical procedures.

C K Pager (2014), conducted a randomized controlled trial of

pre-operative information to Improve satisfaction with cataract

surgery. This study shows that an intervention such as a videotape

explaining to patients the sensations they are likely to experience

during surgery, along with common outcomes and risks, reduces

anxiety and improves patient satisfaction and has benefits for the

patient, surgeons, and the community.

112
Section V- Association between the knowledge, practice and

level of satisfaction with selected socio-demographic

Variables in both Experimental and Control group.

Study findings revealed that there was significant

association between perioperative knowledge and marital status

as the obtained 2 value was higher than the table value in both

experimental (210.623, df =2, p=.010) and control (26.291,

df=4, p=.222) group. Hence stated hypothesis H3 is accepted. In

control group the calculated value was higher in terms of

educational status (2 6.197, df =2, p=.185), hence the stated

hypothesis H3 is accepted

The findings also revealed that there was no association

between perioperative knowledge with age in both experimental

and control groups, as the obtained 2 value was less than the

table value. Hence the stated H3 is rejected.

The findings of the study on the association of perioperative

practice with socio-demographic variables., revealed that the

obtained 2 value was greater than the table value in gender

(23.908, df =1 , p=0.052) , educational status (26.193, df =2,

p=0.008 )type of occupation ( 26.088, df =2 , p=0.031) and

exposure to mass media(2 4.745, df=1 , p=0.038) respectively in

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experimental group, hence the stated H4 was accepted. As the

obtained 2 value was less than the table value with regard to

age, marital status, religion, and family income in the experimental

group, hence the stated H3 was rejected.

In the control group, findings revealed that the obtained 2

value was greater than the table value only in exposure to mass

media (2 11.462, df =2, p=.003), thus the stated H4 was accepted.

With regard to age, gender, educational status, Type of

occupation, marital status, religion, and family income the obtained

2 value was less than the table value, hence the stated H3 was

rejected.

Further with regard to the association between socio-

demographic variables with satisfaction revealed that the obtained

2 value was greater than the table value only in sample of

experimental group with regard to age (2 6.911, df= 2, p=0.013 ),

gender (2.4.148, df- 1, p=0.057), education (26.455, df -2,

p=0.055), occupation ( 24.023, df -2, p=0.056) and exposure to

mass media (24.138, df -1, p=0.057). Hence the hypothesis H5

is accepted. Whereas in marital status, religion, and family income

the obtained 2 value was less than the table value, thus the

stated H5 was rejected.

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In control group none of the variables as age, gender, and

educational status, type of occupation, marital status, religion,

income and exposure to mass media had associated with

satisfaction, as the obtained 2 value was less than the table

value, thus the stated H5 was rejected.

The following studies are consistent with the findings of the

present study:

Upul Senarath, et.al, (2013), in a randomized control trials

on identifying the influence of socio-demographic variables on the

outcome of surgery and satisfaction revealed that morbidity before

surgery and nutritional status of individual status along with stable

hemodynamic influence surgical outcome. Study findings also

revealed that patient of the experimental group showed a positive

outcome when compared to the clients of the control group.

The findings are also similar to the findings of Kolkman and

colleagues, 2008, as advanced age and males were more

satisfied when compared to females.

Although numerous studies have evaluated the

effectiveness of pre-operative information on anxiety, patient

outcomes and satisfaction, little high quality research has

assessed the effectiveness of this information on patient


115
knowledge and ability to perform specific skills such as exercises.

An important finding of the systematic review was the need for

further research to fully evaluate the range of options available for

providing perioperative information to patients.

SUMMARY

This chapter has dealt with the analysis, interpretation,

results and discussion the of the significant findings of the study

in relation to other studies of the study. The analysis and

interpretation have been organized and presented as distribution

of socio demographic and history specific to surgical variables,

level of perioperative knowledge, practice and satisfaction,

effectiveness of the planned teaching program, and association of

knowledge, practice and level of satisfaction of subjects with

selected socio- demographic variables.This helped the investigator

to prove that the findings were true and the planned perioperative

teaching program was effective in increasing the knowledge,

practice and satisfaction level of surgical patients.

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CHAPTER - V

SUMMARY, MAJOR FINDINGS, CONCLUSION, IMPLICATIONS,

AND RECOMMENDATIONS

This chapter presents a summary, major findings,

conclusion, implications, and recommendations of the study.

SUMMARY

An Experimental Two Group before and after intervention

design was adopted to assess the “Effectiveness of Planned

Perioperative Nursing Information on Postoperative Outcome

among the Patients Undergoing Selected Surgeries at Selected

Hospital of Kolar, Karnataka” was designed.

A review of related literature enabled the investigator to

develop the conceptual framework, evolve the methodology for the

study, and to plan analysis of the data, in the most meaningful and

effective way. The conceptual framework adopted for the study

was based on modified Penderson‟s Health Promotion Model

(2002revised), which mainly focuses on attaining a positive

outcome by adopting health promoting behavior.

117
The study was conducted at R. L. Jalappa Hospital and

Research Centre Kolar. The sample of the study consisted of 400

surgical patients‟ (200 for each experimental and control groups).

The random sampling technique was adapted by using the lottery

method to select the sample of the study. The data were collected

from patients who were admitted for selected surgical procedures

like, gastrointestinal, and genitourinary surgeries and were within

the age group of 19-75 years. The data was collected by using a

structured interview schedule, i.e. Knowledge Questionnaire,

Observational Checklist for Practice along with a three point Likert

scale for assessment of the Level of Satisfaction.

Content validity of the tools and planned teaching program

was obtained from ten experts. The experts consisted of five

Nursing and five Surgeons, who were experts in Gastro and

Genitourinary related surgeries. Based on the subject expert‟s

suggestions and consultation of the guide the tool was modified.

Pretesting of the tool was done on ten subjects. The clarity of

items and time taken to complete the tool was assessed. All the

items were clearly understood with appropriate responses by the

subjects. The subjects have taken about 45-50 minutes to answer

the questions.

118
Reliability of the tool was inferred by administering the

tool to ten subjects. The reliability for internal consistency was 0.99

and for stability it was 0.81 which is highly reliable. Hence the

prepared tools were to be is reliable and feasible. The Planned

Teaching Program was conducted to all the selected surgical

patients of Experimental group on the same day of data collection.

The structured interview schedule, i.e. Knowledge

Questionnaire, Observational Checklist for Practice along with a

three point Likert‟s scale for assessment of Level of Satisfaction

was used after a period of 5 to 7days after intervention to the

patients‟ respectively for both Experimental and Control groups.

The collected data were planned and analyzed by using both

descriptive and inferential statistics on the basis of study objectives

and hypotheses of the study. Socio-demographic and information

specific to surgical history related data was analyzed by using the

frequency and percentage.

The level of knowledge, practice level of satisfaction, and

effectiveness of teaching program of the sample before and after

administration determined by using frequency, mean, median,

range, standard deviation, percentage, paired t-test, and unpaired

119
t-test. The association between knowledge, practice and level of

satisfaction with selected socio demographic variables, after

intervention was analysed by using chi-square test.

MAJOR FINDINGS OF THE STUDY:

The analysis and interpretation of data was based on the

objectives and hypotheses of the study:

Findings related to socio- demographic and Information

specific to surgical History variables.

Majority 37.5%(75) of the sample in the experimental group

were between the age of 41-50 years and in the control group

majority 39% of the sample were between the age of 31-40 years.

The majority of the samples were males in both experimental 68%

control groups 67%. The majority of the samples were illiterates, in

both experimental 61.5% and in control groups 41.5%. The

majority of the samples in experimental 65% and control 58%

groups were self employed.

The majority of the sample in both experimental 165 (81%)

and control 60(80%) groups were married. The majority of the

sample in both experimental (75%) and control (76.5%) groups

were Hindus. With regard to family income, the majority of the


120
sample in the experimental group belonged to the income group of

Rs.2001-5000, whereas in the control group majority (41.5%) of

them belonged to the income of Rs. 5001-7000. The majority of

the sample was not exposed to any kind of mass media on

information specific to perioperative care aspects within a six

month period in both experimental (86%) and control (90%)

groups.

The information specific to surgical history regarding previous

exposure to the surgical procedure, the majority of the sample in

both experimental (81.5%) and control (86%) groups had no

surgical exposure to any kind of surgery. The majority of the

sample in both experimental (79%) and control (71%) groups

presented illness symptoms less than 6 months. The majority

(67%) of the sample belonged to major surgical procedure in both

experimental and control groups. Study findings revealed that

majority of samples in both experimental (73.5%) and control

(70%) groups had undergone a surgical procedure under the effect

of general anesthesia.

Findings revealed that the majority of the sample in both

experimental (67.5%) and control (79%) groups had undergone

surgeries related to the gastrointestinal system.


121
In terms of Body Mass Index, majority of samples in both

experimental (42.5%) and control (57%) groups had normal body

weight. In the experimental group majority (71.5%) of the sample

had no history of pre-surgical risk factors and only (28.5%) of them

presented with risk prior to surgery. In the control group, the

majority (56%) of the sample had preexisting risk factors and only

(43.5%) of them did not have any system related risk factors.

Further findings of the study revealed that, the majority of the

sample in both experimental (66.5%) and control (78.5%) groups

were hospitalized for less than 8 days.

Findings related to overall and area-wise level of perioperative

knowledge, and practice.

As per the first objective, the study findings revealed that

before the intervention majority of the sample had inadequate

perioperative knowledge in both experimental (88.5%) and control

(73.5%) groups. But after intervention majority (86.5%) of the

sample in the experimental group had moderate knowledge scores

and only (1%) had inadequate knowledge score. In control group

majority (57.5%) were in moderate level of knowledge scores and

(41%) of them had inadequate knowledge scores.


