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Taking care of fearful patients in OR

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Surgical patients are more anxious prior the operation than after the operation ... Perioperative measurement time points, variables, instruments, and sample ... – PowerPoint PPT presentation

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Title: Taking care of fearful patients in OR


1
Taking care of fearful patients in OR
  • Kirsi Kiviniemi
  • RN, PhD, Director in Nursing, Associate
    lecturer
  • Hospital District of Southwest Finland, Turku
    University Hospital
  • University of Turku, Department of Nursing
    Science

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
2
Content of the presentation
  • Conceptual approach to perioperative anxiety
  • Anxiety, fear and tension / ahdistus, pelko ja
    jännitys
  • Why should we identify and evaluate patients
    perioperative anxiety
  • Review of intensity of perioperative anxiety and
    interventions to relieve patients perioperative
    anxiety
  • Perioperative anxiety in Finnish parturients who
    underwent planned Caesarean operation
  • Challanges for perioperative nursing practice

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
3
Conceptual approach to perioperative anxiety
  • Anxiety is
  • a vague, uneasy feeling of discomfort or dread
    accompanied by an autonomic response the source
    is often non-specific or unknown to the
    individual (NANDA 1999)
  • the degree of perceptions of worry and
    nervousness (Lin Wang 2005)
  • Fear is
  • anxiety caused by consciously recognized and
    realistic danger. It is a perceived threat, real
    or imagined. Operationally, fear is the presence
    of immediate feeling of apprehension and fright
    source known and specific (NANDA 1999)
  • Tension is
  • mental, emotional, or nervous strain (NANDA 1999)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
4
  • Based on the literature review
  • There are various theoretical models considering
    perioperative anxiety
  • Drive theory (f.ex. Janis 1959)
  • Situational and trait anxiety (f.ex. Spielberger
    1972)
  • Perioperative anxiety is measured as intensity
    and incidence of anxiety, fear and tension
  • STAI (Spielberger State Trait Anxiety Inventory),
    VAS or VASA (Visual Analogue Scale for Anxiety)
  • HADS (Hospital Anxiety and Depression Scale)
  • APAIS (The Amsterdam Preoperative Anxiety and
    Information Scale)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
5
  • Physiological, cognitive, and behavioural signs
    are joined to increased perioperative anxiety
    level
  • Perioperative anxiety provoking fears and
    concerns have been reported
  • fears and concerns are extra-, intra- or
    interpersonal
  • There are factors relating to increased
    perioperative anxiety level
  • patients gender, age, education, marital status,
    financial situation, trait anxiety level,
    surgical history, and mode of present surgery
  • some of the relations are conflicting according
    to literature

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
6
High perioperative anxiety relates to
  • Female gender
  • Moerman et al. 1996, Karanci Dirik 2003
  • Age under 40 yrs in adults
  • Shafer et al. 1996, Kindler et al. 2000
  • Major or emergency surgery
  • Leinonen et al. 2001, Karanci Dirik 2003
  • Missing or bad prior surgical experiences
  • Shafer et al. 1996, Kindler et al. 2000
  • Higher trait anxiety level
  • Caumo et al. 2001, Talyor-Piliae Molassiotis
    2001, Ng et al. 2004, Carr et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
7
What can You see on the drawing?
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
8
2. Why should we identify and evaluate patients
perioperative anxiety
  • Documentation of the perioperative nursing
    decision-making process
  • Patient Act (785/1992)
  • Research has demonstrated that anxiety has both
    psychological and physical effects on the patient
  • Guzzetta 1989, Leach et al. 2000, Bally et al.
    2003

