Preoperative and Postoperative

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O Surgical Nurse’s Touch to Life of Patients and Their Family: Preoperative and Postoperative Psychological Approach Altun Baksi Simsek1,

Ozlem Bilik2

1

Altun Baksi Simsek, RN, MSN. School of Nursing, University of Dicle, Diyarbakir-Turkey Ozlem Bilik RN, PhD, Dokuz Eylül University Faculty of Nursing, Assistant Professor to Department of Surgical Nursing, Inciraltı 35340, Izmir-Turkiye 2

Corresponding Author :Altun Baksi Simsek, RN, MSN. , School of Nursing, University of Dicle, Diyarbakır-Turkey, Cell phone: +90 505 3973246, Office Fax: +90 412 2488451, e-mail: [email protected] Abstract Surgical intervention; is defined as “controlled trauma” that can change patient’s normal physiological functions. It’s a stimulus that starts the process of coping with surgical intervention for individuals and causes adaptive or maladaptive behaviour. Various emotional reactions occur in patient who had surgery or in his/her relatives. Anxiety/concern/worry is one of the most common psychiatric disorders that accompany physical illnesses. Medical developments reduced time of staying at hospital by increasing elective and one-day surgery but caused skipping of patients’ psychological treatment. It is necessary to evaluate psycho-social condition and coping mechanisms, to take necessary precautions to provide psychological support, to determine educational requirements of patients and their relatives and to provide education for patients in preoperative and postoperative period by nurses. Researches show that in patients who were prepared well for surgery in terms of psychology; anxiety reduced, less anaesthetic substance is need of during surgery, less analgesic drug is used in postoperative period, the vital signs are regulated in a short time, corticosteroid hormones that are produce as a reaction to stress are less produced, the patient can be cope better with the surgery trauma, the complications are less developed (infection etc.), the patients are healed fastly and are discharged early. Hence, in this article the subject of psychological approach which is a important step in preoperative and postoperative preparation is discussed. Key Words: Psychological Approach, Nursing Care, Preoperative Period, Postoperative Period. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Introduction Some of illnesses in our body are little parts of illnesses hiding in our soul. Nathaniel Hawthorne (1804-1864) is defined as image, life style, life quality etc.) (2). According

Surgical intervention; “controlled trauma” that can change patient’s normal physiological functions (1). Surgical intervention affects life in all aspects (emotional condition, social condition,

cognitive condition, daily life activities, body

to S. Callista Roy, one of nurse theorists; life never cannot be continues in the same way for human, it constantly changes and brings new problems along. To response positively to these changes is defined as adaptation. 91

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O 1 below. Preoperative period is the most The surgical intervention is a stimulus that traumatic period for individuals admitted to starts the coping process, and causes to an the hospital, because while person waits for adaptive or maladaptive behaviour (3). an intervention such as surgery that might Family members and family’s basic thread life, she/he fears a lot of things that functions (roles, communications, economic might happen and experiences a high level arrangements, rules, planning future, of anxiety (8-11). Individuals might show socialization etc.), which are in the centre of different behaviours in these situations. patient’s life and are a significant part of Some patients constantly ask questions his/her life, are affected by this process (4). although answers were given repeatedly As it can be seen, patients who had before, some become calm and introvert, surgical intervention and their families have some acts dependant as a child and some various emotional reactions such as; stress, may deny their illness and hide symptoms anxiety, concern, worry, fear, uneasiness, (8,11). restlessness (5-7). The reasons for patients’ preoperative and postoperative emotional reaction development are presented in Table Table 1. Causes of Patients’ Preoperative and Postoperative Emotional Reaction Development Individuals in preoperative period;

Individuals in postoperative period;

  

  

   

    

Fear of unknown, Uncertainty, Change of environment, unfamiliar strange environment and loneliness along with it, Fear of death, Fear of cancer, Fear of pain, Fear of anaesthesia (the probability to not wake up, to feel pain), To remain separate from family, Lay a burden on family members, Waiting before surgery, Permanent disease, Fear of postoperative processes…….etc. (811).

Emotional reactions experienced by individuals in preoperative and postoperative period are affected by; situation that requires surgery, the size of surgery, patient’s age, religious tendency, psychological situation, knowledge of preoperative period, previous

      



Pain, Fear of long term effects of surgery, Environment (alarm, noise, light, talks of health personnel and noises they made while walking etc.) Weakness, Helplessness, Inability to cope with problems, Change in body image, Low socio-economic level, Change in roles and responsibilities, Organ loss (amputation, ablation of breast or uterus etc.) loss of organ function (conducting bowel excretory from stoma), Loss of job, loss of independence, loss of role etc. (9, 10,12).

unfavourable hospital experiences, socioeconomic condition, adequacy of support systems, competency of health personnel and care opportunities (2). Anxiety/concern/worry is one of the psychiatric disorders that accompany 92