122
Area-wise mean perioperative knowledge of study sample in

experimental group before and after intervention with regard to

surgical information was (1.60 ± .983), (3.11±.678), preoperative

area (11.13± 678), (16.33 ±2.141), intraoperative (1.72 ± .978 ),

(3.27 ± 708) and postoperative care(1.71+ .853 ), (3.20 + .697)

respectively.

In the control group the mean knowledge level before and

after intervention with regard to surgical information it was (1.85 ±

1.028) and (2.41 ± .696), preoperative area (12.70 ± 2.878) and

(13.26 ±2.613), intra-operative (1.91± . 1.117) and (2.38 ± .836)

and post-operative care(1.87+ 1.043) and (2.28 ± .803)

respectively. Findings highlight that after an intervention area wise

the mean knowledge level improved significantly in all the areas of

experimental group, when compared to control group. Area wise

the mean practice score before and after intervention, on breathing

with splinting exercise, (1.77 ± .757), (3.61 ± 838) coughing with

splinting, (1.68 ± .757) (4.18 ± .986) leg exercise with splinting

(1.32 ± .656) and turning exercise with ambulation (1.17 ±.663),

(3.24 ± .716) respectively.

123
In control group the mean practice score before and after

intervention, on breathing with splinting exercise, was (1.74 ±

.816), (2.04 ±795) coughing with splinting, (1.66 ± .689) (1.93 ±

1.044) leg exercise with splinting (1.21 ± .706) and turning

exercise with ambulation (.93 ± .712), (1.34 ± .675) respectively.

The sample of experimental group showed improvement in

all types of exercise, when compared to the sample of control

group.

Findings related Effectiveness of planned perioperative

nursing information on post-operative Outcomes.

With regard to the second objective of the study, findings

revealed that there was a significant difference between mean

perioperative knowledge (18.33) practice (14.32) and level of

satisfaction (95.70) of experimental and control groups knowledge

(16.16), practice (6.84) and level of satisfaction (57.65) after

intervention. The calculated „t‟, value (t‟ 399=3.290, P<.0001) was

greater than the table value, hence the stated hypothesis H1 & H2

is accepted

124
Findings related to level of Satisfaction among surgical

patients

With regard to the third objective, the level of satisfaction

was higher in experimental group when compared to control group.

This finding revealed that the planned teaching program was found

to be effective in improving levels of satisfaction.

Area-wise the mean level of satisfaction of experimental group

with regard to general (15.02 +1.519), preoperative

(30.87 ± 4.957 ), intraoperative (13.44 + 2.149), postoperative

information (13.62 + 2.342) and facilities provided (22.75 + 3.819)

was found to be higher when compared to control group. In the

control group the mean level of satisfaction in general (10.12+

1.965 ), preoperative (22.36+ 5.413 ), intraoperative (7.27 +

2.540) postoperative information (9.24 + 2.632) and facilities

provided (18.78+ 3.869) was found be less when compared to the

experimental group. Further findings revealed that the mean

score with regard to preoperative information was higher in both

experimental (30.87 ± 4.957) and control (22.36 ± 5.413)

groups, when compared to other areas.

These findings support that the teaching program was

effective in enhancing the level of satisfaction.

125
Findings in association between the knowledge, practice and

level of satisfaction with selected socio-demographic

Variables after intervention.

With regard to the fourth objective, the findings of the study

revealed that there was a significant association between

knowledge and marital status as the obtained 2 value was higher

than the table value in both experimental (210.623, df =2,

p=.010) and control (26.291, df=4, p=.222) group, hence the

stated hypothesis H3 is accepted. In the control group the

calculated value was higher in terms of educational status (2

6.197, df =2, p=.185), thus the stated hypothesis H3 is accepted.

The findings also revealed that there was no association

between knowledge with age, gender, educational status, type of

occupation, religion, income, and exposure to mass media in both

experimental and control groups, as the obtained 2 value was

less than the table value, thus the stated H3 is rejected.

With regard to the association between the practice and

socio-demographic variables in the experimental group, the

findings of the study revealed that the obtained 2 value was

greater than the table value in gender (23.908, df =1 , p=0.052) ,

126
educational status (26.193, df =2, p=0.008 ) type of occupation

( 26.088, df =2 , p=0.031) and exposure to mass media(2 4.745,

df=1, p=0.038) respectively, hence the stated H4 is accepted. As

the obtained 2 value was less than the table value in age, marital

status, religion, and family income in the experimental group,

hence the stated H3 is rejected.

In the control group, findings revealed that the obtained 2

value was greater than the table value only in exposure to mass

media (2 11.462, df =2, p=.003).thus stated H4 is accepted. With

regard to age, gender, educational status, Type of occupation,

marital status, religion, and family income the obtained 2 value

was less than the table values hence the stated H3 is rejected.

With regard to the association between socio-demographic

variables and satisfaction level, that the obtained 2 value was

greater than the table value only in sample of experimental group

with regard to age (2 6.911, df = 2, p=0.013 ), gender (2.4.148,

df- 1, p=0.057), education (26.455, df -2, p=0.055), occupation (

24.023, df -2, p=0.056) and exposure to mass media (24.138,

df -1, p=0.057) in the experimental group, hence the hypothesis

H5 is accepted, whereas in marital status, religion, and family

127
income the obtained 2 value was less than the table value, thus

the stated H5 is rejected.

In control group none of the variables as age, gender,

educational status, type of occupation, marital status, religion,

income, exposure to mass media the obtained 2 value was less

than the table value, thus the stated H5 i is rejected.

128
CONCLUSION:

The present study focused on assessing the effectiveness of

planned perioperative teaching on achieving positive Postoperative

outcomes. Based on the findings the conclusions are presented

under the following points;

1. As per the first objective of the study findings regarding the

overall level of perioperative knowledge, the majority of the

sample had inadequate perioperative knowledge in both

experimental 88.5% and control 73.5% group before

intervention. After intervention the perioperative knowledge

level, in the experimental group had improved from inadequate

to moderate 86.5% and 12.5% of them had adequate

knowledge, and only 1% showed an inadequate level of

knowledge. Whereas in control group majority 57.5% of them

had moderate perioperative knowledge with only 1% of them

presented with adequate knowledge, remaining 41.5%

belonged to inadequate peri-operative knowledge level.

2. Regarding the overall level of perioperative practice, in the

experimental group, the majority 96% of the sample had a poor

level of pre-operative practice and none of them belonged to an

adequate practice category before intervention. But after the

intervention the perioperative practice were significantly higher,


129
as majority 90% of them belonged to adequate, 10% to

moderate and none of them had inadequate perioperative

practice level. In the control group the entire sample belonged

to 100% poor perioperative practice level. The findings further

revealed that without the intervention the sample showed some

change in performance level, i.e. 5% had moderate and 0.5%

adequate performance level, and majority 94.5% of them

belonged to the poor level of performance.

3. As per the second objective of the study, the mean

perioperative knowledge (25.92) was higher in the experimental

group after the intervention than before the intervention (16.16).

The calculated „t‟ value („t‟ 199=37.511, P<.0001) was greater

than the table value. Hence the stated hypothesis H1 is

accepted. The mean perioperative practice level (14.33) was

higher in experimental (14.33) group after intervention than the

mean score (5.93) before intervention. The calculated „t‟ value

(„t‟ 199=49.935, P<.0001) is greater than the table value. Hence

the stated hypothesis H1 is accepted. The level of satisfaction

was higher in experimental group when compared to control

group. The majority (84.5%) of the sample in the experimental

group was moderately satisfied and (15.5%) they were fully

satisfied, whereas in the control group majority, (96.5%) of the

sample was not satisfied.

130
4. With regard to the third objective of the study, the findings of the

study revealed that there was a significant association between

knowledge and marital status, in both experimental and control

groups as the obtained 2 value was higher than the table

value, hence stated hypothesis H3 was accepted. In the control

group the calculated value was higher in terms of educational

status, thus the stated hypothesis H3 is accepted. The findings

also revealed that there was no association between knowledge

with age, gender, educational status, type of occupation,

religion, income, and exposure to mass media in both

experimental and control groups, as the obtained 2 value was

less than the table value, thus the stated H3 is rejected.

5. With regard to the association between the practice and socio

demographic variables in the experimental group, the findings

of the study revealed that the obtained 2 value was greater

than the table value in gender, educational status, type of

occupation, and exposure to mass media respectively, hence

the stated H4 is accepted. As the obtained 2 value was less

than the table value in age, marital status, religion, and family

income in the experimental group, hence the stated H3 is

rejected.

131
In control group, findings revealed that the obtained 2

value was greater than the table value only in exposure to mass

media, thus stated H4 is accepted. With regard to age, gender,

educational status, Type of occupation, marital status, religion,

and family income the obtained 2 value was less than the

table value, hence the stated H3 is rejected.

6. With regard to the association between socio-demographic

variables and satisfaction level, that the obtained 2 value

was greater than the table value only in sample of experimental

group with regard to age, gender, education, occupation, and

exposure to mass media in the experimental group, hence the

stated hypothesis H5 is accepted. Whereas in marital status,

religion, and family income the obtained 2 value was less

than the table value, thus the stated H5 is rejected.

In control group none of the variables as age, gender,

educational status, type of occupation, marital status, religion,

income, exposure to mass media as the obtained 2 value

was less than the table value, thus the stated H5 i is rejected.

7. As per the fourth objective of the study, the findings indicated

that the scores on level of satisfaction were higher in

experimental group when compared to control group. The

132
majority (84.5%) of the sample in the experimental group was

moderately satisfied and (15.5%) they were fully satisfied,

whereas in the control group majority, (96.5%) of the sample

were not satisfied.

