A Study to Assess the Effectiveness of Rhythmic Breathing Exercise on Post - Operative Pain

A STUDY TO ASSESS THE EFFECTIVENESS OF RHYTHMIC BREATHING

EXERCISE ON POST - OPERATIVE PAIN

AND SELECTED ACTIVITIES OF PATIENTS

AFTER ABDOMINAL SURGERY IN

SELECTED HOSPITAL.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

Mr. GODWIN JEBADAS

MEDICAL SURGICAL NURSING

Akshaya College of Nursing, Tumkur, Karnataka.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate : Mr.GODWIN JEBADAS And address M.Sc Nursing, 1st Year Akshaya College of Nursing, Tumkur, Karnataka.

2. Name of the Institution : Akshaya College of Nursing

3. Course of Study : M.Sc. Nursing 1st year, And Subject MEDICAL SURGICAL NURSING

4. Date of Admission to :

Course

5. Title of the Topic :" A STUDY TO ASSESS THE EFFECTIVENESS OF RHYTHMIC BREATHING EXERCISE ON POST - OPERATIVE PAIN AND SELECTED ACTIVITIES OF PATIENTS AFTER ABDOMINAL SURGERY IN SELECTED HOSPITAL.

6.1.INTRODUCTION

If your give a man a fish the will have a single meal; If you teach him to fish be will eat all his life”. Kuan Tzer

Pain is a red signal, telling us there is a problem somewhere in the body that needs fixing. In fact it is such an indicator of health, pain assessment has been called the fifth vital sign joining temperature, pulse, respiration and blood pressure. Man is afraid to face an unpleasant sensation of pain. It is one of the symptom or complaint that causes people to seek health care and always manifests a pathologic process. Pain is a subjective experience which can be understood by others only by the verbal expression of the person experiencing the pain. Pain is also manifested by behavioral and physiological responses.

The International association for the study of pain defines pain as an unpleasant and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. The commission on the ‘Evaluation of pain’

(1987) recognizes two basic categories of pain: acute and chronic. Acute pain is usually of recent onset that lasts for 6 months and is most commonly associated with a specific injury. Acute pain is experiences by almost everyone at times. Acute pain serves a biologic purpose; it acts as a warning signal, as it can activate the sympathetic nervous system. Chronic pain is constant or intermittent, lasting for longer periods. It many or may not be associated with structural damage and may persist for a time even long after healing has occurred.

Pain continues to be left untreated or under treated most of the time. It disables or compromises the quality of life more than any other single health related problem.

Hence pain is a problem of great concern to nurses, who must recognize it in their clients and intervene to provide comfort and relief measure. The effective management of pain is a major challenge in medical and nursing practice.

PAIN IN SURGERY

Pain accompanying surgery is one of the example of acute pain but poorly understood and not well managed. Pain results when nociceptors (nerve endings) are stimulated by mechanical, thermal, or chemical factors. Nociceptive stimuli are those that have the potential to cause damage. The impulse is transmitted from the nociceptors to the spinal cord through the dorsal horn which sends the pain message to the brain stem and thalamus. Thus the person feels the pain by the efferent nerves.

Four decades ago, 60% of patients reported that they were dissatisfied with their postoperative pain management. Today the figure remains the same inspite of development in the field of pain relief, new medication and ways of administering drugs. It is estimated that 20% of all patients undergoing surgery experience mild pain,

20% to 40% experience moderate pain, and 40% to 70% experience severe pain

(Bonica, 1983). Despite progress in pain management the incidence of post operative pain remains alarming. An early study of Donavan et al. (1987) found that 75% of surgical patients experiences moderate to severe post – operative pain.

More recent studies show that post – operative pain continues to be a major clinical significance (Bennet & St Marie 2002, MacLellan (2004). For example, an out patient study of post – operative patients showed that 40% continued to experience moderate to severe pain and that 25% consulted a health care professional for pain relief. Even though millions of people worldwide undergo surgery, this experience is not tolerable for anyone.

