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PROFORMA FOR REGISTRATION OF DISSERTATION Paediatriac Nursing Sarvodaya College of Nursing, Bangalore – 560 079 MRS. MERLIN MARY MATHEW 1st year M. Sc. Nursing Child Health Nursing 2008-2010 Sarvodaya College of Nursing, Bangalore – 560 079 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, BANGALORE, KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1. NAME OF THE CANDIDATE & ADDRESS Mrs. Merlin Mary Mathew 1st Year M.Sc. Nursing Sarvodaya College of Nursing, 11/2, Agrahara Dasarahalli, Magadi Main Road, Bangalore – 560079. 2. NAME OF THE INSTITUTION 3. COURSE OF STUDY AND SUBJECT 4. 5. DATE OF ADMISSION OF COURSE TITLE OF THE STUDY Sarvodaya College of Nursing, Bangalore – 560079 1st Year M.Sc. Nursing (Child Health Nursing) 16-04-2008 “A Study On The Effect Of Guided Imagery On Post Operative Pain Among Children In Selected Hospitals, Bangalore.” 1 6. BRIEF RESUME OF THE INTENDED WORK Imagination is the ability to form mental images, or the ability to spontaneously generate images within one's own mind. It helps provide meaning to experience and understand to knowledge.Imagery is the most fundamental language we have. Everything we do, the mind processes through images. When we recall events from our past or childhood, we think of pictures, images, sounds, pain, etc. It is hardly ever be through words. Images aren't necessarily limited to visual but can be sounds, tastes, smells or a combination of sensations. The management of acute paediatric pain can be accomplished using a multimodal approach in which pharmacologic techniques and cognitive–behavioural approaches complement one another. Traditionally, health care practitioners have approached pain management in children and adults as an “either/or,” that is, pharmacologic interventions or “alternative” approaches, and specialties defined which approach and intervention were used. Imagery has been considered a healing tool in virtually all of the world's cultures and is an integral part of many religions. Navajo Indians, for example, practice an elaborate form of imagery that encourages a person to "see" himself as healthy. Ancient Egyptians and Greeks, including Aristotle and Hippocrates believed that images release spirits in the brain that arouse the heart and other parts of the body. They also thought that a strong image of a disease is enough to cause its symptoms. [1] Guided imagery is a way to use our powers of creative imagination, which can be much more immediate and effective than analytical thinking. Guided imagery is more than listening to relaxing sounds. It’s a learning process to listen to someone’s voice, 2 relax the breathing and consciously direct the ability to imagine. The effect of guided vivid imagery sends a message to the emotional control centre of the brain. From there, the message is passed along to the body’s endocrine, immune and autonomic nervous systems. These systems influence a wide range of bodily functions, including heart and breathing rates and blood pressure.[2] Pain is an unpleasant feeling and emotional experience related to injury or damage to child's body. It helps the child avoid more injury by warning him of the presence of a harmful thing. Pain is usually caused by trauma, disease, medical procedure, or surgery. It may cause other signs and symptoms in the child, such as an increased heart rate and blood pressure. Pain may get worse when the child thinks about it often, or when he is very sad because of his condition. The child may suffer if the pain is too bad and always present, or if it affects his usual activities. Pain can affect the child's appetite (ability or desire to eat), how well he sleeps, and his energy and ability to do things. 3 6.1. NEED FOR THE STUDY Management of pain in children is often inadequate and there is no evidence to support the idea that pain is less intense in neonates and young children due to their developing nervous system. Children tend to receive less analgesia than adults and the drugs are often discontinued sooner. Furthermore, it is simply not true that potent analgesics are dangerous when used in children because of the risks of side effects and addiction. As with all pain, successful management depends upon the identification and treatment of all the factors that contribute, in particular fear and anxiety. Non-pharmacological therapies for pain may help improve the child's feelings by making him more comfortable and relaxed. These treatments may help him as he goes through an illness, and also prevent other medical problems from happening. They involve methods such as teaching and guiding your child through thinking exercises and other techniques. These therapies may also be used before and after your child undergoes a painful