Finally the researcher concluded that the findings of the

study clearly showed that planned perioperative nursing

information was significantly effective in improving the knowledge,

practice, level of satisfaction and positive postoperative outcome

as a whole, which is an indicator for evidenced based quality

patient care.

133
IMPLICATIONS:

Nursing care is crucial in the recovery and well being of

patients in general and postoperative patients in particular. The

findings of the study have implication to nursing practice,

education, administration and research. As a whole as it

emphasizes on acquiring knowledge, developing skill and

enhancing the level of satisfaction for all patients by ensuring

quality nursing care and positive post-operative outcome and

increased level of satisfaction which is a key yardstick for

Evidence Based Practice.

Nursing Practice:

 The role of nurses in the health care industry is a vital aspect

of society. Nurses should shoulder the responsibility of

promoting health, preventing illness and rehabilitation of the

clients.

 The findings of the study will help the perioperative nursing

team to carry out the activities in a planned way to achieve

positive Post-operative outcomes which meets the needs of

the patient and his family members.

134
 Perioperative planned teaching program also helps the

patient to understand each episode of operation and helps to

take active part in preventing or minimizing complications

and ensuring quality outcomes.

 Especially in perioperative care settings, nurses should

concentrate and follow the aseptic precautions and surgical

safety precautions as the patient and their significant others

put their trust in them.

 The prepared, planned perioperative teaching information

can be made available to all the surgical patients.

 To achieve evidence based quality nursing care nurses,

should practice pre-operative instruction as they're standing

instruction in enhancing knowledge, practice, level of

satisfaction and positive post-operative outcome.

Nursing Education:

 Education is a base of knowledge. It decides the quality of

future nurses. Nursing educators have the responsibility of

equipping the students with adequate knowledge and skill to

equip them to provide quality care in the future.

135
 The study emphasizes on the significance of short term in-

service education program for nurse, to provide specific care

of the surgical patients in achieving positive outcomes and

satisfaction with care.

 The study findings will help the nurse educator to plan,

construct, and reconsider the importance of perioperative

nursing information on positive postoperative outcomes while

developing curriculum.

 It also helps to specify the expanded and extended role of

nurse in the care of surgical patients.

 The study findings will also help the staff nurses and patients

to improve their level of knowledge, and change their

behavior specifically for better quality of life.

Nursing Administration:

 Administration plays a major role in regulating and

coordinating the laws and policies in patient care. The quality

of an administrator is determined by the quality of her

subordinates.

136
 A nursing administrator has a significant role in encouraging

and motivating the staff nurses to improve their knowledge in

order to keep in pace with the changing needs of the society

as a whole and surgical patients in specific. It is important for

the administrators to facilitate programs to improve the

knowledge for nurses regarding management of surgical

patients throughout the pre-operative episodes.

 The study findings will help the Nurse Administrator to plan

and deliver the health care services in an organized manner

throughout all the phases of perioperative nursing care by

developing policy on the care of surgical patients.

 It further provides the basis for developing and adopting

Standard Concept Maps and Protocols, in nursing care

aspects which emphasize on prevention of postoperative

complications, minimizing the hospital stay, ensuring positive

surgical outcomes by improving the quality of patient care.

 The nursing administrator can mobilize the available

resources, and expert personnel towards educating nurses

regarding perioperative care aspects of all types of surgical

procedures.

137
 The nursing administrator should plan and organize

continuing nursing education programme for nurses in

perioperative care aspects, common measures used in

preventing Post-operative complications.

Nursing Research:

 Research in nursing is the need of the hour to improve the

health status of the clients. It helps the nurses not in

improving their knowledge, but also in incorporating the

findings of new research findings for quality care.

 The findings of the present study serve as a basis for the

professional and student nurses to conduct the future

quantitative and qualitative research on surgical patients in

teaching, managing and preventing Post-operative

complications.

 The study will motivate and initiate researchers to conduct

the same study in different settings on a large sample for

better generalization of study findings.

 The Study findings may reveal the effectiveness of peri-

operative nursing information on Post-operative outcomes,

and also the statistical inferences drawn from the study

findings will help the researcher, to recommend for further

investigation.
138
RECOMMENDATIONS:

Based on the experience gained during the period of the study,

and the interpretations made and conclusions drawn thereafter,

the following recommendations are made:

1. A similar study may be undertaken, using the same tool and

teaching plan on a large scale in various settings for longer

period for better generalization.

2. A study can be conducted to identify the surgical patients‟ need

and expectations during the perioperative care to provide

quality care.

3. A study may be conducted to assess the knowledge on

perioperative care aspects among perioperative team members

and compare it with quality patient outcomes.

4. A similar study may be undertaken by using planned

preoperative nursing teaching for patients posted for ambulatory

(day care) surgical procedures.

5. A descriptive study can be done to explore the level of

satisfaction on care received by the surgical patient.

6. A descriptive study can be done to explore the needs of

surgical patients.

139
7. An Interventional study among staff nurses can be done to

assess the effectiveness of teaching programs in achieving

positive Post-operative outcomes.

SUMMARY:

This chapter dealt with major findings of the study,

implication to nursing practice, education, administration and

research, along with recommendations.

140
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spective_Randomized_Controlled_Trial_of.6.aspx

91. http://www.anestesiasegura.com/2010/06/artigo-recomendado-

patients.html
155
92. https://www.coursehero.com/file/p16el0/bImperative-or-Urgent-

ASAP-within-24-48-hours-cRequired-necessary-for-well/

93. http://www.ncbi.nlm.nih.gov/pubmed/17522511

94. http://www.emeraldinsight.com/doi/pdfplus/10.1108/175118713112

91732

95. http://cre.sagepub.com/content/25/2/99.abstract

96. http://www.pubfacts.com/detail/23531640/Patient-expectations-

outcomes-and-satisfaction:-related-relevant-or-redundant

97. https://www.coursehero.com/file/p13ie5u/It-is-only-removed-as-

soon-as-the-client-begins-to-awaken-and-has-regained-the/

98. http://ecp.acponline.org/janfeb00/jans.pdf

99. http://quizlet.com/17365996/pre-op-intra-op-and-post-op-flash-

cards/

100. http://www.nurseone.ca/en/certification/what-is-

certification/competencies-per-specialty-area/perioperative-

nursing/perioperative-nursing-certification-bibliography/

101. http://www.ncbi.nlm.nih.gov/pubmed/10788032

102. http://www.ncbi.nlm.nih.gov/pubmed/25030256.

103. http://www.researchgate.net/publication/23759488_Prospective_st

udy_of_ambulation_after_open_and_laparoscopic_colorectal_rese

ction

104. http://nursing-theory.org/theories-and-models/pender-health-

promotion-model.php

156
105. http://www.nursinglibrary.org/vhl/handle/10755/163842

106. http://tnaionline.org/june-11/2.htm

107. http://cyberlectures.indmedica.com/show/158/1/%22Holistic_appro

ach_for_patient_satisfaction%22_An_innovative_experiment_at_AI

MS

108. http://planningcommission.gov.in/reports/sereport/ser/std_pdstn.pdf

109. http://www.who.int/patientsafety/safesurgery/checklist_saves_lives/

en/

110. http://nolapender.weebly.com/background.html

111. http://www.rguhs.ac.in/cdc/onlinecdc/uploads/05_N023_1918.doc

112. http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111/j.1479-

6988.2005.00021.x

157
ANNEXURE – 1

I
ANEXXURE - 2

STRUCTURED INTERVIEW SCHEDULE ON PERI-OPERATIVE

NURSING INFORMATION

The interviewer introduces herself and explains the purpose of


the study. She will ask questions listed in the schedule using one to
one technique. She places a tick mark (√) against the items as per
the responses given by the participants in the box provided by giving
the following written information.

1. Kindly answer to all questions and select appropriate answer


based on your choice.
2. Your answer shall be kept confidential.
3. Please feel free and frank in answering the questions.
4. Each correct answer carries one score.
The researcher uses the following Tools for data collection:

TOOL- I SEC- A Socio Demographic Data

Code No:

Experimental Group Control Group

The researcher introduces herself and explains the purpose of the


study. She will obtain Socio Demographic Data and Information
Specific to Surgical History as listed in below by using one to one
technique.