The predictable physiologic causes of post – operative pain are incisions causing pain with motion and coughing, tube or drain management and return of bowel function causing gas cramps. The unpredictable physiologic causes are inadequate use of pain medication, serum or blood collection, tissue trauma and overtly tight suture placement in wound closure, gastric and intestinal distention, bladder distention and so on. Whatever the reason, people undergoing surgery suffer needlessly.

Intra – thoracic and upper abdominal surgical approaches are generally associated with more severs, steady wound pain and pain on movement in the post – operative period. Conversely, approximately one half of clients undergoing superficial surgery of the head and neck, chest wall, or limb report minimal or no pain post – operatively. Muscle splinting procedures are far more painful than muscle stretching ones. MANAGEMENT OF PAIN

Traditionally, pain has not been adequately relieved following surgery. In early periods, there were no advanced technologies, so pain was only overlooked. Before the evolution of anaesthetic drugs, the patient had to bear down the pain on the surgical table. The scene where the patient’s hands and legs forcefully held by the workers was apathetic during olden days. In ancient time the practices of anaesthtics and analgesics were not well developed, yet the evolution of anaesthesiology began in the mid 19th century and it was firmly established less than six decades ago.

The ancient civilizations used opium, poppy, coca leaves, mandrake root, alcohol and even phlebotomy (to the root of unconsciousness) to allow surgeons to operate. Amazingly, some civilizations were also able to perform trephination of the skull. The discovery of surgical anaesthesia is considered to be one of the most significant in human history. The anaesthetic drugs which has central analgesia clinically include dubicaine (1930) tetracaine (1932) lidocaine (1947), and bupivacaine

(1932). Lidocaine and bupivacaine are used for relieving postoperative pain by epidural analgesia. Morphine was isolated from opium in 1805 by Sertuner and subsequently tries as an IV anaesthetic. Morphine and its derivatives are powerful analgesics which enable to assuage the suffering of painful conditions due to disease and trauma.

In the case of surgical patients, it is possible for most to be maintained in a pain free state with the judicious use of pain medications and the use of non pharmacological techniques to promote comfort (Sloman 1995). Furthermore it is humanitarian and ethical imperative for nurses to provide pain relief (Hunter 2000). It is for these reasons, there is a pain assessment movement included as fifth vital sign for the nursing assessment of patients.

The administration of local anaesthetics, opiods, (subarachnoid or epidural) is an excellent technique for managing postoperative pain following abdominal, pelvic or orthopaedic procedures. In contrast to the opiod analgesics, the non opiod analgesics relieve pain without opiod receptors. This may be called as non – steroidal anti – inflammatory drugs. e,g. Ketorolac, Diclofenac Sodium, Piroxicam, Systemic local anaesthetics produce sedation and central analgesia; the analgesics frequently outlasts the pharmacokinetic profile of the local anaesthetics and breaks the “pain cycle”.

Lidocaine, Procaine, and Chlorprocaine are the most commonly used drugs.

They are given either as slow bolus or by continuous infusion. Patient Controlled

Analgesia (PCA) is an expensive detour away from the fundamentals of pain management. But the patient needs to have the physical and cognitive ability to use the technology in addition to staff training and its expense on equipment. Patient

Controlled Analgesia cannot replace the nurse listening to the patient. (David Crouch

2004) Patients often forget or are reluctant to press the button on their PCA pumps for fear of dependence or side effects such as drowsiness and nausea.

No drug methods relieve pain, promotes self – care and enhance personal control for one’s own health. They can be used alone or in combination with drug treatment and frequently minimize drug side effects. Numerous relaxation techniques and behavioural approaches exist, with a range of philosophies and styles of practice. Most techniques involve repetition (of a specific word, sound, prayer, phrase, body sensation or muscular activity) and encourage a passive attitude towards intruding thoughts.

Deep relaxation methods include autogenic training, meditation and progressive muscle relaxation, music, hypnosis, therapeutic touch, guided imagery, biofeed technique, cutaneous stimulation (massage, warm bath ice bag, transcutaneous electrical nerve stimulation) etc. Brief relaxation methods include self – controlled relaxation, paces respiration and deep breathing. Breathing as a method of relaxation is directly linked with the autonomic nervous system which controls physiological arousal. Patient teaching is an important media for communicating self care information about non drug enhancements. Books, audiotapes or videotapes are sometimes used as teaching tools.