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O physical diseases most. disability, financial loss, waiting for Anxiety/concern/worry is one of the most operation, fear of one’s life, harm from common psychiatric disorders that nurse/doctor mistake, change of accompany physical illnesses. It is known environment, nothing by mouth, needing that anxiety level in adults in preoperative blood transfusion, fear of unknown, getting period is about 11-80% (5-7). Medical stuck with needle, awareness during surgery, developments reduced period of staying in respectively (14). In their research to hospital by increasing elective and one-day determine risk factors related to anxiety in surgery but led to skipping patients’ preoperative period in patients who went psychological treatment (13). Anxiety; through elective surgery (n:592), Caumo and affects patient’s coping, learning skills, collegues (2003); it is determined that making cooperation, preparations for anxiety risk increases in women and in surgery; reduces patients’ adaptation to individuals who have cancer and smoking treatment, frequently causes problems such history, psychiatric disorders, perception of as restlessness and sleeplessness, increases negative future, moderate to intense risk of anaesthetic medicine by increasing depressive symptoms, moderate to intense the need of anaesthesia and it prevents pain, ASA III and who received education healing by triggering physiological stress more than 12 years and experienced medium response. It is known that stress reduces surgery; and anxiety risk decreases in natural killer and IL-6 activity, thus affects patients who have surgical history. In a immune system’s function and causes research in which patients’ (n:100) anxiety increase in infection risk in individuals levels and factors that might result in anxiety having high level of stress. Anxiety causes are determined in preoperative period in our difficulties in pain control and management country; it is discovered that patients feel in postoperative period by leading to medium level of anxiety, surgery’s size aggressive situations, and it affects healing affects anxiety and that patients who did not in postoperative period by increasing the receive information related to operation have need of medicine for pain management higher anxiety point averages than the ones (2,5,12). For instance, as a result of pain and who received information (15). In some decrease of activities related to pain and other studies conducted in our country, it is decrease of cooperation skill, patients cannot observed that patients mostly indicated conduct deep breathing exercises, their doctors as a source of information related to breathing slows and pulmonary risks operation and that nurses cannot perform increase. Besides, decrease of patient’s educative role precisely. Since nursing activity induces risk of thrombosis and services provided in our country are carried bowel disorder (8,11). out task-based rather than patient-based, the In the research made by Jawaid and required importance cannot be attached to others (2007) to determine (n:193) anxiety patient education (15-17). factors before elective operations; it is determined that they experience anxiety with So what should we do? rates ranging from 89.6%-38.3% because of Surgical nursing is a branch of nursing in causes such as concern about family, fear of which patient’s physical, psychological and complications, results of operation, social requirements are determined, postoperative pain, fear of physical scientific information-based nursing 93

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O activities are coordinated and individualised  Inefficient coping behaviours care is practiced in order to recover and should be evaluated (to avoid maintain patient’s health and wellness (1). eye contact, alienation Psycho-social condition and coping between patient and family, mechanisms of patients in preoperative and to avoid communication with postoperative period should be evaluated, health personnel and to show necessary precautions to provide hostile behaviour, sleep psychological support should be taken, disorder etc.), educational needs of patient and his/her  Efficiency of support systems relatives should be determined, and should be evaluated, perioperative education should be given by  Patient’s coping mechanisms nurses (12,18,19). Psychological approaches with anxiety and fears should that can be used by surgical nurse are be strengthened by providing summarised below: emotional support  To evaluate patient’s psycho-social (2,11,12,20). condition basing on age and  To evaluate patient’s anxiety level developmental stage (low-medium-high level of anxiety)  Patient’s family profile  Anxiety and fear symptoms (occupation, age, sex, should be observed (anger, family’s coping skills etc.) crying, restlessness, overshould be evaluated, sweating, increase in pulse  Patient’s sources (home rate, palpitation, frequency environment, insurance of urination, diarrhea etc.) situation etc.) should be (2,11,18), evaluated (information and  When possible anxiety/fear is perspectives of patient on noticed, the feeling should be this subject can be obtained discussed with the patient, during daily care and talks)  Patient relatives should be (12). included in planned care,  To evaluate factors (age, previous surgical and patient role  If needed, doctor should experiences etc.) affecting patient’s prescribe medicine to reduce coping anxiety,  Coping mechanisms that  Someone should always were used by patient when accompany patient in order he/she encountered a to help and provide security stressful event in past or in of patient in preoperative similar situations should be period (a facial expression or evaluated, a warm hand-holding etc.) (2,11).  Whether the coping  To encourage patient to mechanisms that are used communicate are efficient should be evaluated, 94

