Multimodal perioperative management programme on postoperative discomfort among clients undergoing abdominal surgery at a selected hospital in Mangaluru

Introduction and Aim: Apart from pain, numerous causes contribute to discomfort during the postoperative period. Hence, early postoperative nursing care should focus on reducing this discomfort. The present study aimed to find the effect of a management programme on postoperative discomfort ( MPMP) among patients undergoing abdominal surgery. Materials and Methods: This quasi-experimental study was conducted in a selected tertiary care hospital and included 183 adult patients who underwent laparotomy. The MPMP includes preoperative education, early ambulation, deep breathing exercises, and incentive spirometry. The participants were randomized into two interventional and one control group. The Intervention Group I patients performed deep breathing exercises and early ambulation after preoperative education, while Group II patients practiced incentive spirometry and early ambulation with preoperative education. The study included a control group who received routine nursing care. The primary outcome variable is postoperative discomfort (measured on days 1,3, and 5). Results: The MPMP showed a significant difference in discomfort factors like pain during day1(p=0.007) and days 3 and 5 (p<0.001). Non-pain symptoms such as nausea, vomiting, movement restriction discomfort due to IV drips, and feeling cold showed higher significance for Groups I and II on days 3 and 5. Similarly, dry mouth, abdominal distension, and constipation showed a significant difference (p<0.05) on days 3 and 5 between the groups at a 5% significance level. Conclusion: This study showed that postoperative discomforts could be minimized by the early practice of the MPMP program in patients undergoing surgery.


INTRODUCTION
urgery induced physical and psychological stress among patients (1).Stress is triggered by physiological changes resulting from hormonal and neuro-physiological activation.While most of these changes are normal responses to injury aimed at recovering body functions, they greatly disturb some patients.Factors like pain, movement restriction, and dry mouth are the most disturbing causes of discomfort.Postoperative nausea and vomiting (PONV), or both experienced during the first 24 hours following surgery, has been reported to be a significant cause of distress and dissatisfaction among surgical patients in the early postoperative hours.Successful prevention of these complications significantly improves patients' discomfort enabling them to resume their daily activities faster (2).Therefore, besides pain, symptoms that cause postoperative discomfort should be addressed to improve the well-being of patients after abdominal surgery.Although patient comfort is an essential concern during surgery, the seriousness of discomfort during recovery is unknown (3).Early ambulation in the postoperative period reduces patient discomfort and hastens recovery (4).Educating the patients in the preoperative period helps them to recover faster after the surgery (5).Deep breathing exercises also help improve lung function in the postoperative period (6).The MPMP program, which includes preoperative education, early ambulation, deep breathing exercises, and incentive spirometry, has been used as a measure to reduce postoperative discomfort among patients undergoing surgery.Hence, in this study, we aimed to use this program on patients undergoing laparotomy and study its effect on reducing postoperative discomfort levels.

Ethical consideration
The Institutional Ethics committee approved the study (NUINS/CEC/2016-2017/036). Written permission was obtained from the authorities, and informed consent was taken from each participant after explaining the patient information sheet in their local language.Written permission was accorded to authors for using the postoperative discomfort questionnaire by Prof. Banos, JE, Universitat Pompeu Fabra, S Barcelona, Spain.

Study design
A quantitative approach with a quasi-experimental design was used for the study.The study was conducted in a 1200 bedded tertiary care hospital at Mangaluru.The data were collected from the surgery, urology, gynecology wards, and postoperative ICUs from September 2017 to December 2019.The sample size calculation was based on the standard formula to compare the group with a mean difference and pooled standard deviation.The estimated sample size with a 10% attrition rate was 201.Using the purposive sampling technique, a total of 201 patients after open abdominal surgery were selected; however, only 183 samples completed the study.Only patients aged 25-65 admitted to the surgery/urology/gynecology wards for elective surgery were included in the study.Patients requiring respiratory support for more than two hours and having pre-existing musculoskeletal problems, delirium, dementia, psychoses, etc., were excluded from the study.
Baseline data (demographic and clinical) was collected from all participants (n=183), after which they were randomly assigned to one control group and two experimental groups (Group I and Group II).The research intervention was the MPMP which had four components (a) preoperative education, (b) early ambulation, (c) incentive spirometry, and (d) deep breathing exercise.The participants in the control group (n=80) received no MPMP intervention and were on routine care during the pre and postoperative period.The patients in experimental Group I (n=44) were implemented with the MPMP components, preoperative education one day before surgery, early ambulation, and deep breathing exercises, while the patients in Group II (n= 59) were trained on incentive spirometry and early ambulation for five days.
A standardized questionnaire was also provided to the patients in Groups 1 and II to investigate the effect of MPMP intervention on postoperative discomfort factors such as pain, nausea, vomiting, movement restriction, sleepiness, dry mouth, insomnia, abdominal distention, constipation, intravenous linerelated problems, and chills (7).Each factor was scored as 1 if the discomfort was present and a 0 if absent.The degree of discomfort was rated further on a ten-point scale, with the least score of one and a maximum of ten, denoting the degree of distress experienced by the patient.

Statistical analysis
Statistical data analysis was performed using the SPSS package 2020 version.Descriptive statistics and inferential statistical tests were applied.The Kruskal-Wallis test was used to compare the factors causing postoperative discomfort between the experimental groups.Dunn's test was calculated to analyse the multiple comparisons of factors causing postoperative discomfort on days 1, 3, and 5 between experimental groups I, II, and the control group.A p-value <0.05 was considered significant.

