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EFFECTIVENESS OF PREOPERATIVE PATIENT ASSESSMENT
BY PERIOPERATIVE NURSES IN PREPARATION FOR
SURGICAL INTERVENTION
AT STUDY AT KENYATTA NATIONAL HOSPITAL, NAIROBI,
KENYA
OMONDI LILIAN ADHIAMBO
MScN, BScN, KRPoN
A PROPOSAL SUBMITTED IN PARTIAL FULFILMENT FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY OF UNIVERSITY OF
NAIROBI.
JUNE, 2010
DECLARA TION
This thesis proposal is my original work and has not been presented in any other
institution for examination
Sign ~ .
IS'H -ju rv £ ~ 0 I 0Date .
CERTIFICATE OF APPROVAL
The proposal has been developed under supervision and approval ofthe following
Supervisors;
1. Dr. Grace Omoni.
Senior lecturer School of Nursing Sciences, University of Nairobi
..~ .
2. Dr. Mary Wangari Kuria. (PhD, Psychiatry UoN, MMed Psych UoN, MBChb UoN).
Lecturer, School of Medicine, department of psychiatry, University of Nairobi,
,,~~.t J~.~l0
11
DEDICATION
This work is dedicated and to my family for their continuous support and to the honor of
the late Professor Joyce Musandu for her inspirations.
111
ACKNOWLEDGEMENT
I am very grateful to my supervisors Dr. Omoni, Professor Ogendo and Dr. Wangare for
their devotion, moral and academic support.
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TABLE OF CONTENT
DECLARATION ii
CERTIFICATE OF APPRO VAL ii
DEDICATION iii
ACKNOWLEDGEMENT iv
TABLE OF CONTENT v
LIST OF FIGURES vii
OPERATIONAL DEFINITIONS viii
ABBREVIATIONS xi
ABSTRACT xii
CHAPTER 1: INTRODUCTION 1
Background Information 1
CHAPTER 2: LITERATURE REVIEW 4
Problem Statement 11
Justification 12
Research questions 13
Research hypothesis 13
Aim 14
Specific Objective 14
Theoretical frame work of the study 15
Conceptual Frame work of Nursing Perspective of Surgical Care 19
Flow of the Study 20
CHAPTER 3: STUDY METHODOLOGY AND MATERIALS 21
Phase One: Formulation of preoperative patient assessment tool 21
v
Phase 2: Evaluating the formulated tool for effectiveness 27
Phase 3: Testing the designed tool in enhancing anxiety reduction as a surgical
outcome 30
BUDGET 39
GANTT CHART 40
REFERENCES 41
APPENDIX 1: GUIDING QUESTIONS FOR THE WORKSHOP .45
APPENDIX 2: PREOPERATIVE CHECK LIST 46
APPENDIX 3: GORDON'S TYPOLOGY OF 11- FUNCTIONAL HEALTH 47
PATTERNS GUIDE LINES 47
APPENDIX 4: A DAMMY OF THE PREOPERATIVE ASSESSMENT TOOL 48
APPENDIX 5: AUTHORITY TO CONDUCT STUDy 51
APPENDIX 6: QUESTIONNAIRE EVALUATING THE DESIGNED
PREOPERATATIVE ASSESSMENT TOOL 52
APPENDIX 7: CONSENT EXPLANATION FORM 56
APPENDIX 8: FORM YA KIELELEZO CHA KIBALI 57
APPENDIX 9: PATIENT ANXIETY EV ALUATION 58
APPENDIX 10: APPENDIXMASWALIYASEHEMUYATATUYA UTAFITI; 62
UKAGUZI KUHUSU JINSI MGONJW A HANA VYOJIHISI KUHUSU HOFU YA
UP ASU AJI 62
APPENDIX 11: AMSTERDERN PREOPERATIVE ANXIETY INFORMATION 65
SCALE 65
APPENDIX 12: MAP OF KENYATTA NATIONAL HOSPITAL 66
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OPERA TIONAL DEFINITIONS
Amsterdam preoperative Anxiety and Information Scale a designed tool for
measuring situational worries of a surgical patient related to the surgical procedure,
anesthesia and desire for more information regarding the surgical process measure on a
five dimensional linkert scale. Modification of the tool includes component of hospital
bill repayment and family role play to suit the local situation.
Anesthesia is a deliberate creation of painless and muscle relaxation state by the
anesthetist to a surgical patient with or without loss of consciousness achieved by use of
drugs to ease the surgical process. Anesthetist is a medical doctor a nurse or a clinician
trained to administer anesthesia.
Anxiety is an emotional reaction elicited by stress, fear and worry of surgery. In the
study context, anxiety will be measured by the patient's perception of his/her anxiety
related to hospitalization, surgery and surgical outcome and the effect thereof on his/her
family using modified Amsterdam preoperative Anxiety and Information Scale (AP AIS).
Assessment in this context refers to preoperative evaluation of a surgical patient during
preoperative ward visit or upon reception to the operating room by the perioperative
nurses in order to complete the preoperative preparation while gathering data pertinent to
the planning of actual surgical care of the patient and documentation of such evaluation.
Checklist is a list of reference to verify specific items of preoperative preparation of a
surgical patient. It is usually filled in the surgical ward and completed when the patient is
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finally handed over to the theatre nurse receiving the patient. The list varies from hospital
to hospital although the key concepts are the same according to World Health
Organization (WHO) standards.