1.1 Age in years

a. 19-30 years ( ) b. 31-40 years ( )

c. 41-50 years ( ) d. 51-60 years ( )

e. 61 years and above ( )

1.2 Gender :

a. Male ( ) b. Female ( )

II
1.3 Educational Status : a. Illiterate ( )

b. Primary education ( ) c Others specify ------

1.4 Type of occupation

a. Government employee ( ) c. Unemployed ( )

b. Self employee ( )

1.5 Marital status

a. Married ( ) b. Unmarried ( )

c. Divorced ( )

1.6 Religion:

a. Hindu ( ) b. Muslim ( )

c. Christian ( ) d. Any other------------

1.7 Family income per month

a .Rs.6750-13499 ( ) b. Rs 5050-6749 ( )

c. Rs. 3375-5049 ( ) d. Rs 676-2024 ( )

1.8 Exposure to mass media about surgery and its care within 6

months period

a. Yes ( ) b. No ( ) If yes through

a. Television ( ) b. Newspaper ( )
c. Magazine ( ) d. Radio ( )
d. Others specify ( )

III
Tool I-SEC- B Information Specific to Surgical History

Date of Interview:

Date of Discharge:

2.1 Previous history of hospitalization for any surgical

procedure:

a. Yes ( ) b. No ( )

If yes specify: ---------------

2.2 Duration of present illness

a. Less than 6 months ( ) b. 6 months 1 year ( )

c. 1 year 2 years ( ) d. 2 years and above ( )

2.3 Type of surgical procedure proposed

a. Major surgery ( ) b. Minor surgery ( )

c. Elective surgery ( )

2.4 Type of anesthesia proposed for present surgical procedure

a. General anesthesia ( )

b. Spinal or Regional anesthesia ( )

2.5 Body system where the surgical procedure is involved:

a. Gastro intestinal system ( ) b. Genito- urinary system ( )

2.6 Body mass index:

a. Normal weight ( ) b. Underweight ( )

c. Overweight ( ) d. Very obese ( )

IV
2.7 History of pre existing surgical risk factors

a. Yes ( ) b. No ( ) If yes specify in which system

a. Cardiovascular disease ( ) b. Coagulation disorders ( )

c. respiratory disorders ( ) d. Renal disease ( )

e. Liver diseases ( ) f. Neurologic disorders ( )

g. Nutritional disorders ( ) h. Alcoholism ( )

i. Use of concurrent or prior pharmacotherapy ( )

j. Advanced age ( ) k. Any others specify---------

2.8 Duration of present stay in the hospital after surgery:

a. 3 days – 5 days ( ) b. 6 days to 8 days ( )

c. 9 days to 11 days ( ) d. 11 days and above ( )

V
TOOL - I SEC-C

Structured Knowledge Questionnaire on Peri-operative Nursing

Information.

3.1. The care received from the time of admission till discharge
is called as
a) Pre-operative care ( ) b) Intra-operative care ( )
c) Peri-operative care ( ) d) Post-op.care ( )

3. 2. The aim of peri-operative teaching is to;


a) Increase the post-operative outcomes ( )
b) Increase the post-operative benefits ( )
c) Increase the patient‟s interest in recovery ( )
d) Increase positive outcomes and shorten the hospitalization( )

3.3. The goal of surgical procedure is to;


a) Cure the disease ( )
b) Prevent the disease and its spread ( )
c) Restore the diseased body part or system ( )
d) All the above ( )

3.4. The following are the disease conditions that require


surgical procedure EXCEPT
a) Increased or decreased glucose level ( )
b) Hole in the body tissue or rupture ( )
c) Tumor or abnormal growth ( )
d) Obstruction or blockage ( )

VI
3.5. The Perioperative (surgical) team includes all the following
members except:
a) Anesthesiologist and nurse anesthetist ( )
b) The surgeon and his assistance ( )
c) Nurse surgeon and his assistance anesthesiologist ( )
d) Causality &ICU nurse. ( )

3.6. The surgical procedure is considered as major based on the


following criteria Except
a) Prolonged intra operative period ( )
b) Large amount of blood loss ( )
c) Greater risk of complications ( )
d) Greater chance of recovery. ( )

3.7 The worst fear related to surgical procedure is


a) Fear of financial burden ( ) b) Fear of death ( )
c) Fear of unknown ( ) d) Fear of loss of job ( )

3.8 The consent (signature) is obtained before the surgical


procedure to protect the following members Except:
a) The surgeon ( ) b) The hospital ( )
c) The patient ( ) d). The patient family members ( )

3.9 The pre surgical health history and diagnostic tests are
needed to estimate the,
a) Risk associated with cost of surgery ( )
b) Risk associated with surgery ( )
c) Risk associated with instruments ( )
d) Risk associated with operative team mem ( )

VII
3.10 The common preoperative investigations include the
investigation of
a). Gastrointestinal system ( ) b). All body systems ( )
c). Respiratory system ( ) d). Urinary system ( )

3.11 An obese patient who has surgery is at risk of getting


which complication post-operatively
a. Impaired wound healing ( ) b) Hunge ( )
c) Bleeding ( ) d) Gastric pain ( )

3.12 The common risk factor which contributes for post-


operative respiratory complication is
a). Preoperative smoking ( )
b) Excessive exercise ( )
c). consumption of oily food ( )
d). Regular inhalation of snuff ( )

3.13. The reason for post operative respiratory complication is


a). Prolonged talking ( ) b). Prolonged standing ( )
c). Prolonged immobility ( ) d). Prolonged sitting ( )

3.14 The advantage of deep breathing and coughing exercise is


to;
a). prevent bed sore ( )
b). Prevent lung infection ( )
c). Promote wound healing, ( )
d). Promote rest and sleep ( )

VIII
3.15 The precaution that should be followed post operatively
while performing breathing and coughing exercise is
a). hold fingers loosely over the surgical site ( )
b). splint the surgical site with the pillow or folded bed sheet ( )
c) cover the surgical site with plain bed sheet ( )
d) cover the surgical site with plain dressing ( )

3.16 When the client is deep breathing and coughing it is


important to have the client to sit because this position
facilitates;
a) Expansion of lungs ( ) b) Comfort ( )
c) The client to sleep ( )
d) the client use of the room air and enhances more relaxing ( )

3.17 The deep breathing and coughing exercise could be


performed postoperatively is;
a). 2-4 times per hour ( ) b). 4-8 times per hour ( )
c). 8-12 times per hour ( ) d). As many times as possible ( )

3.18 The aim of leg exercises after surgery is that to


a. Promote respiratory function ( )
b. Provide dimensional activities ( )
c. Increase venous return ( )
d. Increase cardiac output & renal function ( )

3.19 The turning exercise after surgery can be performed,


a). Every tenth hourly ( ) b). Every eighth hourly ( )
c). Every sixth hourly, ( ) d). Every fourth hourly. ( )

IX
3.20 The advantage of turning exercise after surgery is to,
a). Promote comfort ( )
b). Promote normal bowel elimination ( )
c).Prevent pooling of secretion ( )
d). Prevent respiratory distress. ( )

3.21 The meaning of early ambulation (walking) is to;


a). Walk briskly ( ) b). Running from ( )
c). Transfer from cot to chair ( )
d). Get out of bed at the earliest ( )

3.22 The advantage of early ambulation (walking) is to;


a). Strengthen the bones ( ) b). Reduce anxiety ( )
c). Improve blood circulation ( )
d). Reduce physical discomfort ( )

3.23 The precaution that should be taken while getting out of


bed after surgery for ambulation is,
a). support operated area well and call for assistance ( )
b). get up without assistance ( )
c). supporting the surgical site ( )
d). get up by turning to the side ( )

3.24 The maintenance of fluid and electrolyte balance is


important for;
a). increasing cardiac output ( )
b). Decreasing bronchial secretions ( )
c). decreasing urine output ( )
d). Increasing gastric secretions ( )

X
3.25. The preparation of surgical site (operation area) aims to;
a). reduce surgical site wound infection ( )
b). Reduce the risk of surgical site infection ( )
c). decrease the wound healing process ( )
d). Maintain skin integrity. ( )

3.26. The primary purpose of maintaining NPO (nil per


mouth)for 6-8 hours before surgery aims to
a. Prevent malnutrition ( )
b. Prevent electrolyte imbalance ( )
c. Prevent aspiration pneumonia ( )
d. Prevent intestinal obstruction ( )

3. 27. Pre operative medication may help to reduce


a. Client‟s expenditure ( )
b. Anesthetic requirement ( )
c. Responsibility of family members ( )
d. responsibility of surgical team ( )

3.28. For early wound healing the surgical patient should take
food which is rich in
a. Carbohydrate and vitamin C ( ) b. Protein and vitamin C ( )
c. Fat and vitamin C ( ) d. Minerals and vitamin ( )

3.29 The purpose of giving general anesthesia during a surgical


procedure is to induce
a. Loss of consciousness ( )
b. Relaxation of skeletal muscle ( )
c. Reduction of reflex action ( )
d. Localized loss of sensation ( )

XI
3. 30 The most suitable position that you should assume after
spinal anesthesia is
a). sitting position with head turned to one side ( )
b). Flat on back for 6-8 hours with head turned to one side ( )
c). Side lying position with head turned to one side ( )
d) Sleeping on abdomen with head turned to one side ( )

3.31. The clean and sterile field is maintained throughout the


Intra-operative phase to reduce the
a). infection related to surgery, ( )
b). Cost related to surgery ( )
c). hospital stay related to surgery ( )
d). giving drugs related to surgery ( )

3.32. The swallowing of saliva and vomitus postoperatively


leads to;
a). both sided pneumonia ( )
b). One side pneumonia ( )
c). Aspiration pneumonia ( )
d). allover pneumonia ( )

3. 33 The primary reason for gradual change of position after


surgery is to;
a). prevent muscle atrophy, ( )
b). Prevent sudden drop of BP ( )
c). prevent respiratory infection ( )
d). promote comfort. ( )

XII
3.34. The main cause of post operative hemorrhage is due to;
a). use of unsterile instruments ( )
b). Slipping or dislodging of sutures ( )
c). improper wound dressing ( )
d). Excessive IV fluid infusion. ( )

3.35. An early rise of body temperature in the post operative


period may be the first sign of;
a). infection ( ) b). Dehydration ( )
c). hemorrhage ( ) d). Intestinal perforation ( )

3.36. Wound drainage tube is removed;


a). by the third day of surgery, ( )
b). when drainage stops /ceases ( )
c). after stopping antibiotics, ( )
d). when pain is reduced. ( )
.37 constipation is very common in post-operative period
because of lack of
a). less oil in the food ( ) b) less sugar in the food ( )
c). less water in the food ( ) d). less vitamins in the food ( )

3.38. The number of days required for surgical wound healing is


a). 2-3 days, ( ) b). 7-10 days ( )
c). 10-12 days ( ) d). Above 15 days ( )

3.39. The wound gaping can be prevented by


a. Applying Abdominal binders and sling ( )
b. Holding the hand on & off on the incision site ( )
c. Sleeping in flat position ( )
d. Using pelvic binders ( )

3.40 Discharge plan includes all except


a. Dietary requirements ( )
b. Follow up and medications ( )
c. Regular observation of pulse and BP ( )
d Application of abdominal binders and minimal activities ( )

XIII
Tool –II Sec. A
Observational Checklist on Re-demonstration of Post-operative
Exercises Pre-operatively

1. Deep Breathing Exercises The patient, Yes No NA

Assumes semi fowlers position in bed or takes


a
supine position with the knees slightly bent

b Splints the surgical site with a pillow or blanket

Takes deep breaths through the nose while


c
counting 1,2,3,4, so forth

d Holds his breath for 3-5 seconds.