Relaxation technique for episodes of brief pain enhance wound healing. They are used to reduce anxiety, tension and emotional stress which may aggravate pain. It will reduce the anxiety and fear which intensify a person’s reaction to pain. According to a researcher, the relaxation and music, separately or together has significantly reduced patients pain following abdominal surgery. In addition to the usual pain medication, it was tested that these self care methods reduced pain more than medication. It is due to lack of knowledge or time, many patients and health team members tends to regard analgesics as the only method of pain relief. Patients facing surgery can expect to have less postoperative pain if they use relaxation along with their pain medicine. Although non- invasive pain relied measures are not a substitute for analgesics, a non invasive technique may be all that is necessary for brief episodes of pain lasting for seconds or minutes. In other instance, especially when there is severe pain, that leads for hours or days, the use of non invasive techniques along with medications may be the most effective way to relieve pain.

PAIN ASSESSMENT

In a Dutch study of a pain monitoring program of practicing nurses the majority of patients (83.6%) felt that daily pain assessments fitted in with their routine work and

78.1% liked the idea of recording the pain scores on the vital signs chart. (A.E.E. De

Jong & C. Gamel, 2006). Different instruments are used to measure pain intensity, distress and anxiety. Verbal descriptor scales typically group to measure pain intensity, distress and anxiety. Verbal descriptor scales typically group words such as “none, moderate, or severe” and permit an intensity rating of pain. Visual analogue scales usually use a 10cm line to represent a continuum of pain intensity and include verbal anchors that describe the intensity of the stimuli. The visual analogue scale (VAS) is the most widely used scale to assess acute postoperative pain; the McGill Melzack scale is used for clients with chronic pain.

In 1994, Choiniere et al, introduced visual analogue thermometer. This is an adapted VAS, so that a patient with burns does not have to draw a line. It consists of a rigid strip with a horizontal opening 10cm long by 2-cm wide. The left and right extremities of this opening are identified by the anchor words ‘no pain’ and

‘unbearable pain’. The opening is covered with a red bond that slides from left to right.

On the back there is also a 10cm ruler. As the strip is moved across the opening, the red bang gives a patient a visual indication of pain intensity. The corresponding numerical value is then read to the nearest mm form the back of the device. It is valid, reliable and specific for patients with burns.

Variations in the incremental, numeric, or descriptive scales are important determinants for selecting the appropriate measurement tool. Clients with chronic, nagging, and diffuse pain may have difficulties using broad numeric scales ranging from 0-100mm. Some clients are better able to use word scales and prefer nominal measurements that contain descriptive words or phrases to numeric scales.

Effective pain management is not just a matter of giving a right medicine at the right time. It is a combination of pharmacological and non pharmacological approaches that together give the individual the greatest possible degree of comfort for the longest possible time. It is because of the importance of controlling health care costs, the entire health team must provide care in the most cost effective manner possible while continuing to provide the best quality of care. Effective pain management can help to reach those goals by enhancing comfort, minimizing side effects and complications related to poor pain control, and reducing the length of hospital stay.

6.2.NEED FOR THE STUDY

Pain is a subjective experience in health and sickness. Most of the medical – surgical conditions are associated with pain. For a hospitalized patient, pain may be an actual problem or patient may anticipate it. Almost all medical – surgical interventions are associated with pain. Patient’s responses to pain will depend on individual perception of the pain influenced by past experience and socio- cultural factors. Surgery in abdomen refers to procedures that involve opening the abdomen and the organs in the abdominal cavity. Abdominal surgery involves tissue destruction followed by a repair or removal of the primary problem.

The pain after surgery can hamper recovery by heightening the body’s response to surgical stress and increasing tissue breakdown, coagulation and fluid retention.

Pain also interferes with appetite. Fear of pain leads to avoidance of family, social, recreational, and employment activities. (Chibnall & Tait, Taylor et al. 1998) and contributes to postoperative pain depends on patient’s pain threshold and tolerance.

The inability to manage pain effectively and perform usual activities, lead to feelings of powerlessness (Rapacz 1992, Matas 1997, Mutter 2000) and depression (Turner et al.