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O  To meet the needs of patient’s  Patient should be supported relatives to share his/her feelings, fears, problems etc., patient  Willingness of patient’s should be able to express relative should be evaluated his/her opinions without fear in terms of participating in of being judged or laughed patient’s care (family’s asking at, question indicates their willingness),  Patient should be encouraged to ask anything she/he wants  After family’s willingness is to, his/her questions should determined, family members be answered, he/she should should be informed about be informed and enlightened, perioperative period,  A trust-based relationship  Patient’s relatives should be should be formed with supported to share their patient, emotions, feelings, fears, problems etc.,  Feedback should be received from patient and anything  Questions of patient’s he/she does not understand relatives should be should be re-explained answered, feedback should (2,11). be received and anything  To encourage patient to rest that is not understood should be explained again,  Since preoperative period is stressful physically and  Patient’s relatives should emotionally, patient’s sleep provide support to reduce and resting might be patient’s anxiety and to plan disrupted at the night before the care (2,11), the operation. A proper  Patient relative should be environment should be encouraged about provided for patient to rest accompanying patient before (silent and calm environment, operation to support him/her massage etc.) and if needed, (2,11,18), sedative or hypnotic  Patient relative should be medicines should be given to informed about possible patient (2). changes in time of operation  To divert patient’s attention away and program,  One should try to reduce  It should be described to anxiety with methods such as patient’s family that patient’s listening to music, watching amazement before television, relative’s visit and operations is resulted from reading book especially 24 operation stress, hours before operation (2). 95

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O equipment might be  Depending on numerous attached to patients when uncertainties, anxiety of she/he return to his/her patient relatives reaches its room. These explanations peak when patient is in can reduce patient relatives’ operating room. Hospital anxiety and fear when they should possess a waiting see their beloved one (2,11). room (chairs, televisions,  Patient’s cultural, spiritual and telephone etc.) for patient religious beliefs should be defined relatives to wait during (Patient’s religious tendencies and operation, and waiting room spiritual beliefs have significant roles should be comfortable and in their fight with fear and anxiety have a view to see if and they can be as effective as operation is completed, medicines) (6).  Patient relatives should not  Patient’s beliefs should be respected associate operation’s to and supported. importance with patient’s  time of staying in operation  Patients might deny some room (it should be explained interventions because of religious that the time that passes as reasons, this situation should clearly patient is not in his/her room be defined in preoperative period. is not included in operation  If needed, one should help patient to time, some delays might receive spiritual support (6,11). occur in operation room and  Besides in postoperative early that patient shall stay in period recover room for a while to  In postoperative period and regain consciousness), in intensive care, patients  Additionally, it should also be who are intubated and have explained to patient relatives tracheostomy or changes in in advance with causes and conscious level may have results that patient might still difficulties in expressing be sleeping after returning to themselves, his/her room, intravascular liquids, blood transfusion and oxygen might be implemented, drainage tubes or operation-based special Have you ever thought that a conscious patient who is attached to mechanic ventilator “has fear of possible powercut and to not be able to breath”?

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Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O postoperative period are more  For most literate patients, than usual. Anxiety’s causes only a paper and pen could should be learnt in order to help to understand the provide necessary support to problem, patients and their relatives  Interventions such as a touch, (8,20), a warm “hi”, to explain each  Surgery’s effect on healing, performed process, to tell body image, roles and life date and time to patient for style etc. should be evaluated place and time orientation, with patients and their pictures of patient’s relatives, feelings should be shared (8), privacy are a professional nurse’s most significant  Nurse should listen to patients helping skills (21). and their relatives; she/he should inform patient and his  Besides in postoperative period relatives about processes that  Patient may demand to talk are performed, and about his/her doctor when he/she medicines, care and wakes up after operation, the discharge, and the nurse doctor should talk patient and should answer patient’s his/relatives and give questions, information about surgical process and its results,  Providing a calm environment, reducing noise,  Restlessness might develop helping family members to because of pain, bladder accompany patient, providing distention, abdominal a supportive and relaxing distention, anxiety, lack of environment may reduce oxygen, bleeding and wet or patient’s and their family’s tight dressing of patient after anxiety (20). operation. Problem causing  Patient information in preoperative restlessness should be and postoperative period determined and intervention The literature emphasis on should be performed basing preoperative and postoperative education to on the problem, reduce anxiety caused by the unknown and  When patient comes to clinic the uncertainty is important. In Table 2 after operation, psycho-social below are presented about which evaluation should continue in preoperative and postoperative subjects a proper time after patient’s should given information. Patient physical treatment is information; helps patient to know what will performed (2), happen in every stage of surgical  Patients and their relatives intervention, to feel himself/herself better together continue to have physically and spiritually and to have more stress in postoperative period. positive surgical results. Besides, informing Psychological support both provides support and corrects requirements of a patient who misunderstandings and also ensures roles had a problematic 97

