CHAPTER - VI

MAJOR FINDINGS AND CONCLUSION

6.1. SUMMARY

Abdominal surgery is the most common operative procedure including a wide

range of both emergency and elective surgical interventions. The overall rate of

operation on the abdomen increased with age from 35% in patients less than 60 years

old to 31% in those who above the age of 60. Interestingly, the rate was also different

with respect to ethnic groups. In addition, compared to males, the prevalence of intra-

abdominal surgery in female was significantly higher. Similar to other countries, India

has a very high rate of abdominal surgery. Abdominal surgery involves in not only the

intra-abdominal organ such as liver, pancreas or gastrointestinal tract, but also the extra

abdominal structures like prostate, urinary track or the aortic aneurysm. Since the very

early time of its history, abdominal surgery has developed quickly, from the simple

procedures on gastrointestinal tract to various procedures such as vagotomy,

prostatectomy, cholecystectomy, gastrectomy, pancreatectomy, etc.

There are many complications might occur following abdominal surgery. Some of

the common complications that could be named include postoperative ileus, anastomotic

leakage, and infection. Besides that, the typical complications after operation in general

such as electrolyte imbalance, delirium, respiratory failure, etc., could also occur among

abdominal surgery population. Common general postoperative complications include

atelectasis, pneumonia, orthostatic hypotension, decreased cardiac output and stroke

volume, urinary retention, negative nitrogen balance, depression and sensory

deprivation, decrease tissue sensitivity to insulin, deep vein thrombosis, constipation and

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 fecal impaction, loss of muscle tone and decubitus ulceration in the dependent areas

that is subjected to pressure due to prolonged bed rest. Ileus is a typical complication

after abdominal surgery, which refers to the condition of generalized bowel immobility.

The exact mechanism of ileus is not known. Ileus can be recognized from clinical signs,

such as abdominal distension, nausea, or the absence of bowel sound. There are many

factors contributing to postoperative ileus including intra-abdominal infection, hematoma,

and effects of narcotics, electrolyte abnormalities, and pain. Among interventions

preventing ileus, early mobilization has long been held as the useful method. In addition,

early feeding and no gastric drainage are also benefited.

Early postoperative ambulation has been practiced on the surgical services.

There were 500 abdominal surgery cases compared with the 500 similar cases, they

were left in bed for 10-14 days. The study group allowed walking as early as possible.

The control group were not ambulated and used for comparison. In ambulated group

there was a total 43 postoperative complications as compared with 93 for non-

ambulated. Bronchopneumonia has been reduced from 6% to 3%, atelectasis from 1.2%

to 0.4%, thrombosis from 2.4% to 1% in ambulated group. The early ambulation assists

in prevention of functional decline and may have positive effect on depression and

anxiety. In the past the measurement of ambulation has presented a challenge to the

researcher. Early ambulation following abdominal surgery has been measured as the

time taken to achieve mobility goals such as sitting out of bed, ambulating with

assistance or ambulating independently. Hence it necessitates development of assisted

early ambulation intervention which will promote optimal physical, physiological and

psychological wellbeing.

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 Recognizing this fact the investigator instituted modified early ambulation

procedure done at 16th hour after abdominal surgery. Nursing care after abdominal

surgery must cover all problems occurring after surgery such as respiratory

management, circulation monitoring, drains care, wound care, complication intervention,

etc. Early ambulation following abdominal surgery has been measured as the time taken

to achieve mobility goals such as sitting out of bed, ambulating with assistance or

ambulating independently. "Modified early ambulation is the most significant general

nursing measure to prevent postoperative complications".

Postoperatively, early ambulation is especially important after abdominal surgery

to prevent the formation of thrombus and devastating emboli. Patient‘s blood pressure

should be monitored appropriately. Moreover, a considering of patients' cardiac situation

is essential for early mobilization. To estimate patient cardiac health clinically, the overall

function ability can be the best indicator. Those who can exercise without limitations can

generally tolerate the stress of major surgery. Limited exercise capacity may indicate

poor cardiovascular reserve and the ability to withstand the stress of surgery.