2004). The extent of the operative procedure, the degree of tissue trauma, and positioning of clients during surgery contribute to the overall incidence and severity of postoperative pain.

Pain is an expected outcome of surgery and has not only a sensory component, but also a major psychosocial component, it is highly influenced by many psychosocial variables. Anxiety is perhaps the best explored psychologic determinant in predicting post – operative pain. A highly anxious client may appear to be more distresses and affected by pain. Many patients do not make it important to complain pain and nurses also do not observe or use pain scales to monitor, whereas the vital signs are assessed on regular basis. Nurses play an important role in the postoperative management of patients.

Prevention of complications and speedy recovery of patients for dependency to independency will depend on the nurses’’ role. It is important that the nurses have to understand the pain experience of patients on assessing pain and try to manage pain by adopting measures other than drugs. As seen in the literature, there are various non pharmacological measures to minimize pain. Patents will be able to participate in the postoperative activities only if they are comfortable and are either free from pain or experience minimal pain. Nurses are in a position to try out some of the measures to minimize pain and give a high standard of care to postoperative patients.

In current practice it is the observation of the investigator that postoperative pain is managed in a routine manner without considering the individual patients’ needs.

As usual sedatives are given on the first day of surgery. On following days analgesics are not given regularly, but given only when it is necessary or when patient request for drugs at night. Pain assessment is not carried out in the postoperative care. Patients are compelled to engage in activities and ambulation without giving consideration to patients’ comfort and degree of pain. In a postoperative ward, the immediate care of patients’ comfort and degree of pain. In a postoperative ward, the immediate care of patients after surgery is concerned with monitoring the vital signs, identifying, preventing and treating complications. A patient after abdominal surgery is carefully monitored for the stability of the signs, bleeding, gastro intestinal functions and safe recovery from anaesthesia. Once the patient recovers from anaesthesis, the most important problem faced by the patient is pain. Management of postoperative pain is one of the most important concern of the medical team in order to promote rest, comfort and sleep after surgery and prevent complications that might occur due to intense pain, surgical stress, and restlessness.

When post – operative pain is not managed well give rise to various complications and affect his speedy recovery. A post – operative patient when he is in pain will refuse to participate in early ambulation which might result in complications such as deep vein thrombosis. Pain will interfere with deep breathing and coughing thus resulting in accumulation of secretions in the bronchial tree giving rise to pulmonary complications. Postoperative pain interferes with appetite, nutrition, sleep and delays wound healing. So along with medications, relaxation techniques if practices, pain relief would be more effective.

The health care professionals should not under – estimate the patients perception of pain. Nurses should not entitle to their personal beliefs; however they must accept the clients’ report of pain and act according to professional guidelines, standards, and policy statements. To help a client gain comfort or relief, the nurse must view the experience through the clients’ eyes. Acknowledging personal prejudices or misconceptions helps the nurse to address the clients’ problem more professionally.

The nurse who becomes an active, knowledgeable observer of a client in pain will make a objective analysis of the pain experience. The client makes the diagnosis, that pain is present and the nurse works to apply techniques and skills that ultimately give relief. If clients understand that the health care providers’ goal and theirs are the same, they are likely to cooperate with and contribute to the pain management plan, there by quality care and speedy recovery can be achieved. 6.3.REVIEW OF LITERATURE

For all the happiness that man can gain, it is not in pleasure But in rest from pain John Dryden, 17th Century

The review of literature in a research report is a summary of current knowledge about a particular practice – problem. (Nancy & Burns 2002). A literature review is an organized written presentation of what has been published on a topic by the scholars.

The task of reviewing literature involves the identification, selection, critical analyses and reporting of existing information of the topic of interest.

The literatures found relevant and useful for the present study has been organized under the following headings:

1. Studies related to non- pharmacological interventions

2. Studies related to drugs used in post – operative pain

3. Studies related to stress, anxiety and pain after surgery

4. Studies on pain experience, ambulation after surgery 1. STUDIES RELATED TO NON PHARMACOLOGICAL

INTERVENTIONS

Cason and Grissom (1997) conducted a quasi experimental study to examine the effectiveness of a distraction and intervention on subject’s perceptions of pain.

