Factors related to postoperative symptoms among patients undergoing abdominal surgery – Nguyen Hoang Long

Journal of military pharmaco-medicine n o 3-2018 128 FACTORS RELATED TO POSTOPERATIVE SYMPTOMS AMONG PATIENTS UNDERGOING ABDOMINAL SURGERY Nguyen Hoang Long* SUMMARY Objectives: This study aimed to identify postoperative symptoms and related factors during the first three days after abdominal surgery. Subjects and methods: Data was collected from 147 patients undergoing elective surgery evaluating by Hospital Anxiety and Depression Scale, Multi-Dimensional Social Support Scale and the Memorial Symptom Assessment Scale in pre-operation and three consecutive days of post-operation. Results: The results identified seven symptoms occurred, including pain, tiredness, sleeplessness, abdominal distension, urinary retention, anxiety, and dizziness. The overall mean score of symptoms was high on the first day then was decreased on the two following days. On the first day, symptoms were correlated to age (r = -0.25, p < 0.01), length of operative procedure (r = 0.48, p < 0.01), incision length (r = 0.27, p < 0.01), and preoperative anxiety (r = 0.16, p < 0.05). On the second day, only length of operation time significantly related to symptoms (r = 0.48, p < 0.01). On the third day, there were age, length of operative procedure, and incision length associated with symptoms (r = -0.18, 0.30 and 0.31, respectively). Conclusion: Post-operative symptoms need to be managed properly. Nurses should prioritize their symptoms management program to elderly patients as well as ones with long incision and long operative time. * Keywords: Abdominal surgery; Postoperative symptoms; Unpleasant symptoms; Related factors. INTRODUCTION Worldwide studies have repeatedly reported a high incidence of unpleasant symptoms following surgery [1]. From the same point of view, researchers interested in abdominal surgery demonstrated that symptoms following this type of operation were very problematic. For instance, 51% to 95% of patients reported suffering from at least moderate pain; 92% complained about the increase in fatigue after operation; 20% demonstrated a high level of postoperative anxiety [2]. Some even asserted that abdominal surgery was the most painful of all operative procedures [3]. Paradoxically, since it involves in treatments for many of the organs, abdominal surgery might be the most frequent operative procedure. It is evident that symptoms after operation prolong recovery, increase complication, lower patient satisfaction with health care service, and diminish quality of life [1, 4]. In theory, symptoms are determined by various variables, classified as physiological, psychological, and situational factors [5]. * Vinmec Hospital Corresponding author: Nguyen Hoang Long (long.51@hotmail.com) Date received: 30/12/2017 Date accepted: 28/02/2018 Journal of military pharmaco-medicine n 0 3-2018 129 Nevertheless, there is no general agreement about the relationships among variables such as age, gender, preoperative anxiety, the severity of operations, etc., and postoperative symptoms across studies [2, 3, 4, 6]. The disagreements in findings among previous studies reflected the complexity in determining which factors and how those variables related to an individual’s symptom experience. This research aimed to identify the prevalence of symptoms occurring in 72 hours postoperatively and to examine relationships among factors, including age, gender, social support, length of operative procedure, incision size, pre-operative anxiety and postoperative symptoms among those who undergo abdominal surgery. * Conceptual framework: The theory of unpleasant symptom [5] provided a theoretical reasoning for the present study. Lenz and colleagues assumed that every symptom manifests itself in four dimensions: intensity, duration, quality, and distress. Symptoms may either occur alone or simultaneously, and a certain symptom can precede the occurrence of one other. Symptom experience consequently,. results in the alteration in performance of an individual. Adversely, symptoms are determined by a mixture of factors impacted on how an individual perceives and experiences a symptom. SUBJECTS AND METHODS A correlational descriptive design was used. 147 patients undergoing major elective abdominal surgery were recruited from three teaching hospitals located in Hanoi, Vietnam. Data were collected by structured interview four times. Firstly, on the day before surgery, pre-operative anxiety was evaluated by the Hospital Anxiety and Depression Scale (HADS-A) [7]. Then, postoperative symptoms were measured for three days by the modified Memorial Symptom Assessment Scale (MSAS) [8]. On the third day after surgery, social support was examined by the Multi- dimensional Support Scale (MDSS) [9]. The internal consistency of the instruments was calculated. The Cronbach’s alpha for the HADS-A, MSAS, and MDSS were 0.89, 0.79, and 0.74, respectively. RESULTS AND DISCUSSION Table 1: Symptom occurrences, and symptom scores during three days after surgery (n = 147). 