Exhales completely as possible through the mouth


e
with lips pursued as if whistling

f Repeat the above step three times

2 Coughing Exercise The patient,

Assumes semi fowlers or sitting position with knee


a flexed(uses additional pillow supporting shoulders)
and leans forward

Splints the surgical site with a pillow or folded


b
blanket

Inhales and exhales deeply and slowly through the


c
nose three times.

d Takes a deep breath and holds it for three seconds

e Hack‟s out for three short breaths.

f With the mouth open takes a quick breath

XIV
Coughs deeply once or twice and brings out the
g
secretions.

h Takes another deep breath

4 Leg Exercise The patient,

a Assumes the supine position

Rotates each ankle in complete circle by forming an


b
imaginary circle with big toe

Alternatively move forward and backward of both


c feet and repeats for five times( Dorsi flexion and
Plantar flexion)

Performs quadriceps setting by tightening thigh and


d bring knee down towards mattress, then relaxing
and repeats for five times.

5 Turning Exercise The patient,

Assumes supine position and moves to the side of


the bed, by bending knees and pressing heels
a
against the mattress to raise and move the
buttocks.

b Place right hand over the incision area to splint it.

c Keeps the right leg straight and flexes left knee up.

d Holds the right side rail of bed with left hand and
rolls to right.

XV
TOOL II : Sec. - B

Observational Checklist on analyzing Complication Pre

and Post operatively

PRESENCE OF CIOMPLICATION
ASSESSMENT Pre &
PARAMETERS post D1 D2 D3 D4 D5 D6 D7
SYSTEM
Y N Y N Y N Y N Y N Y N Y N Y N

1. CVS

2. RS

3. CNS

4. GIS

5. GUS

6. MSS

7 INTEG. S

8 PSY

XVI
TOOL III Sec- A Modified Aldert‟ scale.
1
Ad 30. 45 60
Area of assessment Point 5
m m m m
m
Activity- (Able to move spontaneously
2
or an command)
Ability to move two extremities 1
Unable to control any extremities 0
Respiration –
2
Ability to breathe deeply and cough
Limited respiratory efforts(Dyspnea or
1
splinting)
No spontaneous effort 0
Circulation BP _+ 20% pre anesthetic
2
level
BP +_ 20%-49% of Pre anesthetic level 1
BP +_ 50%of Pre anesthetic level 0
Area of assessment P
Consciousness Fully awake 2
Arousal on calling 1
Not responding 0
O2saturation Able to maintain oxygen
2
saturation>92% on room air
Needs oxygen inhalation to maintain
1
oxygen saturation>90%
Oxygen saturation<90% even with
0
oxygen supplement
Note: Required for discharge from post anesthesia care unit: 7-8
points

XVII
TOOL III- Sec. C- Observational Checklist on Assessment of Post Operative Outcome

SI SYSTEM Day I Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 REMARKS


No ASSESSMENT
1 2 3 4 5 6 R 1 2 3 R 1 2 R 1 2 R 1 2 R 1 2 R 1 2 R Y N
ASPECTS
VITAL PARAMETERS

1 Temperature

2 Pulse

3 Respiration

4 Blood pressure
Level of
5
consciousness
ASSESSMENT ON
D N D N D N D N D N D N R D N D N D N R D N D N R D N D N R D N D N R D N D N R D N D N R
EXERCISE
Deep breathing
1
exercise

2 Coughing exercise

3 Leg exercises

4 Turning exercise
Splinting of surgical
5
site

Note: D= Done N= Not Done R= Remarks Y= Yes N=No

xviii
TOOL-III Sec. B
Patient Satisfaction Scale on Peri-operative Nursing
Information.
Sl. Satisfaction parameter on Peri-operative surgical
F MN
No events
1 Satisfaction related to general information
11 Information provided on need for surgery and its purpose
1.2 Information provided on types of surgery
1.3 Information provided on phases of surgical procedure
1.4 Information provided on different positions used for surgery
Information provided on common risk factors and its
1.5
prevention
2 Satisfaction related to pre-operative preparation
Information provided on need for legal consent/operation
2.1
permits
Information provided on psychological stress reduction and
2.2
its techs.
Information provided on need for history coll. & and all body
2.3
sys. asst.
Information provided on need for physiological system
2.4
review
Information provided on preparation of surgical site, bowel
2.5
and bladder along with NPO status
Information provided on need for deep breathing, coughing
2.6 exercise, splinting technique, leg and turning exercise and
pain control measures
Information provided on control of post operative nausea
2.7
and vomiting
Information provided on post operative drains and its
2.8
purpose
Information provided on post operative diet and its purpose
2.9
was
Information provided on immediate and late post operative
2.10
complication
Information provided on use of anesthesia and its purpose
2.11
was
Information provided on need for preoperative medication
2.12
and its purpose.

XIX
3 Satisfaction Related to Information on Intra-operative
Preparation
Information provided on pre surgical waiting room and
3.1
maintaining vital signs stability its purposes
Information provided on common safety measures on infection
3.2
control and operation room set up was
Information provided on measures followed in safe anesthesia
3.3
administration
3.4 Information provided on surgical site and its closure
3.5 Information provided on PACU and its purpose s
4 Satisfaction Related to Postoperative Care
Information provided on post anesthesia related complications
4.1
and its prevention
Information provided on wound healing process, factors
4.2
favoring and hindering wound healing
Information provided on need for monitoring symptoms and
4.3
prevention of post operative complication
Information provided on expected outcome of the surgical
4.5
procedure upon my future health was
Information provided on home care aspects and need for
4.6
regular follow up and its benefit
5 Satisfaction Related to General Peri-operative Care Aspects
The means to approach and clarify the doubts from Peri-
5.1
operative health care team members
The facilities available and information in utilization of
5.2
emergency services
5.3 The overall privacy provided throughout the surgical events was
The overall confidentiality maintained throughout the
5.4
hospitalization care provided from admission to discharge
The overall medico-technical competencies of the
5.5
Peri-operative team
The overall spiritual support provided from admission to
5.6
discharge was
The overall method of recording maintained throughout the
5.7
Peri-operative surgical events
The overall information on Peri-operative nursing information
5.8
and care provided throughout

XX
ANEXXURE - 4

Lesson Plan
on
Peri-operative Nursing care Information on
Post-operative Outcome
Guided by Prepared by
Dr. B.A. Pataliah Mrs. Zeanath Cariena J.
M.A. M.Sc (N). Ph. D.(N), Prof. SDUCON -KOLAR
Principal Ph.D. Nursing Scholar
Shushruthi CON, V M URF Salem
Bagalore- 91

XXI
LESSON PLAN
Name of the Instructor : Mrs. Zeanath Cariena J.
Topic : Perioperative Nursing care Information on Post operative Outcomes
Group : Patients undergoing Selected Surgical Procedure
(Gastro-intestinal and Genitourinary system)
Method of Teaching : Discussion cum Video Assisted Teaching
Audio Visual aids : PPT
Duration : 50 minutes .
Place : OPDs and Wards of Selected Hospital at Kolar.
Previous Knowledge : The surgical clients have some knowledge regarding common surgical related
procedure and their purposes
General Objectives : At the end of Video Assisted Teaching on Perioperative Nursing care
Information the surgical client will gain in-depth knowledge regarding common
surgical related procedures and their purposes and appreciate their importance by
applying the knowledge throughout perioperative phases to attain
positive postoperative outcomes.

XXII
SPECIFIC OBJECTIVES:

At the end of Video Assisted Teaching on Perioperative Nursing care Information the surgical Client

will be able to:

1. State the meaning, goal and phases of perioperative nursing care,

2. Discuss on categories of surgical procedure with common positions used during selected surgeries

3. Explain on Factors that affect the estimation of Surgical Risk with their effect on anesthesia and

surgery

4. List the common diagnostic measures used during surgical procedure along with their purposes

5. Describe on preoperative phase with its related preparations and procedures

6. Explain on intraoperative phase along with anesthesia and its stages

7. List post operative complications along with its preventive measures

8. Explain on important aspects of home care considerations after surgery.

XXIII
Specific
Time Content Teaching Learning Activity Visual Aids Evaluation
Objectives

Introduces 2-Min. INTRODUCTION


the topic Health is both personal and economic asset. Optimal health
is the best physiologic and psychologic condition an individual
can experience.Disease is the inability to adequately counteract
physiologic stressors that cause disruption of the body‟s
homeostasis. Additional influences such as congenital
anomalies infection or trauma interfere with optimal human
health and quality of life. What are the
The treatment of wide variety of illness, injuries and human common
conditions include some type of surgical or procedural modes of
intervention. Surgery gave physician the means to treat treating
conditions that were difficult or impossible to manage only by disease?
pure medicine. Surgery may be planned or unplanned,
elective/optional or necessary, major and may include any body
part or system. Surgery is a stressor that requires physical and PPT &Video
physiological adaptations for both. Assisted Teaching
surgical client and his family members.