Data were collected on adults, 21 to 65 years old, scheduled for phlebotomy as a part scheduled visit to a family practice clinic. Subjects rated their perception of pain experience during phlebotomy with each of three instruments: Wong – Baker faces scale, Present Pain Intensity Scale and visual Analog Scale. Data were collected from

100 subjects.No significant difference emerged between the two groups on demographic variables (age, gender, education, and ethnicity) or on phlebotomy history. Subjects in the control group had higher average ratings of experiences pain than did those in the experimental group.

Marion good et al., (2005) conducted a study on three non pharmacological nursing interventions: relaxation, chosen music, and their combination for pain relief following intestinal surgery in a randomized clinical trial. Nearly one hundred and sixty seven patients were randomly assigned to one of three intervention groups or control, and were tested during ambulation and rest of first and second postoperative days. Pain sensation and distress were measured with visual analog scales.

Multivariate analysis of covariance showed significantly less post – test pain in the intervention group than in the control group on both days after rest and at three of six ambulation post – tests (p = 024-001), resulting in 16-40% less pain. Mixed effects after ambulation were due to the large variation in pain and difficulty in relaxing while returning to bed. These interventions are recommended along with analgesics for greater postoperative relief without additional side effects.

Roykulcharoen & Marion Good (2004) conducted a study on systematic relaxation to relieve postoperative pain. The purpose of the study was to examine the effects of a systematic pain, anxiety, and opiod intake after initial ambulation. A randomized controlled trial with relaxation and control groups was used. The convenience sample of one hundred and who adults underwent abdominal surgery at a large hospital in Thailand. Systematic relaxation was used for 15 minutes during recovery from the first ambulation after surgery. Pain was measured with 100 mm

Visual Analogue Sensation and Distress of Pain Scales before and after the intervention. State anxiety was measured before surgery and after the intervention; opiod intake was recorded 6 hours later.

The results showed that the relaxation group had less post – test sensation and distress of pain (26 & 25mm less, respectively) than the control group (P=0.001).

Relaxation did not result in significantly less anxiety or 6- hour opiod intake.

However, group differences in state anxiety were in the expected direction and fewer participants in the relaxation group requested opiods. Most of them reported that systematic relaxation reduced their pain and increased their sense of control.

Substantial reductions in the sensation and distress of pain were found when post-operative patients used systematic relaxation. Although tested in Thailand, it was recommended that nurses in other countries try systematic relaxation with postoperative patients in addition to analgesic medication, measuring pain scores and asking about cultural acceptance.

Marion Good (2006) conducted a study to assess the effect of music, relaxation on pain following surgery. Marion Good made a study on five hundred patients aged

18-70 years over a period of 29 months. Good and her research team tested relaxation, music and their combination on the first two days following surgery while patients were resting and walking. They measured the patients’ pain before and after 15 minutes of bed rest and four times during ambulation to see if the sensation and distress of pain changed.

Method: One group used a jaw relaxation technique, another group listened to music, and a third group received a combination of relaxation and music. The control group received none of these. All study participants received morphine or Demerol by pressing a button to their intravenous patient controlled analgesia pumps.

The result showed that the three treatment groups had significantly less pain control than the control group at all measurement points during ambulation and rest on postoperative days one and two. This study showed the during both walking and rest, patients who used relaxation, music, or the combination along with their medication had less pain than those who used medication alone. The author recommended that physicians and nurses must encourage patients to use relaxation and music with medication to control postoperative pain. This study concluded that both medication and self – care methods were needed for relief. 2. STUDIES RELATED TO DRUGS USED IN POST –OPERATIVE PAIN Abou Zeid Haitham Ahmed et al., (2004) conducted a study to compare the efficacy of Bilateral paravertabral block with general anesthesia for anterior abdominal wall hernias in advanced schistosomal liver disease patients.

Sixty patients were randomly allocated into two groups to receive either

General anesthesia or bilateral paravertebral block. Variables were hospital stay, hemodynamic stability, postoperative nausea and vomiting and postoperative pain measured on a visual analogue scale with assessment of the hepatic cell integrity using glutathione ‘S’ transferase alpha and other liver enzymes.