experience, such as a medical procedure or surgery. They may bring comfort to your child during a long standing condition or illness. Guided imagery is a therapeutic technique that allows a person to use his or her own imagination to connect their body and mind to achieve desirable outcomes such as decreased pain perception and reduced anxiety. In guided imagery the child is taught to imagine that he is in his favorite place and doing his favorite things. By imagining that he is in his favorite place, he may feel safe and relaxed, and pain may be decreased. This may also take his mind off his pain. 4 When children undergo surgery they often experience a loss of control and feel they become a victim instead of a participant. Their emotions may be disarray. Anxiety, fear of the unknown, fear of pain, dependency, uncertainity and helplessness are prominent. These emotions can intensify the perception of pain associated with invasive medical procedures. Physical and psychologic stress contribute to perceived surgical pain, prolonging postoperative recovery time and enhancing immunosuppression. Guided imagery uses audio tapes to create mental images that bring about a state of focused concentration. This state, in turn allows relaxation and produces a sense of physical and emotional well being. The ability to relax, to clear the mind, and to engage in healing images enhances both physiologic and psychologic wellness. In this way, guided imagery can help patients control their reactions to anxiety depression, and stressful situations and may also strengthen the immune system, which potentially also strengthen the immune system, which potentially enables patients to enhance their own healing.[3] Clinical studies have also shown that children who use relaxation and guided imagery have fewer complications, reduced bleeding, are more comfortable after surgery, and spend less time in the hospital. Pre-operative preparation for paediatric surgical patients has been found helpful in improving children following instructions in the hospital. It can also reduce problems at home after the surgery. Reducing children’s anxiety, and increasing their sense of control is also beneficial – leading to shorter hospital stays, shorter procedure time, and less need for some medications.[4] A study conducted on children who have successfully used hypnosis/guided imagery to significantly reduce the pain associated with invasive procedures and to 5 improve selected medical conditions. The purpose of this study was to examine the effect of hypnosis/guided imagery on the postoperative course of paediatric surgical patients. Fifty-two children (matched for sex, age, and diagnosis) were randomly assigned to an experimental or control group. The experimental group was taught guided imagery by the investigator. Practice of the imagery technique included suggestions for a favourable postoperative course. Significantly lower postoperative pain ratings and shorter hospital stays occurred for children in the experimental group. State anxiety was decreased for the guided imagery group and increased postoperatively for the control group. This study demonstrates the positive effects of hypnosis/guided imagery for the paediatric surgical patient.[5] Paediatric nurses are often present with children who are in discomfort or pain, and are essential to successful management of this pain. Selected nonpharmacologic techniques are effective in reducing children's discomfort and pain, and thus have value in nursing practice. Considering the positive effect of guided imagery in postoperative children the researcher felt it necessary to conduct this study and to relieve pain. HYPOTHESIS H1 There is a significant reduction in the degree of post operative pain among children in the experimental group than the control group. 6 6.2REVIEW OF LITERATURE The review of literature is a summary of current knowledge about a particular problem and includes what is known and not known about the problem. The literature is reviewed to summarize knowledge for use in practices or provide a basis for conducting the study. An experimental study was conducted recently to investigate the effect of guided imagery on 130 patients undergoing colorectal surgery. A control group received standard surgical care. Another group listened to a guided imagery tape to help them become calm and focused. The guided imagery tape included soft, soothing music, and a story that brought patients to a "special place" in their mind - a place that was safe, secure, protected, supported, and relaxed. The imagery story encouraged patients to confront and work through any feelings of fear, anxiety, and negativity. Patients were instructed to listen to the tape without interruption twice per day, once in the morning and once in evening, for three days before the operation and for six days after. During surgery and in the recovery room they listened to a tape with only the music. Those who listened to guided imagery tapes fared much better--both before and after surgery. Before surgery, anxiety increased in the control group but decreased in the guided imagery group. After surgery, pain and anxiety levels were significantly lower for the imagery patients. They needed only about half the amount of narcotic pain medications as the control group and their bowel function also returned much more quickly.