1st day 2nd day 3rd day Freq. (%) x (SD) Freq. (%) x (SD) Freq. (%) x (SD) Total scores (0 - 84) 40.47 (5.16) 26.33 (5.03) 19.16 (3.63) Pain 147 (100%) 9.14 (0.79) 147 (100%) 7.15 (1.30) 147 (100%) 4.55 (0.82) Tiredness 147 (100%) 8.80 (1.27) 147 (100%) 6.61 (1.19) 147 (100%) 4.93 (1.19) Sleeplessness 147 (100%) 9.23 (1.57) 147 (100%) 6.22 (1.16) 147 (100%) 4.65 (1.03) Journal of military pharmaco-medicine n o 3-2018 130 Abdominal distension 147 (100%) 5.88 (2.19) 47 (32%) 0.8 (1.23) 0 (0%) 0 Urinary retention 132 (89.8%) 5.60 (2.61) 44 (29.9%) 0.85 (1.43) 0 (0%) 0 Anxiety 79 (53.7%) 1.78 (1.83) 111 (75.5%) 2.86 (2.07) 63 (42.2%) 1.59 (2.09) Dizziness 2 (1.4%) 0.03 (0.29) 104 (70.7%) 1.84 (1.31) 128 (87.1%) 3.45 (1.87) The findings identified seven symptoms existed during 72 hours after surgery, including pain, tiredness, sleeplessness, abdominal distention, dizziness, urinary retention, and anxiety. Notably, while pain, tiredness, and sleeplessness presented in all patients along three days, abdominal distention and urinary retention occurred in only the first two days. The overall mean score of symptoms on the first day, the second day, and the third day were 40.47 (S.D = 5.16), 26.33 (S.D = 5.03), and 19.16 (S.D = 3.63), consecutively. Most of the symptoms reduced gradually. However, dizziness constantly increased during three days. Anxiety increased in the second day, but then decreased in the third day. During three days, pain remained as one the most severe symptoms. This finding reinforced the problematic presence of pain reflecting that postoperative pain management was still suboptimal [3, 6]. The findings revealed significant relationships among pain, tiredness, and sleeplessness along three days (correlation coefficients ranged from .19 to .64). Cluster analysis suggested that these symptoms could be grouped as the cluster occurred during three postoperative days. Lenz et al (1997) assumed that the accumulate effect of multiple symptoms is not, and more problematic than a “simple” combination of those individual discomforts [5]. Thus, the coexistence of pain, tiredness and sleeplessness highlights a need for a proper symptom management. It also recommends that these symptoms should be included together in all nursing assessment, planning, and implementing therapeutics. Although previous studies demonstrated that dizziness generally reduced after increasing in the second day [1], this study found it continuously increased during three days. Possibly, this difference resulted from the delay in early ambulation of the current sample. Despite patients were recommended to ambulate since the second day after operation, they tended to start later because of pain, tiredness and the worry about incision stability. Therefore, both the number of persons involving in and the volume of ambulation activities increased from day to day. Consequently, because of the mobilization patients felt dizzier. This study pointed out that anxiety increased on day two and then decreased on day three after operation. Probably, on the second day, symptoms had generally decreased but still remained high severity. Thus, patients felt more anxious. However, on the third day, when patients got better and symptoms were significantly relieved, anxiety decreased. For the independent variables, it was shown that 53.1% of the sample was males and the mean of age was 55.2 years (SD = 15.06). The average duration of Journal of military pharmaco-medicine n 0 3-2018 131 operations was 153.3 minutes (SD = 50.10); and the mean length of incision was 15.7 cm. Additionally, patients reported a mild level of preoperative anxiety (mean = 6.9, SD = 3.4). The mean of social support score was 13.8 (SD = 3.2). Table 2: Pearson correlation coefficients among independent variables and total symptom scores in three days (n = 147). Total symptom scores The first day The second day The third day Age -.25(**) -.08 -.18(*) Gender .02 -.01 .10 Length of operative procedure .48(**) .48(**) .30(**) Incision length .27(**) .10 .31(**) Pre-operative anxiety .16(*) -.05 -.01 Social support (total) -.01 -.001 .05 (** Correlation is significant at the 0.01 level (1-tailed); * Correlation is significant at the 0.05 level (1-tailed)) There were small to moderate positive associations among duration of operative procedure, incision length and postoperative symptoms. In some degree, these two factors could be used as the representative of the operation’s severity. When the operation is more severe, consequently, symptoms occurred more problematically. Similar to incision length and operation length, anxiety prior to surgery was found to be positively associated with postoperative symptoms on the first day (r = 16, p < .05). This stressed that psychological factors should not be neglected in symptom management. Furthermore, it also suggested that patients might benefit from nursing intervention alleviating pre-operative anxiety with regard to reduce postoperative symptoms. Age is negatively related to postoperative symptoms. The finding was in agreement with another study by Kalkman et al (2003) [3]. However, this result did not imply that nurses can under-consider symptoms among elderly individuals. In fact, it highlights that nurses should assess the old patients more carefully since the presence of symptoms in this population is easily to be overlooked. While previous studies asserted significant relationships among gender, social support and postoperative symptoms [3], this study had failed to confirm these associations. It reflected a complexity in determining the roles of factors related to symptom experiences. In addition, it was recommended that the effectiveness of support from others should be improved to cushion patients’ postoperative symptoms. CONCLUSION AND RECOMMENDATION This study figured out the problematic presence of symptoms occurred the early time after abdominal surgery. The roles of severity of operation, age and preoperative anxiety in relation with post-surgery symptoms had also been proven. These findings pointed to the need of a proper symptom management for post-surgery population. Further investigations on symptom experience and symptom management in this population are also recommended with regard to enhancing the treatment outcomes. Journal of military pharmaco-medicine n o 3-2018 132 RERERENCES 1. Rosén H, L Clabo, L. Matensson. Symptoms following day surgery: A review of the literature. Journal of Advanced Perioperative Care. 2009, 4 (1), pp.7-18. 2. Carr E et al. Patterns and frequency of anxiety in women undergoing gynaecological surgery. Journal of Clinical Nursing. 2006, 15, pp.341-352. 3. Kalkman C et al. Preoperative prediction of severe postoperative pain. Pain. 2003, 105, pp.415-423. 4. Mace L. 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