The research question that guided this investigation to identify the effectiveness

of modified early ambulation and postoperative recovery of patients had undergone

abdominal surgery. The prospective pretest, posttest true experimental design was

adopted for this study. Patients subjected to modified early ambulation for the first time

on elective basis were in the age group of 20-60 years, irrespective of number and type

of abdominal surgery recruited for the study. Patients who were having systemic

diseases like diabetes mellitus, cardio respiratory disorders and hypertension etc.

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 The important outcome variables were activities of daily living (ADL), functional

activity and psychological wellbeing. Activities of daily living (ADL) measured with

observation schedule on restoration of daily living scale. The functional activity

measured with observational schedule on restoration of functional activity scale. The

psychological wellbeing measured with interview guide on psychological wellbeing. The

tool validity done by 10 experts (5 surgeons and 5 nursing experts). The investigator

developed modified early ambulation guide, the modified early ambulation guide has 3

main phases: sitting in the bed, standing and limited walking and extended walking.

The investigator approached the study and control group on the day before

surgery, baseline data and consent were obtained. Modified early ambulation procedure

steps and randomization done on study group. The pretest was done at 15th hour after

surgery regarding activities of daily living, functional activity and psychological wellbeing

in both study group and control group. The patients in the study group were ambulated

at 16th hour after surgery. The patients in the control group were not ambulated at 16th

hour. The postoperative observations were done in both study group and control groups.

Activities of daily living were observed every 24 hours, till 120 hours after surgery.

functional activities was observed every 12 hours till 75 hours after surgery.

Psychological wellbeing was assisted by interview every 24 hours till 120 hours after

surgery. Each observation was made for 6-8 minutes. The observation and the oral

response were recorded in the tool. On an average 5-6 patients were recruited in the

study and were followed-up. The data were collected and analyzed using appropriate

descriptive and inferential statistics. The results were discussed in light of the

hypothesis. Although the review of literature did not yield studies that typically tested the

effect of modified early ambulation and activities of daily living, functional activity and

psychological wellbeing, this study findings raise number of pertinent points for

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 discussion and have clinical implications. The data collected were analyzed using

appropriate descriptive and inferential statistical method. The major findings of the study

were presented below.

6.2. MAJOR FINDING OF THE STUDY:

The major finding of the study is presented under the following headings:

1. Finding on selected demographic variables of patients undergone abdominal

surgery in the study group and control group.

2. Finding related to effectiveness of modified early ambulation on activities of daily

living activities in the study group and control group.

3. Finding related to effectiveness of modified early ambulation on functional

activities in the study group and control group.

4. Finding related to effectiveness of modified early ambulation on psychological

wellbeing in the study group and control group.

5. Findings in difference among selected variables and activities of daily living in the

study group and control group.

6. Findings in difference among selected variables and functional activity in the

study group and control group.

7. Finding in difference among selected variables and psychological wellbeing in

the study group and control group.

I. Findings on demographic variables of the patients undergone abdominal

surgery in study group and control group.

Majority of the patients had undergone abdominal surgery in the in the study

group 26 (35%) were in the age group of 51-60 years, 42 (56%) were male, studied

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 primary school 19 (26%), did not do regular exercises 39 (52%), known about the

benefits of early ambulation through friends 20 (27%) and 18 (24%) has hypertension.

Majority of patients had abdominal surgery in the control group were in the age

group of 41-50 years 28 (37%), male 44 (59%), studied high school 21 (28%), did not do

regular practice of exercises 42 (56%), known about the benefits of early ambulation

through friends 26 (35%) and 19 (25%) also has hypertension.

II. Findings on effectiveness of modified early ambulation on activities of daily

living of patients undergone abdominal surgery in the study group and control

group.