[6] A questionnaire survey was conducted on Acute and postoperative pain in children. All anesthesia, ENT, surgery, pediatric surgery, orthopedic, general pediatric and plastic surgery departments were sent questionnaires to sample both nurse and 7 physician perspectives of acute pain in children. The response rate was 75%. Reasons for inadequate management most often mentioned were inadequate prescription, children's anxiety, and parents' fears. Pain assessments were regularly performed in 43% of departments and 74% of departments had access to a doctor who worked at least part time on pain management.[7] A study was conducted to investigate the effectiveness of imagery, in addition to routine analgesics, in reducing tonsillectomy and/or adenoidectomy pain and anxiety after ambulatory surgery and at home. Seventy-three children, aged 7–12, were recruited from five AS settings. Thirty-six children randomly assigned to the treatment group watched a professionally developed videotape on the use of imagery and then listened to a 30-min audio tape of imagery approximately 1 week prior to surgery. They listened to only the audiotape 1–4 h after surgery, and 22–27 h after discharge. The 37 children in the attention-control group received standard care. Pain and anxiety were measured at each time-point in both groups. Measures of sensory pain were the Oucher and amount of analgesics used in AS and home; affective pain was measured with the Facial Affective Scale. Pre-operative preparation for paediatric surgical patients has been found helpful in improving children’s following instructions in the hospital. It can also reduce problems at home. Reducing children’s anxiety, and increasing their sense of control is also beneficial – leading to shorter hospital stays, shorter procedure time, and medications.[8] A study to test the efficacy of imagery and relaxation in hospitalised children's postoperative pain relief was conducted. Sixty children aged 8-12 years who had undergone appendectomy or upper/lower limb surgery and had been randomly assigned to the experimental group listened to an imagery trip CD, whereas those in 8 the control group received standard care. An investigator-developed questionnaire was used, and the intensity of pain was assessed using a visual analogue scale: before, immediately after, and 1 hour after intervention or standard care. The children in the experimental group reported having significantly less pain than the control children based on a comparison of VAS pain scores. There were no significant differences in nurse-assessed pain scores. The type and time of operation were related to pain intensity in children. The nurses underestimated the pain of paediatric patients. The imagery trip CD can be used to reduce children's postoperative pain in a hospital setting, although its effect is short lasting.[9] A study was conducted on Guided imagery, which uses the power of thought to influence psychologic and physiologic states. Some studies have shown that guided imagery can decrease anxiety, analgesic requirements, and length of stay for surgical patients. Group 1 received standard perioperative care, and Group 2 listened to a guided imagery tape three days preoperatively; a music-only tape during induction, during surgery, and postoperatively in the recovery room; a guided imagery tape during each of the first six postoperative days. Both groups had postoperative patientcontrolled analgesia. All patients rated their levels of pain and anxiety daily, on a linear analog scale of 0 to 100. Guided imagery significantly reduces postoperative anxiety, pain, and narcotic requirements of colorectal surgery and increases patient satisfaction. Guided imagery is a simple and low-cost adjunct in the care of patients undergoing elective colorectal surgery.[10] 9 6.3.OBJECTIVES OF THE STUDY 1. To assess the degree of pain on post operative chidren in the experimental and control group. 2. To compare the post operative pain between experimental and contol group after guided imagery. 