Effect of Early Ambulation on Reducing Respiratory Tract Infection among Postoperative Elderly Patients with Abdominal Surgeries

Introduction

Surgical procedures are now more common in the elderly because of longer life expectancies and enhanced surgical safety. Fifty percent of individuals older than 65 years undergo surgical procedures during their remaining years. Abdominal surgery is one of the most common operative procedures performed among the elderly surgical patients including both emergency and elective surgical interventions which constituted  36 % (Chen et al., 2011).

Age-related physiological changes which include decrease in cognition, cardiac, respiratory, renal functions and other co-morbidities, as well, dependence on activities of daily living and frailty are interrelated and overlapping. These interplaying factors work to demand multifaceted care in an elderly surgical patient. (Tan &Chua, 2013)

 The primary concerns of the postoperative nursing care and monitoring for the hospitalized elderly patients in the general surgical units at the initial hours postoperative involves; adequate ventilation, hemodynamic stability, incisional pain control , preventing nausea and vomiting, assessing the neurological status, prevention from fall, surgical site integrity, dressing, ensuring  tubes and lines are well secured, and amount of drainage, and spontaneous voiding, as well as, assessing capillary refill time, percentage of oxygen administration, oxygen saturation using pulse oximetery, intake and  output charts , bowel sounds, performing respiratory exercises etc.,…. (Griffiths, 2014)

Postoperative respiratory tract infection (RTIs) are more common in elderly surgical patients with abdominal surgery due to lack of lung inflation that occurs due to change of breathing pattern, prolonged recumbent positioning, also, adds to impairment of mucociliary clearance with decrease cough effectiveness and increase risk associated with retained pulmonary secretions. In addition to, anaesthesia, opioids, analgesics and post-operative pain, they also contributes to change in ventilation pattern. (Masse, 2017)       

To decrease the incidence of these complications, several studies highlighted that, practicing postoperative early ambulation  in elderly patients with abdominal surgery promotes clearance of thick secretions and production of surfactant, improving lung expansion and decreases hypoventilation. As well as responsible for 71% reduction of postoperative RTIs  Chatterley, L. (2017). It also gives positive results on both physical and psychological status and help elderly to return to their activities of daily living within a shorter period of time (Sabate, 2014).

Significance of the study:

Abdominal surgeries are among the most common operations performed in older patients. Postoperative RTIs are more prevalent in elderly patients with this type of surgery, with incidence varying from  6% to 80% (Bustamante, et al., 2017). Early ambulation play an important role in mobilizing bronchial secretion, improving oxygenation and reducing postoperative RTIs.

Aim of the Study

The aim of the present study was to evaluate the effect of early ambulation on reducing the respiratory tract infection among postoperative elderly patients with abdominal surgeries.

Research hypothesis

Using early ambulation for the studied group would reduce  the  respiratory tract infection  among postoperative elderly patients with abdominal surgeries than control group.

Subjects and Methods

Research design

Quasi-experimental research design was utilized in the current study.

Setting:

The current study was carried out at the general surgery departments (A and C) at Minia University Hospital.

Sample and sampling:

Convenient sample of 80 elderly patients male and female were collected through one year,  and they were classified equally into two groups; study group (n =40) who performed early ambulation and control group (n =40).

Inclusion criteria:

• Patients had 60 years old and more.
• Patients with elective abdominal surgeries performed by conventional laparotomy.
• Both gender.

Exclusion criteria:

• Patient's with neuropsychiatry diseases.
• Patient with preoperative respiratory tract infections, COPD and asthma.
• Patient with emergency abdominal surgeries.
• Patients with uncontrolled postoperative  complications.
• Patients with uncontrolled chronic disease.
• Immobilized patient.

Setting:

The current study was carried out at the general surgery departments (A and C) at Minia University Hospital. 

Tools of data collection: - three tools were used:

Tool I:  Patient interview structured questionnaire. It covered two main parts:

• Part I; The bio-socio-demographic data of the patients which included   (age, gender, level of education, and………..etc.
• Part II; The medical and surgical patient's assessment data  included:  Past and present medical data such as; history of smoking, recurrent chest infections, and date of admission, diabetes, hypertension, and ect,....  The current surgical data such as;  surgical diagnosis, absence or presence of NGT, postoperative analgesia, ect,….

Tool II: Patient's physical and respiratory assessment that included :

• Measuring vital signs as temperature, pulse, respiration.
• Respiratory assessment such as  chest sounds, oxygen saturation,  RTIs manifestations as cough, sneezing, runny nose, sore throat, and etc….