The posttest mean scores (SD) reported in the study group at regular interval of

24 hours after surgery 12.96 (1.14), 17.75 (0.9), 20.51 (0.83), 20.95 (0.23) and 21 (0) in

control group 7.72 (1.03), 10.56 (1.71), 13.88 (1.68), 16.98 (1.42) and 19.6 (1.03)

respectively.

The obtained t value between study group and control group posttest activities of

daily living scores at regular intervals of 24 hours after surgery were t = 29.54 (p<0.01), t

= 32.22 (p<0,01), t = 30.64 (p<0.01), t = 23.9 (p<0.01), and t =11.77 (p<0.01) modified

early ambulation significantly contributed.

III. Findings on effectiveness of modified early ambulation and functional activity

of patients undergone abdominal surgery in the study group and control group.

The posttest mean scores (SD) reported in the study group at regular intervals of

12 hour after ambulation 4.24 (0.49), 5.77 (0.69), 7.53 (0.9), 9.4 (0.86) and 9.85 (0.35)

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 and in the control group 2.5 (0.68), 3.62 (0.67), 4.61 (0.73), 5.77 (0.74) and 6.85 (0.81)

respectively.

The obtained t value between study group and control group posttest functional

restoration scores at regular intervals of 12 hours after ambulation were t = 17.98

(p<0.01), 19.36 (p<0.01), 21. 82 (p<0.01), 27.71 (p<0.01) and 29.44 (p<0.01) modified

early ambulation significantly contributed.

IV. Findings on effectiveness of modified early ambulation and psychological

wellbeing of patients undergone abdominal surgery in the study group and

control group.

The posttest mean scores (SD) reported in the study group at regular intervals of

24 hours after surgery 5.89 (0.62), 7.8 (0.69), 9.72 (0.48), 10 (0), and 10 (0) and in the

control group 2.57 (0.59), 3.62 (0.69), 4.78 (0.94), 5.9 (1.12) and 7.2 (1.3) respectively.

The obtained t value between study group and control group posttest

psychological wellbeing scores at regular intervals of 12 hours after ambulation were t =

33.59 (p<0.01),t = 37.1 (p<0.01), t = 40.53 (p<0.01), t = 31.7 (p<0.01) and t = 18.65

(p<0.01) modified early ambulation significantly contributed.

V. Findings on difference among selected variables and activities of daily living,

functional activity and psychological wellbeing on patients undergone abdominal

surgery in the study group and control group.

The obtained F and t values among demographic variables and activities of daily

living in the study group were F=.721 (P =.554), t =1.13 (p =.273), F= 1.62 (1.328), t =

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 1.24 (.283), F=.731 (.564), F=.724 (p=.543) and F=.725 (p=.543). In the control group F=

1.625 (.217), t=.027 (p =.058), F =1.752 (P =.243), t =.29 (p =.059), F =1.723 (P =.224),

F=.724 (p=.543), F=1.645 (P=.346) and F=1.645 (P=346) regarding activities of daily

living and demographic variables like age, sex, education, exercise, source of

knowledge and co-morbidity were not significant at .05 level in the study group and

control group. The demographic variables did not influence the posttest activities of daily

living scores in the study group and control group, the effectiveness of modified early

ambulation was independent of the demographic variables.

The obtained F and t values among demographic variables and functional activity

in the study group were F=.826 (p =.499), t = .518 (p =.611), F =.632 (p =.347), t =.618

(p =.643), F =.743 (p =.387) and F=.639 (P=.462). In the control group F = 1.153 (p

=.358), t =.373 (p =.714), F =1.075 (p =.219), t =.328 (p =.643), F = 1.348 (p =.475) and

F=1.462 (p=.592) regarding functional activity and demographic variables like age, sex,

education, exercise, source of knowledge and co-morbidity were not significant at .05

level in the study group and control group. The demographic variables did not influence

the posttest functional activity scores in the study group and control group. The

effectiveness of modified early ambulation was independent of the demographic

variables.