Peri-operative nursing is a challenging fast paced,


specialized client centered care, which focuses on positive
surgical events. Today‟s Nurses enter a realm of opportunities
by making significant contribution to the health care outcomes of
surgical clients who are hospitalized through their care and
teaching or instructions.

Announces the topic; today‟s topic of teaching is


EFFECTIVENESS OF PERIOPERATIVE NURSING
INFORMATION ON POSTOPERATIVE OUTCOMES.

XXIV
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
Benefits of Peri-operative Education

 Increases patients‟ overall satisfaction

States the  Reduces patient anxiety and fear


meaning,
goal and  Reduces use of pain medication
phases of 1 min
 Reduces complications following surgery
peri-
operative  Reduces recovery time
nursing care.
I: Definition of Surgery
Surgery is any procedure performed on the human body that uses
Observing, PPT What do
instruments to alter tissue or organ integrity. listening and &Video you mean
i. Purposes of surgical intervention learning Assisted by surgery?
1 min Teaching
1. Curative
2. Restorative
3. Palliative surgery, which makes the patient more comfortable
4. Diagnostic
5. Cosmetic surgery, which reconstructs the skin and underlying
structures.
ii. Indications or Conditions Requiring Surgery:
1. Obstruction or blockage (Impairment to the flow of vital fluids)
2. Perforation or rupture of an organ
3. Erosion or wearing away of the surface of a tissue
4. Tumors or abnormal growth

XXV
Specific Time Content Teaching Visual Evaluation
Objectives Learning Activity Aids
States the 2 min II: Information on peri-operative phases with goal
meaning, A. Meaning and Definition of Peri-operative Nursing Care:
goal and List the
phases of The Nursing care provided for the patient Before, During and After phases of
perioperative surgery is called as Perioperative Nursing. peri-
nursing care PPT operative
A. The Goal of Peri-operative Nursing are: &Video nursing?
The peri-operative nursing practice goal is to promote and assist the Assisted
patient and family to achieve a level of wellness equal to or greater than Teaching

what they had prior to the procedure ( Aron 2006c)


B. Phases of Perioperative Nursing Care: Observing and
learning
The patient who is having surgery progresses through several distinct
phases called the perioperative period.
The Three Phases of perioperative patient care are;
i. Pre-operative phase:
The preoperative phase, beginning with the decision, together with the
surgeon, that surgery is necessary or wanted and will take place, and When
preoperativ
lasting until the patient is transferred to the. e phase
i. Intra-operative phase: begins?
The intra operative phase which begins when the patient is transferred to
the bed or also called table, until transfer to the post operative recovery
area.

XXVI
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
ii. Post operative phase:
The postoperative phase lasting from admission to the recovery area to
complete recovery from surgery.
III Categories of Surgical Procedures:

Discusses on a. Seriousness: Degree of risk


categories of PPT
i. Major- Involves extensive reconstruction or alteration in body parts;
surgical 2 min &Video
poses great risks.
procedure. Assisted
ii. Minor- Involves minimal alteration in body parts; often designed to Teaching
correct deformities; involves minimal risk compared with major Observing and
procedures. learning

According to Purpose:
a. Diagnostic: to verify suspected diagnosis, e.g. biopsy
b. Exploratory: to estimate the extent of the disease, e.g. exploratory
laparotomy
c. Curative: to remove or repair damaged or diseased organs or
tissues
d. Palliative: to relieve pain, relieve distressing Signs and symptoms
Urgency: reason for procedure:
Elective-Performed on the basis of client‟s choice; not essential and may
not necessary for health.
Urgent- Necessary for client‟ health, may prevent additional problem
from developing (e.g. tissue destruction); not necessarily emergency.

XXVII
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids

IV Factors that Affect the Estimation of Surgical Risk


Explains on 3 min Benefits from surgery ←→ Risk of complications
Factors that
a. Physical and Mental Condition of the Client
Affect the
1. Age: premature babies and elderly persons are at risk
Estimation of Observing and
Surgical Risk 2. Nutritional status: malnourished and obese are at risk learning
3. State of fluid and electrolytes balance: dehydration and
hypovolemia predispose a person to complications
4. General health: infectious process increase operative risk
5. Mental health PPT
&Video
6. Economic and occupational status
Assisted
b. Types of drugs taken regularly: Teaching
Steroids( may improve the body‟s ability to response to the stress of
anesthesia and surgery), Anticoagulants( may increase bleeding during
Surgery), Antibiotics( may be incompatible with anesthetic agents),
Tranquilizers: potentiate the effect of narcotics and can cause
Hypotension Anti-hypertensive: may predispose to shock by the
combined effect of blood pressure reduction and anesthetic
vasodilatation), Diuretics( may increase potassium loss) and Alcohol:
will place the surgical client at risk when used chronically.

XXVIII
Specific Teaching Visual
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Objectives Learning Activity Aids
c. The Extent of the Disease
d. The Magnitude of the Required Operation
Discusses on
peri- e. Resources and Preparation of the Surgeon, Nurses, and the Observing and
operative Hospital learning
team V- THE PERIOPERATIVE TEAM AND THEIR ROLES
members i. The Surgeon
and their Responsible for conducting surgical procedure by following all the
roles 1min safety precautions
ii. An Anesthesiologist or Nurse Anesthetist
Makes the preoperative assessment to plan for the type of
anesthesia to be administered and to evaluate the client‟s status PPT
iii. The Professional Registered OR Nurse &Video
Makes preoperative assessment and documents the peri-operative client Assisted
care plan (Scrub, Circulating, PACU Nurse) Teaching
a. The Circulating Nurse
Manages the OR and protects the safety and health needs of the client
by monitoring the activities of the members of the surgical team and
monitoring the conditions in the OR.
b.The Scrub Nurse
Responsible for scrubbing for surgery, including setting up sterile tables
and equipment and assisting the surgeon and surgical technicians
during the surgical procedure
c. The PACU Nurse
Responsible for caring for the client until the client has recovered from
the effects of anesthesia, is oriented, has stable vital signs, and shows
no evidence of hemorrhage.

XXIX
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Objectives Learning Activity Aids
12 VI- PREOPERATIVE PHASE : The preoperative period begins at the time of
Describes min decision for surgery and ends when the client is transferred to the OR.
on Goals:
preoperative a. Assessing and correcting physiologic and psychological problems that PPT
phase with might increase surgical risk &Video
its related b. Instructing and demonstrating exercises that will benefits Assisted
preparations the person during post-op period Teaching
and C. Planning for discharge and any projected changes in lifestyle due to
procedures surgery.
The preoperative phase consists of the following preparations: Observing and
1. Psychological preparation.
learning
2. legal preparation,
3. Physiological preparation,
4. Preoperative instructional preparation,
5. Physical preparation;
a). On the Night of the Surgery b). On the Day of Operation.
1. Psychological preparation :
Psychological preparation aims to reduce the anxiety of the patient. The
anxiety related to surgery is reduced by
1. Explaining the reason for hospital admission
Explains on 2. Explanation of the procedures that will be carried out routinely,
the 3. Discussing on the probable outcome, expected duration of hospitalization,
psychologica cost, length of absence from work, and residual effects.
l preparation Causes of Fears related to surgery are:
a. Fear of the unknown, b. Fear of anesthesia, vulnerability while
unconscious c. Fear of pain, d. Fear of death, e. Fear of disturbance of
body image f. Worries: loss of finances, employment, and family role.

XXX
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
Manifestations of Fears:
1. Anxiousness
2. Confusion
3. Anger
4. Tendency to exaggerate
5. Sad, evasive, tearful, clinging
6. Inability to concentrate
7. Short attention span
8. Failure to carry out simple directions
9. Dazed PPT
Interventions to Minimize Anxiety:
&Video
1) Assessing client‟s fears, anxieties, support systems, and patterns of
Assisted
coping
Teaching
2) Establishing trusting relationship with client and significant others
3) Explaining routine procedures, encourage verbalization of fears, and
allow client to ask questions
4) Demonstrating confidence in surgeon and staff Observing and
5) Providing for spiritual care if appropriate learning
Highlights on 6) Divert tonal and music therapy.
legal permit 2. Legal Preparation: “Informed Consent”, operative permit, surgical
and its consent
importance a. This is to protect the surgeon and the hospital against claims that
unauthorized surgery has been performed and that the patient was
unaware of the potential risks of complications involved
Explains on b. Protects the client from undergoing unauthorized surgery.
need for 3. Physiologic preparation
physiological a. History collection: Medical History, Previous surgeries, Medication
preparation History, Client Expectations, Occupation, Cultural and Spiritual Factors and
Body image.