Tool III: Early ambulation record:

• Used  to record frequency of early ambulation step such performance as ankle planter flexion, getting out in bed, sitting, standing, waking in room and corridor.

Tools validity:-

Content validity was done to identify the degree to which the used tools measure what was supposed to be measured. The developed tools were examined by a panel of three experts opinion in the field of the study {Minia University - faculty of nursing (Medical Surgical Nursing Department)} All jury members (100%) agreed that current study tools were valid and relevant with the aim of the study. 

Tools reliability:

Intraclass correlation coefficients at baseline and follow up was performed  for reliability testing internal consistency for the modified Medical Research Council dyspnea scale were 0.84 - 0.90.

Pilot study:

A pilot study was carried out on  10% (n = 8)   of the total sample to test the clarity of tools and estimate the time required for fulfilling it. Based on results of the pilot study no modifications or refinements were done and the subjects included to the actual sample.

Ethical Considerations:

An official permission to conduct the study was obtained from the Ethical committee in the Faculty of Nursing, Dean of nursing faculty and the Manager of Minia University Hospital, the Head of the General Surgery Departments ( A and C) and agreement from Egypt academic for research center and technology. to carry out this study. Subject's participation in this study was voluntary and  each involved subject was informed about the purpose, procedure, benefits, and nature of the study, and that he/she had the right to withdraw from the study at any time without any rationale, then oral consents were obtained. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data. Subjects were informed that obtained data will not be included at any further researches without a second oral consent.

Educational training practices about the postoperative early ambulation formulated by the researchers after revising extensive relevant literature review such as (Tariq, 2017) &  (Castelino, 2016,), and other information from websites. They were applied to reduce the postoperative RTIs among elderly patients with abdominal surgeries. They  included Arabic photo brochure.

The researchers asked the participants to ambulate as soon as possible for at least 2 hours on day of surgery, and after that, ambulated for six hours per day  till the  5th postoperative day.  Some assistance were provided to them  to maintain safety. Duration of ambulation according to the elderly patient's tolerance.  Early ambulation involved ankle planter flexion, getting out in bed, standing, walking in room, walking in corridor, stair climbing, and  side lying  position. Early ambulation record was designed to record frequency of early ambulation steps performed by the participants in the study group from the 1st to the 5th postoperative day.

Ankle planter flexion: Bend and stretch the ankles up and down firmly and quickly (repeat 10 times) Figure (1).

Figure (1) Churchill surgical physiotherapy team, (2018).

Getting out in bed: (figure: 2 ,3,4)

Step 1: Roll onto your side, with your knees bent.                             

Step 2: Move your feet off the bed. Push your body up to a sitting position.

Step 3: Sit on the side of the bed before you stand up. (Churchill surgical physiotherapy team, 2018)

Sitting:

Sit upright in a supportive chair, if possible, with both feet on the floor. Do not slouch. You may find it helpful to place a small cushion or rolled towel in the small of your back. (10 minutes recommended) . ( Churchill surgical physiotherapy team, 2018)

Standing or walking:

• Starting to walk after surgery must be slowly to avoid feeling dizzy or faint  when first  getting up after surgery:
• Dangle at the bedside for a few minutes
• Move from the bed to a chair
• Walk in the hallways for  20 minutes or according to patient tolerance. (Churchill surgical physiotherapy team, 2018)

Procedure:

• The current study was conducted by preparing of different data collection tools, in addition to, obtaining formal paper agreement which was taken in duration one week before conducting the current study. The researchers act their collection of  the current  study data from its setting  on daily basis (along the 1st five days postoperative) during morning or afternoon shifts over a period of one year starting from mid July 2016 to mid-July 2017.
• The researchers started data collection from the control group firstly at the first six months of the study duration by using the three tools; Tool I: patient interview structured questionnaire & Tool II: physical and respiratory assessment sheet, Tool III: early ambulation record, then data collection from the study group started at the second six  months  of the study duration by using the same three tools before and after they applying  early ambulation steps.
• Preoperative training  about early ambulation over a period of two or three days was done by the researchers to each participant in the study group  individually through face to face interview to follow the prescribed instructions. The number of total sessions during training them average from 2-3 sessions varied according to each participant understanding, and every session lasted 30-45 minutes. The demonstration and re-demonstration was done by the study group to ensure that the participant can perform this procedure perfectly.
• Each participant was informed by the researchers to perform and repeat early ambulation daily from the 1st to 5th day postoperative. After that, the researchers performed respiratory assessment daily after the participant practiced early ambulation by using the second and third tools (physical and respiratory assessment sheet and early ambulation record)
• On the other hand; the researchers trained the internship nursing students as co-researchers who had shift in the same study setting to follow up the study group who was applied early ambulation in accurate time during specific work shift to ensure that the elderly patients perform the procedures when the researchers not found, as elderly surgical patients were considered critically ill and easy forget, so, they need close observation to perform the procedures.