3. To find out the association between degree of pain and selected demographic variables among experimental group and control group. OPERATIONAL DEFINITION Effect : It refers to the extent to which the guided imagery has achieved the desired effect in reducing the pain in post operative children as assessed by pain scale. Guided Imagery: It refers to an audio assisted relaxation and stress-reduction technique which uses positive thoughts and images to relieve pain, slow the heart rate, and stimulate the body's healing responses used in two sessions for three consecutive days from the first day after surgery. Post Operative : It refers to children between 11- 18 years who under went major surgery of Gastro- intestinal, cardiac and musculoskeletal system on the first day of surgery. VARIABLES Independent Variable - Guided Imagery Dependent variable -Post operative pain 10 Demographic Variable - Age -Sex -Type of surgery -Education -Source of information 7.MATERIALS AND METHODS 7.1SOURCE OF DATA Data will be collected from children who have undergone surgery in selected hospitals Bangalore. 7.2METHODOLOGY OF THE STUDY i. Research design -True Experimental Design ii. Sample - Children who have underwent major surgeries on Gastro-intestinal, cardiac and musculoskeletal system. iii. Sample criteria Inclusion Criteria 1. Children with post operative pain who have underwent major surgeries on Gastro- intestinal, cardiac and musculoskeletal system 2. Who are willing to participate 3. Who are available at the time of study 11 4. Who can speak and understand English 5. Children between the ages of 11- 18 years Exclusion Criteria 1. Children who are physically and mentally disabled. 2. Children who are not willing to participate. 3. Children who cannot speak or understand English iv. Sample technique - Simple Random Method v. Sample size - 30 control and 30 experimental group vi. Method of data collection - Self Administered Rating Scale vii. Tool for data collection - Numerical Pain Scale viii. Method of data analysis - The researcher will use appropriate statistical technique for data analysis and present in the form of tables, graphs and diagrams Frequency and percentage distribution will be used for the demographic profile. Students t test will be used to compare the postoperative pain between the experimental and control group. Chi- Square will be used to determine the association between the postoperative pain and selected variables. ix. Duration of the study -4 weeks 12 7.3Does the study requires any investigation or intervention to be conducted on the patient or other human beings or animals? No 7.4Has ethical clearance has been obtained from your institution YES, ethical clearance report is herewith enclosed. 13 LIST OF REFERENCE: 1. Wikipedia The Free Encyclopedia (online); (cited on 2008 October 3): Available on: URL://www.en.wikipedia.org/wiki/imagination 2. UCL Institute of Child Health Research and Development (online) (cited on 2008October3) Available URL:http://www.ich.ucl.ac.uk/research_and_development 3. Alternative therapies (online) (cited on 2008 October 2): Available on: URL:http://holisticonline.com/guidedimagery 4. Victoria Menzies; Ann Gill Taylor, Cheryl Bourguignon. The Journal of Alternative and Complementary Medicine, January 1, 2006,12 (1), 23-30(cited on 2008 September 24). Available on URL:http://www.liebertonline.com/doi/abs/10.1089/acm.2006.12.23. 5. Lambert SA, “ The Effect of Hypnosis\ Guided Imagery on the Post Operative Course of Children”. J Dev Behav Pediatr: 1996 Oct; 17(5): 307-10. Cited on (2008 September 30): Available On: URL:http:www.pubmed.com 6. David.S. Sobel “ Guided Imagery Speeds Surgical Recovery”. Institute for the Study of Human Knowledge. 1998; (cited on 2008 September 25): URL:http://www.healthy.net/scr/Article.asp?ID=414 7. Karling M, Renstorm M, Lyungman G, “ Acute and post operative pain in children” Blackwell Synergy- scand J caring science. Volume 17.Issue 4.Page 373(cited on 2008 September 24) Available on URL.http.//www.Blackwellsynergy.com/doi/abs/10 14 8. Huth. M. Broome, M. Good. “ Imagery reduces Children’s Post-operative Pain”. Health Science Journals, Volume 110, Issue 1-2, Pages 439-448. (Cited on2008Sept21) Available from: URL: http://www.linkinghub.elsevier.com/retrieve/pii/s0304395904002009. 9. Diane.L.Tusek, James. M. Church, Scott.A.Strong, Jeffrey. A. Grass and Victor. W. Fazio. “ Guided Imagery A Significant Advance In The Care Of Patients Undergoing Elective colorectal Surgery”. Diseases of the Colon and Rectum: Springer New York. Volume 40, number 2 1997. Feb: 172-178. Available from URL: http://www.linkinghub.elsevier.com/retrieve/pii/S0304395904002209 10. Polkki T, Pietila AM, Vehvilainen Julkunen K, Laukkala H, Kiviluoma K. “Imagery-induced relaxation in children's postoperative pain relief: a randomized pilot study.” J. Pediatr Nurs. 2008 June; 23(3): 217-24. (Cited on 2008 September 21) Available From URL:http://www.pubmed.com. 15