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O and responsibilities in care to be  Time should be allowed for comprehended. When patient is informed, patient for his/her questions, his/her participation to care and maintaining unanswered questions should self-control are ensured, thus anxiety is felt be directed to the appropriate less (2,11). Informing is the responsibility of person, the whole health team (22). Preoperative  Patient must be able to informing starts in doctor’s office for contact with doctor, operation elective or planned surgery. Many informing room nurse and anaesthesia stage starts with diagnose tests (2,10,11,22). personnel about his/her fear  Content of preoperative and problems, education that starts after  Operation place and patients’ admittance to service postoperative anaesthesia care is quite individual. Too many unit should be shown around details may increase anxiety (2,11,12), for some patients, for this  Patients should be informed reason preoperative education in a clear and comprehensible program should be organized way, and informing must be basing on individual’s written and visual since learning needs, verbal information will be  Patient’s anxiety level should forgotten [Level of Evidence; always be evaluated X (Specialist opinion)] (2,10,11,22), (23,24),  Patients and their relatives  The environment in which should be informed about patient will be educated can surgical process and it should be prepared, patient relatives be ensured they understand and, if needed, persons who the process, had the same surgical  Patient’s situation of experience can be ensured to knowledge and understanding participate in, patient can get should be evaluated (reaching to watch video of similar or information via internet both same operations (2,10,11,23). may help and also cause a problem),

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Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O

Table 2. Which Subjects Should Be Done Giving Information Related Preoperative and Postoperative Period? Informing about preoperative processes; place of surgical clinic, hospital rules, waiting room for operation, recovery room and intensive care unit, postoperative unit and location of waiting room, wound, anatomic and physiological changes about the operation (2,11,22,25,26). Defining and explaining preoperative routine processes; unknown terms and processes, processes required for diagnosis, EKG, laboratory tests, nutrition and fasting situation, bowel preparation, skin preparation, preoperative sedation, removing dental plates and prosthesis, operation room, anaesthesia (2,11,22,25,26). Information about senses in preoperative education; information about what patient will see, hear and feel before operation, in operation and recovery room, patient’s feelings during local or general anaesthesia, feelings created by drug given before operation, patient’ management of drugs which is using or will use, drugs used in general anaesthesia intervention, pain after operation, feelings during being carried from operation table to stretcher, feelings based on some processes after operation (throat ache caused by intubation etc.) (2,11,25,26). Defining postoperative routine processes; postoperative drains, liquids, drugs, dressings, diet and nutrition, postoperative nursing evaluations, to show right use of exercise and techniques to prevent complication after operation (deep breathing, cough exercises, early mobilization, finding and symptoms of surgical site infection, hang hygiene, dressing [Level of Evidence; R (Consensus statement, Concensus report, Narrative review)], discharge education (2,11,22,25,26). Information about time; date and time of operation, time to come clinic for patient, waiting time before operation, duration of operation, waiting time in recovery room after operation, information about nutrition (last time of eating),when materials such as drain, plaster, dressing etc. will be removed, visiting times for family (2,11,25,26).

 When postoperative and preoperative informing should be made? Selecting the right time is among factors that increase efficiency of education. Timing of education before operation which starts after patient is admitted to hospital is individual. When education made in an early

phase it could result in patient’s forgetting information, and if it is made in late phase just before the operation, it could result in patient’s failure to understand because of his/her over-anxiety. Since patient is completely focused on surgical intervention in the phase before urgent operation, it is proper only to inform about necessary 99

Review Article International Journal of Basic and Clinical Studies (IJBCS) 2014;3(1): 91-101 Simsek AB and Bilik O activities. What is ideal is to allow enough and proper time (11). We should think the difference between knowing these and not… But we should not forget that it is patient’s choice to know these…..

As a result, researches show that in patients who prepared well for operation psychologically; anxiety is reduced, less anaesthetic material is needed during operation, less analgesic is used in postoperative period, the vital signs are regulated in a short time, corticosteroid hormones that are produced as a reaction to stress are less produced, the patient can be better with the surgery trauma, the complications are less developed (infection etc.), the patients are healed fastly and are discharged early (8,11,12). By creating appropriate environment and conditions, nurses and manager need to ensure that patients stay in a good condition in this process defined as traumatic and to meet their roles and responsibilities in order to increase patients’ life quality. References 1. Eti Aslan F. History of the surgical nursing. Atatürk University School of Nursing Journal. 2009; 12, 1. 2. Patton RM. Interventions for preoperative clients. In: DD Ignatavicius, ML Workman, eds. Medical Surgical Nursing. 5th ed. St. Louis, Missouri: Elsevier Saunders; 2006; 293-357. 3. Roy C. The Roy Adaptation Model. 3rd ed. Upper Saddle River New Jersey: Pearson Education; 2009. 4. Smeltzer SC, Bare BG. Brunner&suddarth's Textbook of Medical Surgical Nursing. 10th ed. USA: Lippincott Williams&Wilkins; 2005; 1970–1977.

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