The obtained F and t values among demographic variables and psychological

wellbeing in the study group were F = .032 (p =.992), t = .186 (.855), F =1.64 (p =.843), t

=.543 (.684), F =.138 (p =.993) and F=.149 (p=.732). In the control group F =2.159 (p

=.133), t =.269 (p =.943), F = 2.492 (p =.148), t =.652 (p =.537), F = 2.243 (p =1.45), F

=2.243 (p =1.45) and F=1.746 (p=.139) regarding psychological wellbeing and

demographic variables like age, sex, education, exercise, source of knowledge and co-

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 morbidity were not significant at .05 level in the study group and control group. The

demographic variables did not influence the posttest psychological wellbeing scores in

the study group and control group. The effectiveness of modified early ambulation was

independent of the demographic variables.

The above findings were supported by the finding of Kaur Nirmal (2007), Deepa

M (2007), Munikumar (2002), and Ramachandran (1972). Regarding modified early

ambulation intervention, most of the study group subjects said that it was very useful for

early recovery. All most all of them said this procedure should be done to all the patients

subjected to abdominal surgery.

6.3. CONCLUSION

The study finding is supportive of the hypothesis-1-i.e there is a significant

difference in the activities of daily living among the patients undergone abdominal

surgery who availed the intervention than who do not. It can be inferred that the

difference revealed in the posttest activities of daily living (ADL) scores between study

group and control group in relation to modified early ambulation intervention. Hence

hypothesis 1 is accepted.

The hypothesis 2: there is a significant difference in the functional activity among

the patients undergone abdominal surgery who availed the intervention than who do not.

It can be inferred that the difference revealed in the posttest functional activity scores

between study group and control group in relation to modified early ambulation

intervention. Hence hypothesis 2 is accepted.

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 The hypothesis-3: There is a significant difference in the psychological wellbeing

among the patients undergone abdominal surgery who availed the intervention than who

do not. It can be inferred that the difference revealed in the posttest psychological

wellbeing scores between the study group and control group in relation to modified early

ambulation intervention. Hence hypothesis 3 is accepted.

The hypothesis-4: there is no significant difference among selected variables and

activities of daily living, functional activity, psychological wellbeing among the patients

undergone abdominal surgery who availed the intervention than who do not. It can be

inferred that the selected demographic variables were not significant at .05 level in the

study group and control group. The selected demographic variables did not influence the

posttest activities of daily living, functional activity and psychological wellbeing in the

study group and control group. Therefore hypothesis 4 is rejected.

Based on the above study it may conclude that the modified early ambulation

intervention in the study group had high score in activities of daily living, functional

activity and psychological wellbeing. The modified early ambulation found to be effective

for patients had undergone abdominal surgery in the study group. The modified early

ambulation intervention is capable of producing favorable outcomes that is restoration of

activities of daily living, functional activity and psychological wellbeing.

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 6.4 IMPLICATIONS FOR NURSING PRACTICE:

Surgery is a stressful, complex event; complications of abdominal surgery

include bleeding, infection, post-surgical adhesions, shock and paralytic ileus. There is

need necessary to encourage early ambulation, which facilitates rapid tissue recovery as

well as returning of normal day to day functions, would depend on the movements that

take place at the initial phase of postoperative recovery. Mobilization helps the bowel to

move and the gas to expelled thus eliminating the discomfort of abdominal distention,

constipation as well as improves the appetite following surgery (Pandula siriaddana

2009), to get the long term success of the procedure, the modified early ambulation

intervention should made as mandatory for patients undergoing abdominal surgery.