XXXI
Specific Teaching Visual
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Objectives Learning Activity Aids
B. Physical Examination Through System Review
1. Cardiovascular system: History of preexisting or existing disease
Explains on
need for 2. Respiratory System: Patient t who smokes should quit 6 weeks
reviewing the before surgery
systems for 3. Nervous System: Ability to pay attention, concentrate, and respond
analysis of appropriately pre-op are extremely important for post–operative
risk factors outcomes
PPT
4. Urinary System: Many drugs are metabolized and excreted by the &Video
kidneys Assisted
5. Hepatic System: The patient with hepatic dysfunction may have Observing and Teaching
problems with glucose control, clotting abnormalities and adverse learning
response to drugs
6. Musculoskeletal System: Frequently, postoperative pain is due to
chronic musculoskeletal pain and positioning during surgery, rather
than acute pain of the surgery
7. Endocrine System: The diabetic patient is at risk for the
development of hypoglycemia, hyperglycemia, cardiovascular
alterations, delayed wound healing and infection
8. Immune system: Patients with active infection will frequently have
elective surgeries cancelled

9. Fluid and electrolyte status: The patient should be asked about


vomiting, diarrhea and any difficulty swallowing

XXXII
Specific Teaching Learning Visual Evaluati
Time Content
Objectives Activity Aids on
10. Nutritional status: Obesity stresses both the cardiac and pulmonary
system
and makes access to the surgical site and anesthesia more difficult.
Obesity predisposes the patient to wound dehiscence, wound infection
and herniation.The patient has a slower recovery from anesthesia
because inhaled anesthetic is absorbed and stored in adipose tissue,
thus
leaving the body more slowly
Explains on
need for C-Common Preoperative Investigations
common
investigation  Urinalysis…………..Renal status, hydration, infection, disease
s for analysis  Chest X-ray………...Pulmonary disorders, cardiac enlargement Observing and
of risk factors  CBC with dif……....Anemia, immune status, infection learning
 Electrolytes..……….Metabolic status, renal function, diuretic PPT
effects &Video
 ABG‟s, oximetry…..Pulmonary and Metabolic function Assiste
 PT/PTT (INR)……..Bleeding tendencies d
.  Blood glucose…….Metabolic status, diabetes mellitus Teachin
 BUN/Creatinine………Renal function g
 EKG…………………Cardiac disease,
electrolyte abnormalities
 Pulmonary function …Pulmonary status studies
 SGOT/SGPT, albumin…………Liver function
 Type and Cross match………….Blood availability for
replacement
 Pregnancy……………………...Reproductive status

XXXIII
Specific Teaching Learning Visual Evaluati
Time Content
Objectives Activity Aids on
4. Pre operative Instructional Preparation : PPT
Discusses on Preoperative information highlights on: Three types of information: &Video
importance – Sensory information Assiste
of Pre » Hear, see, smell, feel d
operative – Process information Observing and Teachin
» General flow
Instructional – Procedural Information or skill training learning g
Preparation » More specific
on post 1. Breathing exercise
operative 2. coughing exercise,
outcomes. 3. splinting techniques
4. Leg, ankle and foot exercises
5. Turning in bed
6. Early Ambulation
7. Surgical drains
Breathing and Coughing Exercises
1. The sitting position gives the best lung expansion for coughing and
deep breathing exercises. Inhale through the nose and exhale
through the mouth with pursed lips
2. Hold breath for three seconds and cough
Describes on 3. Cough and deep breathe q 2 h while awake
deep Quadriceps (thigh) setting
breathing  press the back of the knees against the bed, and then
and Straight leg raises
coughing  Have the patient tighten the thigh muscle and lift the leg several
inches off the bed
exercises  Hold this position for 5 to 10 seconds
along with  Repeat several times
splinting Note: Do not use for patients having abdominal surgery or patients with
technique back problems

XXXIV
Specific Teaching Visual
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Objectives Learning Activity Aids

Observing
And
learning

Leg Exercises
Explains on Ankle Pumps
leg exercise  Slowly push the foot up and down.
and its  Do this exercise as often as every 5 to 10 minutes.
purpose  This exercise can begin immediately after surgery and continue
until fully recovered to relax the knee
 This contracts and relaxes the thigh and calf muscles to prevent
thrombus formation
 Repeat this exercise 10 times in a ten minute period

Foot Circles
 rotate each foot in a circle
 Repeat 5 times in each direction 3 to 4 times a day

XXXV
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
Surgical drains;
The surgical drains are used to enhance wound healing process .
Discuss on PPT
common Types: open and closed drains. &Video
surgical The drains are removed on the third or fourth day as soon as the Assisted
drains discharge ceases, as it serves as a source of infection. Teaching
Observing and
learning

XXXVI
Specific Teaching Visual Evalua
Time Content
Objectives Learning Activity Aids tion
Explains on Physical Preparation
the need for On the Night of the Surgery:
physical a. Preparing the skin: shaving the part of the skin against the grain of
preparation. the hair shaft to ensure clean and close shave
b. Preparing the GIT:
 NPO after midnight
 Administration of enema may be necessary
 Insertion of gastric or intestinal tubes Observing and
 Preparing for Anesthesia learning PPT
 Promoting rest and sleep: use of drugs &Video
∞ Barbiturates: Secobarbital Na, Pentobarbital Na Assisted
∞ Non barbiturates: chloral hydrate, Flurazepam Teaching
Note: preoperative medications are given after all pre-op treatments have
been completed.
On the Day of Operation:
a. Early morning care: about 1 hour before the pre-operative medication
schedule
 Vital signs taken and recorded
 changes into hospital gown that is left untied and open at the back
 Braid long hair and remove hair pin
 Provide oral hygiene
 Prosthetic devices, eyeglasses, dentures removed
 Remove jewelries
 Remove nail polish
 Void immediately before going to the OR
 Make sure that the patient has not taken food for the last 10 hours
by asking the client
 catheterization may be performed in the OR pr in the preoperative
ward

XXXVII
Specific Time Content Teaching Visual Evaluati
Objectives Learning Activity Aids on
b). Pre-Operative Medications:
Generally administered 60-90 min before induction of anesthesia
Lists the Purpose:
purposes i. To relieve anxiety: the primary reason for pre-operative medications
medication ii. To decrease the flow of pharyngeal secretions
and its uses. iii. To reduce the amount of anesthesia to be given
iv. To create amnesia for the events that precedes surgery
VII INTRAOPERATIVE PHASE
Begins the moment the patient is anesthetized and ends when the last
5 min stitch or dressing is in place. Observing and PPT
Anesthesia –
Explains on learning &Video
A state analgesia, relaxation and reflex loss (severe central nervous
intraoperativ Assisted
system [CNS] depression produced by pharmacologic agent).
e phase Teaching
Four Stages of Anesthesia:
along with Stage I: Onset [Beginning of Anesthesia]
anesthesia The common symptoms that you experience during this stage is
and its Warmth, dizziness, & feeling of detachment may be experienced, Ringing,
stages roaring, or buzzing in the ears, Inability to move extremities, Surrounding
noise is exaggerated and Still conscious
Stage II: Excitement
Struggling, shouting, singing, laughing or crying may be experienced,
Pupils dilate rapid PR, irregular RR, Patient restrain might be necessary
Stage III: Surgical Anesthesia
Continued administration of anesthetic agent, RR, PR normal, skin pink
and flushed and Patient is unconscious
Stage IV: Danger Stage [Medullary Depression]
Reached when too much anesthesia has been administered, Respiration
shallow, pulse weak, pupils dilate, Cyanosis develops, without prompt
intervention death may ensue.

XXXVIII
Specific Teaching Visual Evalua
Time Content
Objectives Learning Activity Aids tion
Types of Anesthesia:
Discusses
on types of 1. General
anesthesia
2. Regional or local
and its effect
1. General Anesthesia causes:
i. Loss of all sensation and consciousness
ii. Loss of protective reflexes Observing and
iii. Block awareness centers in brain learning

iv. Administered by IV or inhalation PPT


&Video
2. Regional or Local Anesthesia Assisted
Teaching
i. Topical or surface
ii. Local or infiltration
iii. Nerve block
iv. Intravenous block or Bier block
v. Spinal
vi. Epidural or peridural
vii. Conscious sedation

XXXIX
Specific Teaching Visual Evaluati
Time Content
Objectives Learning Activity Aids on
VIII: Positioning the Client:
Commonly Used Operative Positions in gastrointestinal and
Lists on genitourinary surgeries are :
common
surgical 2. Patient positioning in the Operating room
positions. Four basic surgical
positions include:
1. Supine
2. Prone Observing and
3. Lateral learning
4. Lithotomy
Goals of Proper Positioning is to:
1. Maintain airway and avoid pressure on the chest cavity
2. Maintain circulation
3. Prevent nerve damage
4. Provide adequate exposure of the operative site
5. Provide comfort and safety to the patient

1. Supine position:

PPT
&Video
Assisted
Teaching

XL
Specific Teaching Visual Evaluati
Time Content
Objectives Learning Activity Aids on
Most common with the least amount of harm
1. Placed on back with legs extended and uncrossed at the ankles
12 2. Arms either on arm boards with palms up or tucked PPT
min 3. Head in line with the spine and the face is upward &Video
5. Padding is placed under the head, arms, and heels with a pillow Assisted
placed under the knees Teaching
6. Safety belt placed 2” above the knees while not impeding
Lists post circulation Eg; hernia repair, explore lap, cholecystectomy, mastectomy Observing and
operative learning
complication Lithotomy position
s along with 1. With the supine position, the legs are raised and abducted to expose
its preventive the perineal region
measures. 2. The buttocks are even with the lower break in the OR bed
3. The arms are placed on padded arm boards, tucked at the sides, or
placed across the abdomen
4. The legs and feet are placed in stirrups that support the lower
extremities
5. Stirrups should be placed at an even height
6. The legs are raised, positioned, and lowered slowly and
simultaneously, with the permission of the anesthesia care provider

XLI
Specific Teaching Visual Evaluati
Time Content
Objectives Learning Activity Aids on
IX: POSTOPERATIVE PHASE
Postoperative Care
 Begins when the client returns from the recovery room or surgical
suite to the nursing unit and ends when the client is discharged
 It is directed toward prevention of complication and post-operative
discomfort
Post-Operative Complications
a. Respiratory Complications: atelectasis and pneumonia
 Suspected whenever there is a sudden rise of temperature 24-48
hours after surgery
 Collapse of the alveoli is highly susceptible to infection:
pneumonia Occurs usually in high abdominal surgery when
prolonged
*Inhalation anesthesia has been necessary and vomiting has occurred
during the operation or while the patient is recovered from anesthesia.
Measures to prevent pooling of secretions:
 Frequent changing of position
 High fowler‟s position
 Moving out of bed
Measures to liquefy and remove secretions:
 Increase oral fluid intake
 Breathing moist air
 Deep breathing followed by coughing
 Administer analgesics before coughing is attempted after thoracic
and abdominal surgery
 Splint operative area with draw sheet or towel to promote comfort
while coughing.