Baseline characteristics of the study participants
The baseline demographic and clinical characteristics of the study population (n=183) are given in Tables 1  and 2. Among the participants, the majority were between 25 and 35 years, with females being more predominant than men.Most of the participants in the experimental Group 1 (43.2%),Group II (50.8%), and the control group (58.8%) had normal BMI.In all groups, most participants were observed to be educated up to the level of primary and secondary school and also seen to be unemployed.The demographic characteristics of the participants from all three groups were found homogenous as the p values were >0.05 at a 5% significance level (Table 1).As seen from Table 2 the length of stay by the majority post-surgery was 6-10 days by patients in all groups.
Most participants had no history of surgery in all groups, with comorbidities like hypertension, Diabetes mellitus, and obesity.Immunosuppressive factors like AKI, anaemia, CKD, and steroid intake were elicited only in less than 10% of the participants in all three groups.A vast majority in all three groups did not have any malignancy or health deteriorating habits like smoking and alcoholism.Statistical analysis of clinical parameters showed a p value >0.5 at a 5% significance level, indicating a homogeneity for participants in the three groups.

Effect of MPMP on postoperative discomfort factors among control and experimental groups
The effect of the MPMP intervention on patients who underwent abdominal surgery is presented in Table 3.
The pain was seen to be the most discomforting factor in all groups (Day 1), which gradually decreased by Day 5 in the experimental groups that received MPMP as compared to controls (Table 3).for all the factors except discomfort caused by IV drips across three observations.A significant difference in the discomfort factors between Day 1 and Day 5 in the control and experimental groups was observed (Table 3).

*Indicates significance
Table 4 shows the comparison (controls versus experimental Groups (I and II) as well as between Groups I and II) of the discomfort symptoms caused on day 1, 3, and 5 after surgery.Between Group I and II wherein different components of the MPMP were given, no significant difference for scores (p>0.05) were observed for the discomfort factors of pain and nausea on days 1, 3 and 5. Similarly, except for dry mouth, the scores obtained for symptoms such as movement restriction, abdominal distension, insomnia, IV drip and feeling cold were significantly higher (p>0.05) between Groups I and II on days 3 and 5.
Discomfort due to insomnia was found to be significantly different only between experimental group II (p=0.002) and the control group.Discomfort due to IV drip showed a significant difference between experimental group I who received deep breathing exercises on day 3 (p=0.011)with the control group.At the same time, experimental group II exhibited a difference in all three observations too (day 1 p=0.014,day 3 p=<0.001,and day 5 p<0.001) at 5% level of significance.

DISCUSSION
The present study showed pain and nausea as the most discomforting factors post-surgery, which agrees with earlier reports showing that pain and nausea are experienced in the early postoperative period (2).A high prevalence of moderate to severe postoperative pain has also been recorded by several researchers following other surgeries (8)(9)(10)(11).Studies also show that apart from pain, patients may experience various other discomforting factors immediately after surgery and anaesthesia (12).In a prospective observational study on postoperative discomfort after abdominal surgery the leading causes of discomfort at 24 hours were pain, movement restriction and dry mouth (13).In a recent study pain, movement restriction, abdominal bloating and dry mouth were reported to be the leading cause of discomfort after abdominal surgery (7).Significant discomfort due to vertigo, nausea, vomiting, and anxiety have been reported to be experienced by patients after 24-72 hrs following cruciate ligament reconstruction (14).Our study is in accordance with these earlier studies and showed that apart from the pain the other causes of discomfort are vomiting, nausea, movement restriction, dry mouth, insomnia, constipation and feeling cold in postoperative abdominal surgery patients.
The treatment of pain has been the focus of medicine for many years and has been approached in different ways by physicians to manage pain during and after surgery (15,16).However, recent approaches have focussed on non-invasive therapies such as deep breathing exercises (6) and integrated educational programs (17) to alleviate post-operative non-pain symptoms after surgery.Here we studied the effect of the MPMP intervention on the post-operative discomfort factors in patients undergoing abdominal surgery.Our studies showed an overall gradual reduction from day 1 to day5 in post-surgery discomfort levels in patients educated by the MPMP programme.Further, no significant difference was observed for the MPMP intervention given to Group I (implemented with the MPMP components of preoperative education, early ambulation, and deep breathing exercises) and Group II (trained on the spirometry and early ambulation of the MPMP program) patients in this study.However, compared to patients in the control group that did not receive any intervention, Group II showed a higher significance in reducing discomfort factors than Group I.This could probably be due to patient training on spirometry (lung breathing exercise) and ambulation (involving physical activity such as sitting, standing, or walking) for execution as soon as possible after surgery.The effect of spirometry has been previously shown to reduce postoperative pulmonary complication following laparotomy (18).
Thus, our study recommends implementing the MPMP program, making provisions and educating patients on techniques such as spirometry and ambulation to lower the post-operative discomfort symptoms and faster recovery.

CONCLUSION
The study highlights the various factors causing discomfort in the postoperative period.Combining the various interventions throughout the perioperative period helps alleviate these discomfort factors and enhances recovery from surgery.

Table 1 :
Demographic characteristics of participants

Table 2 :
Clinical characteristics of the study population

Table 3 :
Comparison of the degree of postoperative discomfort between the experimental Groups and control