The main significant finding was an apparently significant shorter length of hospital stay following bilateral paravertebral block as compared with general anesthesia in patients (p<0.005). The study concluded that the bilateral paravertebral block was superior to general anesthesia following abdominal ventral hernia repair in schistosomal liver fibrosis patients.

Chun – Chang Yeh et al., (2004) conducted a study on Thoracic Epidural

Anaesthesia for pain Relief and Post – operative Recovery with Modified Radical

Mastectomy.

The purpose of this study was to investigate whether the thoracic epidural anesthesia provides better postoperative pain relief and recovery than general anesthesia for modifies radical mastectomy surgery.

Sixty four patients who underwent modifies radical mastectomy surgery were included in the study. In Thoracic Epidural Anesthesia group patients, 2% lidocaine (15-20 ml) was administered via the epidural route as primary anesthesia, in conjunction was midazlam (5-10 mg) and fentanyl (<250 7g) for amnesia. A wore visual analog scale pain score was observed in the general anesthesia group than in

Thoracic Epidural Anesthesia patients. Overall satisfaction score were significantly higher in the Thoracic Epidural Anesthesia group than in the General Anaesthesia group.

The results showed that the Thoracic Epidural Anaesthesia provided a more prolonged analgesic effect than general anesthesia after operation.

Con study concluded that the Thoracic Epidural Anaesthesia group provided better post – operative pain relief and recovery and lower cost than General Anaesthesia for Modified Radical Mastectomy surgery.

3. STUDIES RELATED TO STRESS, ANXIETY AND PAIN AFTER SURGERY Stephen et al., (2005) conducted a study to reduce stress and improve outcome by showing a videotape of a patient undergoing total hip replacement surgery covering the time period from hospital admission to discharge. Before elective total hip replacement surgery, one hundred patients were randomly assigned to a control group or a preparation group; the latter group was shown the videotape on the evening before surgery.

Anxiety and pain were evaluated daily for 5 days, beginning with the preoperative day by means of the State – Trait Anxiety Inventory and a visual analog scale. Intra operative heart rate and blood pressure, as well as postoperative intake of analgesics and sedatives were recorded. Urinary levels of cortisol, epinephrine, and norepinephrine were determined in 12 – hours samples collected at night for 5 nights, beginning with the preoperative night.

On comparison the result showed that the preparation group showed significantly less anxiety on the morning before surgery and the mornings of the first 2 postoperative days than the control group and significantly fewer of them had an intra operative systolic blood pressure increase of more than 15%. The pain ratings did not differ significantly between the two groups, but the prepared patients needed less analgesic medication after surgery. Prepared patients had significantly lower cortisol excretion during the preoperative night aqnd the first two post – operative nights.

Excretion of catecholamines did not differ significantly between groups. a study on correlated of Recovery among Older Adults after Major Abdominal Surgery. The purpose of the study was to determine whether pain, depression, and fatigue were significant factors in the return of older adults who gad abdominal surgery to functional status and self – perception of recovery in the first three months after discharge from the hospital. It was a correlational predictive study.

Data were collected from adults who had major abdominal surgery during hospitalization (n=192) than 3 to 5 days (n=141), 1 month (n=132), and 3 months after discharge to home (n=126) using the Brief pain Inventory, the Geriatric Depression

Scale – Short From, the Modified Fatigue Symptom Checklist, the Enforced Social

Dependency Scale, and the Self – perception of Recovery Scale.

Results: Multiple regression analysis indicated that the pain, depression, and fatigue were significantly related to patients’ self – perception and functional status.

The pain, depression, and fatigue explained 13.4% of the variations in functional status at 3 to 5 days, 30.8% at 1 month, and 29.1% at 3 months after discharge. These three factors also explained 5.6% of the variation in self – perception of recovery during hospitalization, 12.3% at 3 to 5 days, 33.2% at 1 months, and 16.1% at 3 months after discharge.

The study concluded that pain, depression, and fatigue were important factors to be considered in the provision of care to abdominal surgery patients with a relatively uncomplicated post – operative course. Specific interventions to reduce pain, depression, and fatigue need to be evaluated for their impact on the post – operative recovery of older adults.