Statistical analysis of data:

Data were summarized, tabulated, and presented using descriptive statistics in the form of means and standard deviations as a measure of dispersion. A statistical package for the social science (SPSS), version (20) was used for statistical analysis of the data, as it contains the test of significance given in standard statistical books. Qualitative data were expressed as percentage. Correlation coefficient was done by using Pearson correlation test. Fisher's Exact test is a way to test the association between two categorical variables. when in case of  small cell sizes (expected values less than 5). Chi-square test is used when the cell sizes are expected to be large.

Results

Table (1): Distribution of the study and control groups regarding their Socio demographic characteristics (n = 80)

NS= not significant

Table (1): Showed that, the mean age among study and control groups  was nearly similar (63.9 ± 2.1 years, and 62.8 ± 2.0 years) respectively. In respect to gender; The results revealed that 55% of the study group were  female while 65 %  of the control group were male.  Concerning to educational level; the study data demonstrated that, 47.5 %  of the study group were illiterate. While,  17.5% of them were basic education. Lastly ; the findings displayed  that, 55%, 35 % respectively among the study and control groups were house wives. There were no statistical significant differences between both groups in relation to socio demographic characteristic.

Figure (1): Distribution of the  type of surgery among the study and control groups (n= 80).

Figure (1): illustrated that, 50%  of both groups were performed  cholecystectomy.

Table (2):- Comparison between the study and control groups regarding to auscultatory breathing sound in the 1st five days  postoperative (n= 80).

** highly statistical significance differences

Table (2):- Represented that, 100 %,100 %, 92.5 %, 87.5 %, 87.5 % respectively of  the study group had clear chest sound  along the 1st five  days postoperatively, in comparing with, 100% of  control group had clear chest sound only at the 1st  and 2nd  days postoperatively and in the rest of days was had  crackles. There were high statistical significant differences between the both groups regarding to breathing sound in which p-value = .000**

Table(3):- Comparison between the study and control groups regarding to RTIs manifestations through the 1st five days postoperative (n= 80).

                         * statistically significance differences   ** highly statistical significance differences

                            RTIs = Respiratory tract infections.

Table (3):-  Showed that, 12.5% of the study group had abnormal respiratory manifestations & positive chest x-ray findings, in contrast to, 85.0% of the control group had abnormal respiratory manifestations & positive chest x-ray findings with other manifestations constituted  60%, 62.5%, & 62.5%  respectively. There were high statistical significant differences among  both  groups regarding the manifestations of RTIs, in which P-value = .000**, .027*, .021*

Table (13):- Correlation between the socio-demographic data and  RTIs manifestations  at the 1st  five days postoperative (n= 80).

* statistically significance differences          ** highly statistical significance differences

   RTIs = Respiratory tract infections.

Table (13):- Founded that, there was a strong negative correlation (.903-, .222-) between the study group' average age & gender and  RTIs manifestations with statistical significant differences (P – value=.020*, .198*) respectively. While,  there was a strong positive correlation (.789, .779) between the control  group' average age & gender and  RTIs manifestations with statistical significant differences (P – value=(.008**, .023 *). As well,  results revealed that, there was  weak positive correlation (.129, .627, .275, .450, .162, .148)  respectively among both  groups between the rest of their socio-demographic data and  RTIs manifestations.

Table (4):- Correlation between frequency of early ambulation steps and peripheral oxygen saturation measurements at the 1st  five days postoperative (n= 80).

*statistically significance differences          ** highly statistical significance differences

Table(4):- displayed that,  there was a statistical significant positive correlation among both groups between all items of frequency of early ambulation steps  and normal peripheral oxygen saturation measurements.

Table (5):- Correlation between RTIs manifestations and frequency of early ambulation steps along the 1st  five days postoperative (n= 80).

* statistically significance differences                                                   ** highly statistical significance differences

                          RTIs = Respiratory tract infection   

Table (5):- Showed that, there was a strong negative correlation among the study group between absence of  all RTIs manifestations items and high frequency of early ambulation steps performance with highly statistical significance differences , while, reverse results with the control group.