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
9
Decision-making in perioperative nursing
following patients, nurses and physicians
assessment INTERPRETATION AND UNDERSTANDING OF
PATIENTS SITUATION
Patients care status
What?
Assessing the need of the care
How?
Nursing interventions
CHOOSING THE RIGHT INTERVENTION
Planning and implementing
Outcomes of the care
Why?
state of health, coping, opinion ANTICIPATING THE
PROGRESS OF THE CARE
Evaluating the outcomes
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
10
Pre-operative anxiety is associated with many
unwanted effects such as
  • Increased analgesic requirement
  • Davies et al. 1997
  • Increased anaesthetic requirement
  • Osborn Sandler 2004, Granot Ferber 2005
  • Increased postoperative pain
  • Granot Ferber 2005, Lin Wang 2005, Pellino et
    al. 2005, Watts McEachan 2005, Carr et al. 2006
  • Prolonged recovery and hospital stay
  • Kulik et al. 1996, Shuldham 1999 Agarwal et al.
    2005, Hobson et al. 2006
  • Misunderstanding of pre-/ postdischarge
    information
  • Orr 1986, Kulik et al. 1996, Shuldham 1999
  • Missatisfaction with the received care
  • Callaghan et al. 1998, Leinonen et al. 2001
    Hobson et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
11
3a) Review of intensity of perioperative anxiety
  • Surgical patients are more anxious prior the
    operation than after the operation
  • While waiting surgery at home (Koivula 2002,
    Cooke et al. 2005)
  • On arrival at the hospital (Bellan et al. 2002)
  • Immediately prior to surgery (Jones et al. 2004)
  • Patients anxiety level tends to remain high and
    constant from the afternoon before to surgery to
    the morning of surgery Doering et al. 2000
  • There is a linear and positive correlation
    between patients anxiety level prior and after
    the operation
  • Kain et al. 2000, Gejervalla et al. 2005, Carr
    et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
12
Intensity of perioperative anxiety
  • Perioperative anxiety measured by STAI (ranging
    from 20 to 80)
  • Mild anxiety 20 39, moderate anxiety 40 59,
    strong anxiety 60 - 80
  • Anxiety level on arrival at hospital
  • 28.0 43.9 (Parent Fortin 2000, Jones et al.
    2004)
  • Anxiety level immediately prior the operation
  • 33.9 59.0 (Lin et al. 1997, Marucci et al.
    2003)
  • Anxiety level postoperatively at hospital
  • 27.6 43.0 (Karanci Dirik 2003, Gejervall et
    al. 2005)
  • Anxiety level at home, one to six months after
    operation
  • 28.4 37.3 (Heikkilä et al. 1999)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
13
3b) Review of interventions which relieve
patients perioperative anxiety
  • Studies have assessed the effect of the provision
    of information on preoperative anxiety
  • Beddows 1997, Shuldham 1999, Hodgkinson et al.
    2000, Sjöling et al. 2003, McDonald et al. 2004,
    van Vliet et al. 2004
  • Routine preoperative information/education and in
    addition
  • A tour of the operating department (Deyirmenjian
    et al. 2006)
  • A kit of nonpharmacologic strategies for anxiety
    and pain (Pellino et al. 2005)
  • A computer website intervention. The website
    instruction module content was a replication of
    the standardized verbal instruction module
    enhanced with digital photos (Hering et al.
    2005)
  • A preoperative nursing intervention for pain (Lin
    Wang 2005)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
14
  • Preoperative information mostly relieves
    patients perioperative anxiety
  • Patients need information about illness, surgical
    processes, possible risk factors, anticipated
    sensations/discomforts
  • Patients expect written and verbal information
  • Walker 2002, Johansson et al. 2003
  • Preoprative information is preferred to receive 1
    to 3 weeks prior to surgery
  • Mitchell 2000
  • Preoperative teaching should be individually
    tailored
  • Guruge Sidani 2002
  • Incorporating preoperative psycho-educational
    interventions is recommended
  • Calvin Lane 1999

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
15
Music and perioperative anxiety
  • The theoretical basis for music as an
    intervention for anxiety lies in its ability to
    promote relaxation through the autonomic nervous
    system
  • Thaut 1990
  • Music promotes feelings of physical and mental
    relaxation by refocusing attention on to
    pleasurable emotional states
  • Bailey 1986,Bonny 1986, Brown et al. 1989,
    McCaffery 1990, Magill-Levreault 1993
  • Patients awareness of time passing becomes hazy
    as they focus on the music thus promoting a
    relaxation response
  • Guzzetta 1995

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
16
Examples of music interventions and results
  • Receiving 20 minutes of music vs. having 20
    minutes of rest in bed after cardiac surgery
  • Sendelbach et al. 2006
  • Receiving 30 minutes of music therapy vs. only
    routine care
  • Chang Chen 2005
  • Listening to music of patient choice during the
    preoperative wait (30 min) vs. wearing the
    headphones but receiving no music for 30 minutes
    vs. control group receiving routine care only
  • Cooke et al. 2005
  • Music decreased preoperative anxiety in patients
    having outpatient and day surgery
  • Wang et al. 2002, Lee et al. 2004