4. STUDIES OF PAIN EXPERIENCE, AMBULATION AFTER SURGERY

C. Gelinas (2007) conducted a study on management of pain in the intensive care unit after cardiac surgery. The purpose of the study was to describe the pain experience of patients after cardiac surgery. After their transfer to the surgical unit, ninety three patients were interviewed using a questionnaire about their pain experience while they were in intensive care unit. Sixty – one patients (65.6%) recalled being ventilated and 72 patients (77.4%) recalled having pain. Turning was the most frequent source of pain experienced by the patients. All patients had sternotomy incision. A large proportion of the patients (47.3%) identified the thorax as the location of their pain. Pain was mild for 16 patients, moderate for 21, and severe for 25 of them. While ventilated, head nodding and movements of the upper limbs were the most frequent means of communication used by the patients. Despite advances in pain management, the study’s findings were disturbingly similar to those of 17 years ago (Puntillo K.A. (1990). It was suggested that evidence from research about clinical guidelines for pain management needs to be applied to the care of cardiac surgery patients in order to reduce patient suffering.

Mrs. Nirmalkaur et al., (2006) have examined the level of performance of patients on early ambulation on patients who underwent abdominal surgery. The purpose of the study was to assess the level performance on early ambulation during post – operative period. A quasi experimental design was adopted. It comprised of 30 subjects, 15 in each of the experimental (group I) and control group (group II). Pre- operative teaching plan was developed and given to the experimental group.

The researchers assessed the level of performance during pre-operative period

(one day before surgery) before the implementation of teaching as will as on the 3rd and

5th post –operative day by non participatory observational checklist. The control group did not receive any pre – operative teaching.

A non significant difference of pretest performance scored wad found between the two groups (p>0.05) when analyzed by analysis of variance. There was a strong statistically significant difference (P>0.001) found between the post – test performance scores of experimental and control group when analyzed by unpaired ‘t’ test. There was no statistically significant (p>0.05) relationship of the variables like ages, sex education and income level with performance regarding early ambulation.

Charmaine et. Al, (2007) conducted a study on pain – sensitive Temperament and postoperative pain. The purpose of the study was to describe the relationship between pain – sensitive temperament and self – report of pain intensity following surgery. Fifty – nine adolescents and young adults undergoing spinal fusion for adolescent idiopathic scoliosis completed the sensitivity Temperament Inventory for

Pain – Child version (STIP-C). The Pearson correlation between STIP –C score and the highest pain intensity for each of the first three post – operative days were investigated.

RESULTS: There was a small but significant correlation between the perceptual sensitivity and symptom Reporting subscales of the STIP – C and pain intensity measured on the third postoperative day. It was concluded that aspects of the pain – sensitive temperament may be important in understanding the variability in post

– operative pain. This was the first investigation of the relationship between pain sensitive temperament and surgical pain.

Donaven et al., (1987) conducted a study on Incidence and Characteristics of pain in medical – surgical patients. The purpose of the study was to examine the incidence and characteristics of pain in patients hospitalized on a general medical – surgical unit and the type and perceived effectiveness of pain relief strategies. The sample included three hundred and fifty three patients who reported pain during their hospital stay, half of these patients reported that their pain was excruciating. Patients’ pain was assessed with the use of selected portions of the Mc Gill Questionnaire and an author designed tool. Review of patients’ reports and chart data regarding the administration of analgesia indicated that the analgesia administered was inadequate to achieve pain relief. Although only one hundred and ninety three (43%) of the patients initially admitted to being in pain when asked if they were currently experiencing pain, an additional forty six patients reported that they too were in pain when they had the opportunity to rate their pain on a pain rating scale. Despite widespread problem of pain of moderate to severs intensity in this sample, only 45% of patients who experienced pain recalled that a nurse discussed their pain with them. Methods perceived by patients to be most effective in reducing their pain were analgesics, sleep, immobilization and distraction.

Distraction was perceived as beneficial in reducing pain in one third of the patients who attempted to use it, regardless of the severity of the pain. The author is of the view that nurses along with other health care providers tend to underestimate the incidence and severity of pain in medical – surgical patients.