XLII
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
Other measures to increase pulmonary ventilation PPT
 Blow bottle exercise &Video
 Rebreathing tubes: increase CO2 stimulates the respiratory center Assisted
to increase the depth of breathing thus increasing the amount of Teaching
inspired air
 IPPB: intermittent positive pressure breathing apparatus.
b. Circulatory Complication: Observing and
venous stasis learning
Causes of venous stasis
» Muscular inactivity
» Respiratory and circulatory depression
» Increased pressure on blood vessels due to tight dressing
» Intestinal distention Prolonged maintenance of sitting.
Contributing factors for venous stasis:
 Obesity
 CV disease
 Debility
 Malnutrition
 Old age
Most common circulatory complications:
 Phlebothrombosis (clotting in the veins)
 Thrombophlebitis ( clotting of blood)
MEASURES FOR PREVENTION:
− Limbs must never be massaged for a post-op client
− If possible, client should lie on his abdomen for 30 min several time
a day to prevent pooling of blood in the pelvic cavity
− Do not allow the client to stand unless pulse has returned close to
baseline to prevent orthostatic hypotension
− Wear elastic bandages or stockings when in bed and when walking
for the first time.

XLIII
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
c. Fluids and Electrolytes Imbalance:
Causes:
− Blood loss PPT
− Increased insensible fluid loss through the skin; &Video
 After surgery through vomiting, from copious wound drainage, and
Assisted
from the tube drainage as in NGT
− Since surgery is a stressor, there is an increased production of ADH Teaching
for the first 12-24 hours following surgery resulting to fluid retention
by the kidney
- The potential for over hydration therefore exists since fluids being given Observing and
IV may exceed fluid output by the kidney learning
Electrolyte Imbalance:
 Particularly Na and K imbalance as a result of blood loss
 Stress of surgery increases adrenal hormonal activity resulting to
increased aldosterone and glucocorticoids, resulting in sodium
reabsorption by the kidney
 And as Na is reabsorbed, K coming from tissue breakdown is
excreted
Action: IV of D5W alternate with D5NSS or half strength NSS to prevent
Na excess
d. GIT complications:
a. Paralytic ileus: Cessation of peristalsis due to excessive handling
of GI organs
Nursing management:
NPO until peristalsis has returned as evidenced by auscultation of bowel
sounds or by passing out of flatus.
b. Vomiting: usually the effect of certain anesthetics on the stomach,
or eating food or drinking water before peristalsis returns.
Psychological factors also contribute to vomiting.

XLIV
Specific Teaching Visual
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Objectives Learning Activity Aids
NURSING MANAGEMENT:
Position the client on the side to prevent aspiration
 When vomiting has subsided, give ice chips, sips of ginger ale or hot
tea, or eating small frequent amounts of dry foods thus relieving
nausea
 Administer anti-emetic drugs as ordered: Trimethobenzamide Hcl
(Tigan); Prochiorperasine dimaleate (Compazine)
c. Abdominal distention: results from the accumulation of non-
absorbable gas in the intestine.
Causes:
o Reaction to the handling of the bowel during surgery
o Swallowing of air during recovery from anesthesia
o Passage of gases from the blood stream to the atonic portion of the
bowel Observing and
d. Gas pains: results from contraction of the unaffected portion of the learning
bowel in order to move accumulated gas in the intestinal tract
Management:
 Aspiration of fluid or gas: with the insertion of an NGT
 Ambulation: stimulates the return of peristalsis and the expulsion of
flatus
 Enema: Rectal tube insertion: inserted just passed the anal sphincter
and removal after approximately 20 minutes Adult: 2-4 inches,
children: 1-3 inches. Prolonged stimulation of the anal sphincter may
cause loss of neuromuscular response, and pressure necrosis of the
mucous surface.
e. Constipation: due to decreased food intake and inactivity
 Regular bowel movement will return 3-4 days after surgery when
resumption of regular diet and adequate fluid intake and
ambulation.

XLV
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
e. GUT Complications
Return of urinary function: usually after 6-8 hours
- First voiding may not be more than 200 ml, and total out put
may not be more than 1500ml
-Due to the loss of fluids during surgery, perspiration,
hyperventilation, vomiting, and increased secretion of ADH
Complication: urinary retention PPT
Causes: &Video
 Prolonged recumbent position Observing and Assisted
 Nervous tension learning Teaching
 Effect of anesthetics interfering with bladder sensation and the
ability to void
 Use of narcotics that reduce the sensation of bladder distention
 Pain at the surgical site and on movement
Urinary tract infection Management:
» Instruct the client to empty the bladder completely during voiding
» Catheterize if needed, done by sterile technique

f. Post-operative Discomforts
a. Post-operative pain
Narcotics can be given every 3-4 hours during the first 48 hours post-
operatively for severe pain without danger of addiction
b. Singultus
Brought about by the distention of the stomach, irritation of the
diaphragm, peritonitis and uremia causing a reflex or stimulation of the
phrenic nerve.
Management:
» Paper bag blowing; CO2 inhalation: 5% CO2 and 95% O2 x 5
minutes every hour.

XLVI
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
g. Wound Complications:
 Sutures are usually removed about 5th-7th day post-op with the
exception of wire retention sutures placed deep in the muscles
and removed 14-21 days after surgery
h. Hemorrhage from the wound PPT
 Most likely to occur within the first 48 hours post-op or as late &Video
as 6th-7th post-op day Assisted
Causes: Teaching
2. Hemorrhage occurring soon after operation: mechanical dislodging of
a blood clot or caused by the reestablished
blood flow through the vessel
2.Hemorrhage after few days: Sloughing off of blood clot or
of a tissue
3.Infection Observing and
Assessment reveals : learning
 Bright red blood
 Decreased BP
 Increased PR and RR
 Restlessness
 Pallor
 Weakness
 Cold, moist skin
ii. Infection
Cause: streptococcus and staphylococcus
Assessment: 3-6 days after surgery, low grade fever, and the
wound becomes painful and swollen. There maybe purulent
drainage on the dressing

XLVII
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
i. Dehiscence and Evisceration
Dehiscence or wound disruption: Refers to a partial-to-complete
separation of the wound edges
PPT
Evisceration: Refers to protrusion of the abdominal viscera t &Video
through the incision and onto the abdominal wall Assisted
Assessment: Teaching
 Complain of a “giving” sensation in the incision
 Sudden, profuse leakage of fluid from the incision Observing and
 The dressing is saturated with clear, pink drainage learning
Management:
 Position the client to low Fowler‟s position
 Instruct the client not to cough, sneeze, eat or drink, and remain
quiet until the surgeon arrives
 Protruding viscera should be covered warm, sterile, saline
Explains on dressing
important X: Discharge Instructions:
points of Early discharge, which has become common, typically increases
home care client teaching needs
consideration Information about
s 1. Wound care,
2.Actiity restrictions, driving, lifting weight, bending
3.Dietary management, and hygienic practices-bathing, clothing,
4. Medication administration,
5.Symptoms to report
6. Rest sleep and bladder and bowel monitoring,
7. Follow-up care and resuming back to work.

XLVIII
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
Promoting Good Health by following the common Do‟s
5 min 1. Do take Adequate Rest

PPT
&Video
Observing and Assisted
learning Teaching

2. Do take Good Nutrition

XLIX
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids

3. Do Regular Exercise

PPT
&Video
Assisted
Teaching

Observing and
learning

4. Do Maintain adequete balance between work and leisure time


which balances stress levals

L
Specific Teaching Visual
Time Content Evaluation
Objectives Learning Activity Aids
5. Do Limit Alcohol Intake

PPT
&Video
Assisted
Teaching

Observing and
learning
6. Do quit (stop) smoking

LI
Teaching
Specific Visual
Time Content Learning Evaluation
Objectives Aids
Activity

1. Do follow Safety tips to


prevent injuries PPT
a. At home &Video
b. At work Assisted
Teaching
c. At play

Observing
and
2. Proper use of medications learning
a. Do not change dosage
b. Do not mix medications
c. Report unusual reactions
d. Tell doctor about any OTC
medications

LII
Teaching
Specific Visual
Time Content Learning Evaluation
Objectives Aids
Activity
4min. Conclusion
Concludes the Perioperative nursing is a specialized area of nursing practice which
topic provides care before, during and after the surgery. As a fundamental member of
health care team, nurse works in collaboration with other health care
professional to provide quality care to obtain positive post operative outcomes.

Summary
Summarizes the topic by asking the following questions : Observing
1. What is the main purpose of surgical procedure? and
2. What are the common phases of surgical experience care? learning
3. What exercises will help to prevent post operative complications?
4. What are the common post operative complications and the ways to
prevent them?
Reference:
 Textbook of Medical Surgical Nursing 7th Edition by Joyce Black
 Brunner and Suddarth’s Textbook of Medical Surgical Nursing 11th
Edition by Suzanne Smeltzer
 Berry & Kohn’s Operating Room Technique 10th edition by Nancymarie
Philips
 The Lippincott Manual of Nursing Practice 7th Edition by Sandra Nettina
 Mastering Medical-Surgical Nursing 2nd edition by Josie Udan
 NCLEX-RN Review Materials

LIII