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
17
Other interventions and perioperative anxiety
  • Guided imagery
  • Tusek et al. 1997. Walker 2002, Mitchell 2003
  • Relaxation, hypnosis, reflexology
  • Goldman et al. 1988, Ernst Koder 1997
  • A systematic method of relaxing the body on the
    sensory relaxation did not result in
    significantly less anxiety. However, group
    differences in state anxiety were in the expected
    direction
  • Roykulcharoen Good 2004
  • Guided imagery and relaxation decrease
    perioperative state anxiety

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
18
  • Hand massage and hand holding as nursing
    interventions on the anxiety
  • Richards et al. 2000, Moon Cho 2001, Oh Park
    2004
  • Humour
  • Gaberson 1995, Ã…stedt-Kurki et al. 2001
  • Aromatherapy
  • Jellinek 1999
  • Psychosocial support
  • Mitchell 2003, Krenzischek et al. 2004
  • Nurse Case Manager (NCM) Model to care the
    patients
  • Palese et al. 2005
  • Massage, hand holding, humour, aromatherapy,
    psychosocial support, and NCM model have been
    reported to decrease perioperative anxiety. The
    decrease is not always significant but the
    patients feel better and they are satisfied

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
19
4. Perioperative anxiety in Finnish parturients
who underwent planned Caesarean operation
  • ARE YOU ANXIOUS, AFRAID OR TENSE
  • Perioperative anxiety and empowering nursing
    prior, during and after planned caesarean
    delivery
  • By
  • Kirsi Kiviniemi
  • Annales Universitatis Turkuensis Ser. D Tom. 704
  • Medica Odontologica
  • University of Turku 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
20
Summary of the theoretical starting points of the
study
21
The research questions were
  • What kind of perioperative anxiety do women
    express prior, during and after planned Caesarean
    delivery?
  • What kind of expectations and experienced do
    women express regarding empowering perioperative
    nursing prior and after planned Caesarean
    delivery?
  • What kind of association there is between
    perioperative anxiety and empowering
    perioperative nursing prior and after planned
    Caesarean delivery?

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
22
Perioperative measurement time points, variables,
instruments, and sample
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
23
Intensity of state anxiety across the
perioperative period
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
24
The relation between high state anxiety and
background factors
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
25
Empowering perioperative nursing
  • Empowerment is a process of helping or preparing
    people to assert control over their health
    problems and the consequences
  • Gibson 1991, Rodwelle 1996, Kuokkanen
    Leino-Kilpi 2000
  • Six dimensions of empowering perioperative
    nursing
  • Bio-physiological empowerment
  • Cognitive empowerment
  • Experiential empowerment
  • Functional empowerment
  • Ethical empowerment
  • Social empowerment
  • Modified from Leinonen et al. 1996, Leino-Kilpi
    et al. 1998, 1999

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
26
Parturients expectations of the empowering
perioperative nursing
  • Feeling safe
  • Smooth collaboration between the staff
  • Ongoing information of the newborn child
  • Peaceful atmosphere
  • Trust-creating non-verbal communication
  • Sincere interest from the staff
  • Being taken seriously
  • Understandable verbal information
  • Possibility to participate in their treatment
    planning
  • Pleasant position on the OR table
  • Technical competent staff

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
27
Parturients perceptions of empowering
perioperative nursing
  • Technical competent staff
  • Nurses and physicians were kind and cheerful
  • Non-verbal communication was trust-creating
  • Smooth collaboration between staff members
  • Peaceful atmosphere
  • Being taken seriously
  • Feeling safe
  • Their privacy was protected
  • Staff was able to act in sudden situation
  • Staff demonstrated sincere interest

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
28
Expected and received empowering perioperative
nursing care
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
29
5. Challanges for perioperative nursing practice
  • Perioperative anxiety should be evaluated and
    documented systematically
  • Simple visual analogue scale for anxiety is a
    useful instrument
  • Spielberger state trait anxiety inventory is
    another noteable instrument
  • Electronic patient documentation systems should
    involve an instrument to evaluate patients
    perioperative anxiety level
  • A check-list of usual factors which strengthen
    perioperative anxiety should be employed when
    patients perioperative needs are evaluated
  • Its important to evaluate pain and anxiety
    simultaneously

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
30
Challenges for perioperative nursing
administration
  • Developing practice to evaluate patients
    perioperative anxiety
  • Developing anxiety-related perioperative nursing
    interventions
  • Defining patients dependency and in allocating
    perioperative nursing staff resources accurate

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
31
Thank you for your attention
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
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