The modified early ambulation intervention shown significant changes in the

postoperative recovery, it positively influence and improves the postoperative recovery

and also physical, functional and psychological wellbeing after surgery will be of greater

advantage to the patient. Moreover it forms a holistic approach that helps to maintain

health of patients in study grouo. In this context, finding of this study that modified early

ambulation exhibit greater postoperative recovery and higher performance of activities of

activities of daily living than control subjects during the initial period of recovery after

surgery is noteworthy. The modified early ambulation intervention has 3 main steps

sitting in the bed, standing and limited walking and extended walking. The strong

motivation, great support and assistance is very much needed for the patient after

abdominal surgery.

Similar modified early ambulation intervention after abdominal surgery, related

perioperative protocols not only helps in reducing postoperative complications but also

enhancing the postoperative recovery and self-care capabilities. The nurse should

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 realize that modified early ambulation is very important tool for postoperative recovery.

The need for early ambulation should be thought to the patient in preoperative phase.

Therefore the modified early ambulation intervention after surgery should be an

established as a norm in the postoperative ward. The study findings clearly demonstrate

better patient outcomes attributable to the modified early ambulation.

6.5 IMPLICATIONS FOR NURSING EDUCATION:

The holistic approach to modified early ambulation following abdominal surgery

has better patient outcomes. Integration of modified early ambulation procedure into

nursing curricula would benefit the nursing students themselves. They in turn could

apply it in the clinical practice for the benefit of the patients too. Continuing nursing

educational programs may be organized for the faculty and practicing nurses to acquire

skills in modified early ambulation intervention.

Facilitating patients and family coping is one of the vital and integral components

of nursing care. Nurses must ensure that patients develop appropriate understanding

through application of patient education principles. The syllabus of medical and surgical

nursing should enable nursing students to do modified early ambulation during

postoperative period as a nursing procedure in the ward. Nurse educator should provide

adequate training and opportunity to the nursing students regarding modified early

ambulation.

6.6 IMPLICATIONS FOR NURSING ADMINISTRATION:

Modified early ambulation is the most significant general nursing act to prevent

postoperative complication. The commonly accepted postoperative benefits include a

decrease in venous stasis, stimulation of circulation, prevention of deep vein thrombosis

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 / pulmonary embolism, increase in muscle tone, coordination, independence and

improved gastrointestinal, genitourinary and pulmonary functions (Dirksen 2004).

Therefore modified early ambulation saves time and money and a more rapid turnover of

the patients per bed per month. The study assists the nursing administrative authorities

to initiate and carry out the early ambulation activities as effective preventive measure to

prevent postoperative complications.

The administration should take the initiate to organize in-service education

programme for nursing personnel skills in early ambulation. Also, the provision should be

made for money in the budget for various activities like in-service education, advance

training and conducting research in this field. In summary the in cooperation of this

modified early ambulation intervention can benefit patients and staff while at the same

time reducing hospital care costs.

6.7. LIMITATIONS:

In this study the subjects were selected using random sampling technique where

lottery method was applied in all the 150 samples taken, out of that every odd number

were grouped as study group and even number as control, the nature of this study

adhere to exclusive criteria such as who had undergone laparoscopic surgeries, patients

unconscious and disoriented. were not included in the study, no interventions were done

to the control group except getting informed consent to participate in the study but where

helped when was asked to do so.

The study population from Kempagowda Institute of Medical Sciences,

Bangalore. The study findings were limited to only the study group who had abdominal

surgeries. Selecting the study group, who can be ambulated (16, 24, 32, 40, 48 hours)

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 was a challenge, though the study group was located postoperatively and selected

based on anticipated postoperative timings as per the study. Ambulation was little harder

during 7pm to 7am since it will be disturbing normal routine activities of ward and

patients sleep therefore those timings were included in exclusion criteria.

6.7. RECOMMENDATIONS FOR FUTURE STUDIES:

1. A similar study can be conducted in other surgical postoperative patients such as

cardiac thoracic surgery, orthopedic surgery and gynecological surgeries.

2. A comparative study can be conducted between private set-up and government

set-up.

3. A similar study can be conducted with more variables like preoperative

education, psychological preparedness regarding early ambulation.

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