The analgesia prescribed and administered is often insufficient for adequate pain relief and subsequently patents suffer with unrelieved pain. The effectiveness of non – invasive methods of pain relied very based on the severity and type of patients’ pain. Further research of non – invasive methods of pain relief is warranted.

6.4.STATEMENT OF PROBLEM

A study to assess the Effectiveness of Rhythmic Breathing Exercise on post - operative pain and selected activities of patients after abdominal surgery in selected hospital.

6.5.OBJECTIVES The specific objectives of the study were

1. To assess the level of post-operative pain in the experimental and control

group from the 2nd to 4the post –operative day.

2. To assess the ability of patient to carry out the selected activities in the

experimental and control group.

3. To find out the level of pain in relation to selected variables such as age, sex

and education.

4. To test the hypothesis.

6.7.OPERATIONAL DEFINITION

Post – operative pain:

It is unpleasant sensation verbally and non- verbally expressed by the patients post-operatively which can be measured by visual analogue scale.

Rhythmic breathing exercise:

It is a slow deep breathing involving the muscles of abdomen, diaphragm and intercostals muscles.

Post – operative period:

It refers to the period from the second day to fourth day after surgery.

Abdominal surgery: It refers to the operation involving the abdominal organ through incision on the abdominal wall.

6.8.ASSUMPTIONS  All patients will experience pain post – operatively.

 Pain experience will differ from patient to patient.

 Post – operative management of pain in abdominal surgical patients will vary

from hospital to hospital.

6.9.Hypothesis

Ho1 : There will be no significant difference between the mean pain score of experimental and control group before intervention.

Ho2 : There will be no significant difference between the mean pain score of first and second observations in control group.

H1 : There will be significant difference between the mean pain score of experimental and control group after intervention.

H2 : There will be significant difference between the mean pain score of experimental and control group before and after intervention.

H3 : There will be significant difference between the mean pain score of experimental group after intervention and the second observation mean pain score of the control group.

H4 : There will be significant difference in the mean performance score of the selected activities between experimental and control group.

H5 : There will be significant difference between the mean performance score of the experimental and control group on the 2nd post – operative days.

7.MATERIALS AND METHODS 7.1 SOURCES OF DATA

Research Design : Quasi experimental One group pre test and Post test design

Setting of the study : District hospital Tumkur

Population : clients undergoing open abdominal surgeries such as

umbilical hernia, laparotomy, hysterectomy, and open

cholecystectomy.

Sampling technique : Purposive sampling Sample size : 30 Sampling Criteria: Inclusion criteria

 Clients who were able to follow instructions in Tamil or English

 Clients who were in the age group of 30 – 60 years

 Clients who had the ability to take at least 400 ml of air on the incentive

spirometry.

 Clients who were operated with an incision on the abdominal wall.

 Clients who were willing to participate in the study.

Exclusion criteria

 Clients who had lower segmental caesarean section

 Laparoscopic surgery

 Clients who were below 30 or above 60 years.

7.2 METHODS OF DATA COLLECTION After obtaining the permission from the concerned authorities the investigator will introduce himself to the study subjects and explains the purpose of study. The data will be collected by interview method using structured questionnaire.

Description of the tool : Structured questionnaire Part A : Proforma for collecting demographic data Part B : Structured questionnaire to assess the knowledge on Rhythmic Breathing Exercise.

7.3Methods of Data analysis and interpretation Data will be analyzed according to the objectives of the study using descriptive and inferential statistics and will be presented in the form of tables, graphs and diagrams.

7.4Duration of the study : 6 weeks.

7.5Does the study require any investigation or intervention to be conducted on the patients or other human being or animals? If so please describe briefly.

7.6Has Ethical Clearance been obtained from your institution in case of the above? yes 1. Ignatavicius (1991) Medical – Surgical Nursing, Philadelphia: W.B.

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9. Signature of student :

10. Remarks of the Guide :

11. NAME & DESIGNATION OF :

11.1 Guide :

11.2 Signature :

11.3 Co-Guide (if any) :

11.4 Signature :

11.5 Head of Department :

11.6 Signature :

12. 12.1 Remarks of the Principal :

12.2 Signature :