Collaborative health care refers to all healthcare personnel contributing their expertise
towards the care of a surgical patient for example, a radiographer and a plaster technician
in orthopeadic surgery.
Effective means ability to meet holistic need of the surgical patient and the entire surgical
team within a specified time frame and standard of care.
Elective surgery is scheduled or planned surgery.
Elective Cases are a category of patients scheduled for elective surgery
Emergency Surgery refers to surgery for a category of patients for immediate surgical
remedy failure to which morbidity or mortality ensues and preoperative preparation
protocol can be breeched.
Perioperative nurses are nurses working in theatre who care for the patients during the
three phases of surgery; preoperatively from the time patients are received in theatre and
before induction of anesthesia; intraoperatively from induction of anesthesia, during the
actual surgical procedure until the patient leaves the operating table; and postoperatively
from the time the patient leaves the operating table to Post Anesthetic Care Unit (PACU)
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until discharge to the ward or from the operating table and transfer to Critical Care Unit
(CCU).
Preoperative assessment tool is the assessment tool succinct to perioperative patient
care that will be designed by the peri operative nurses guided by perioperative objectives
for such assessment; the Association of peri-Operative Nurses (AORN) standards of
practice and practical experience. The tool will serve as a documentary evidence for such
assessment.
Preoperative visit is ward visit by a number of perioperative nurses usually done a night
or moments before elective surgery or in the receiving area of the operating theatre in
emergency cases. The aim is to allay anxiety through acquaintance and patient orientation
to the operating room, evaluate patients' readiness for surgery, assessing actual surgical
needs for effective planning of perioperative care, and for effective collaboration with the
significant surgical care delivers. The assessment information is disseminated to the rest
of the nurses during the shift reports.
Surgical team members are nurses in the operating room, the surgeon, assistant surgeon
and the anesthetist who primarily participate in the actual surgical procedure.
Collaborating members include the radiographer and theatre technicians among others.
Succinct preoperative assessment preoperative patients' assessment focused to
perioperative nursing care of an individual patient during a surgical intervention.
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ABBREVIA TIONS
APAIS
AORN
ISO
JeAHO
KRPoN
KNH
NANDA
NATN
NNAK
NPs
OR
OT
PACU
SOPs
SPSS
WHO
Amsterdam Preoperative Anxiety and Information Scale
Association of peri- Operating Room Nurses
International Standard of Operations
Joint Commission of Association of Health Care Organizations
Kenya Registered Peri-Operative Nurse
Kenyatta National Hospital
North American Nursing Diagnosis Association
National Association of Theatre Nursing.
National Nurses Association of Kenya
Nurse Practitioners
Operating Room
Operating Theatres
Post Anesthetic Care Unit
Standard Operation Procedures
Scientific Package for Social Sciences
World Health Organization
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ABSTRACT
The perioperative nurses play important role in care delivery of surgical patients
preoperatively, intraoperatively and post operatively. The nurses coordinate collaborative
activities during surgery and are directly concerned with preparation of the operating
room. Preoperative patient assessment by perioperative nurses is critical in planning,
preparation and implementing individualized patients' surgical care for safe and quality
surgical outcomes. The busy theatre schedules do not permit an objective ward visit to
perform such assessment. Perioperative nurses plan for surgical procedures using theatre
list and relying on preoperative patient assessment by non theatre personnel to verify
preoperative preparation using a preoperative checklist. Checklists and theatre lists do not
adequately address the actual procedural needs of the nurse and the patient. The result is
fragmented nursing care, cancellation of surgery in theatre due to excessive anxiety; .
intraoperative surgical delays related to preparation omissions and reduce cost
effectiveness to the patient and the institution. Postoperatively, some patients still harbour
surgical myths clarified during the assessment.
The aim of the study is to enhance the quality of surgical outcomes such as anxiety
reduction by promoting the practice of preoperative patient assessment by peri operative
nurses in planning individualized patients' surgical care. A preoperative assessment tool
will be formulated to standardize assessment and as a documentary evidence. The tool
will complement theatre list and preoperative checklists for effective surgical intervention
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The study setting will be at National Nurses Association (NNAK) building complex
(phase one) and Kenyatta National Hospital (KNH) operating theatres (phase Two) at and
KNH general surgery wards (phase 3).
The design will be descriptive cross sectional (phase one and two) and controlled trial
(phase three). Study phase one will be formulation of the assessment tool through
perioperative nurses workshop to be organized through NNAK Theatre Chapter. Study
phase two will be evaluating the tool practically. Phase three will be evaluating the tool
on surgical outcome of anxiety.
Instruments for the study will be focused group discussions (phase one) structured
questionnaires.
Data analysis will be done usmg Scientific Package for Social Sciences (SPSS).
Descriptive statistics will be used. Paired sample T- test and Independent sample T- test
will be used for testing mean differences between the experimental and control groups.
The Chronbach's alpha will be set at 0.05 corresponding to 95% confidence limit.
Ethical considerations will be observed and authority to conduct the study sought from
KNH Ethics and Research Committee.
The study will take duration of three years at a cost of approximately Ksh. 454,960.00
(four hundred and fifty four thousand, nine hundred and sixty Kenyan shillings).
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