EFFECTIVENESS OF PREOPERATIVE TEACHING ON ANXIETY OF PATIENTS UNDERGOING
CRANIOTOMY
Project Report
Submitted in partial fulfillment of the requirements for the Diploma in Neuro Nursing
Submitted by PRINU.P.KOSHY
Roll No: 5651
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY
TRIVANDRUM OCTOBER 2007
CERTIFICATE FROM SUPERVISORY GUIDE
This is to certify that Ms.Prinu.P.Koshy has completed the projectwork on effectiveness
of preoperative teaching on anxiety of patient undergoing Craniotomy under my direct
supervision and guidance for the partial fulfillment for the Diploma in Neuro Nursing in
the University of Sree Chitra Yirunal Institute for Medical Sciences and Technology,
Trivandrum.
It is also certified that no part of this report has been included in any other thesis for
procuring any other degree by the candidate.
Trivandrum
October 2007.
C2(]]0(~ re\' ~ ..- ,_ ;~-( P-/u )
SARAMMA. P. P.
Lecturer in Nursing
Sree Chitra Tirunal Institute for
Medical Sciences and Technology,
Trivandrum- 695011.
CERTIFICATE FROM CANDIDATE
This is to certifY that the project on Effectiveness of preoperative teaching on anxiety of
patient undergoing Craniotomy is a genuine work done by me at the Sree Chitra Tirunal
Institute for Medical Sciences and Technology, Trivandrum, under the guidance of
Mrs. Saramma. P. P. It is also certified that this work has not been presented previously
to any University for award of degree, diploma or other recognition.
Trivandrum
October 2007.
Prinu.P.Koshy
Roll No :5651
Sree Chitra Tirunal Institute for
Medical Sciences and Technology,
Trivandrum- 695011.
APPROVAL SHEET
This is to certify that Miss. Prinu.P.Koshy bearing Roll No : 5651 has been admitted to the
Diploma in Neuro Nursing in January 2007 and she has undertaken the project entitled
· Effectiveness of preoperative teaching on anxiety of patient undergoing Craniotomy which is
approved for the Diploma in Neuro Nursing awarded by the Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Trivandrurn, as it is found satisfactory.
Date:
Place:
(Examiners)
SARAMMA. P. P.
Lecturer in Nursing
Sree Chitra Tirunal Institute for
Medical Sciences and Technology,
Trivandrum - 695011.
ACKNOWLEDGMENT
I am very grateful to the almighty, without whose blessings I couldn't complete this
work. It is my great pleasure to express my profound sense of gratitude to Mrs. Saramma
P.P, Lecturer in Nursing, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Thiruvananthapuram for her valuable guidance, technical inputs and review
throughout the study.
With profound sentiments and gratitude the investigator acknowledges the
encouragement and help received from the following persons for the successful
completion of this study.
The investigator takes this opportunity to express the special thanks to Dr. A.V.George
(MA,B.Ed, PhD) Registrar, SCTIMST, Thiruvananthapuram
The investigator takes this opportunity to express the special thanks to Mrs. Sudarsana
(Ward sister), Neuro Surgery ICU, SCTIMST, Thiruvananthapuram. The investigator
is thankful to all the staff of Neuro Surgery ICU at SCTIMST.
The Investigator takes this opportunity to express the special thanks to Mrs. Remadevi,
(ward sister) Neurosurgery ward, SCTIMST, Trivandrum. The investigator is thankful
to all the staff of neuro surgery ward in SCTIMST.
The investigator also takes this opportunity to express the sincere thanks to Mr.
Jayachandran, (Senior Social worker) .
The investigator records special thanks to library staff of SCTIMST for granting
permission to utilize the library facility.
The investigator likes to express thanks to all friends who helped directly or indirectly
throughout this project.
The investigator wishes to express heartful thanks to parents and near ones for their
prayer, encouragement and help throughout this project.
The investigator also takes this opportunity to express the special thanks to her senior
Rani.R. Nath and all other seniors who helped directly or indirectly throughout this
project.
The investigator also takes this opportunity to express the sincere gratitude to all
patients who co-operated during the time of data collection.
ABSTRACT
Effect of Pre operative teaching on anxiety of patients undergoing Craniotomy.
Craniotomy is an elective neuro surgical procedure. Majority of people have fear
about surgery, post operative complication and outcome . Many studies have shown
that preoperative health education reduces post operative anxiety. Objective of the
study was to find out the effectiveness of health education on anxiety of patient
undergoing cranitomy. The study was conducted in Neuro Surgical ICU and Neuro
Surgery Ward of Sree ,Chitra Tirunal Institute for Medical Sciences and Technology.
Consecutive sampling technique was used for selecting the sample. The sample size
was 30. In this study the investigator used standardized malayalam version of
Speilberger's State Trait Anxiety Inventory, for assessing anxiety . One group pretest
post test design was used. Individual health education using a self prepared pamphlet
was given after initial assessment . Major findings of the study was that the state
anxiety of the patients was reduced both in male and female after surgery while the
mean trait anxiety score remained the same before and after surgery. The results
supports the existing knowledge that preoperative health education reduces post
operative anxiety.
TABLE OF CONTENTS
Chapter 1 Introduction
1.1. Introduction
1.2. Back ground of the study
1.3. Need and significance of the study
1.4 Statement of the problem
1.5. Objectives
1.6. Operational definitions
1.7. Methodology
1.8. Tool
1.9. Delimitations
1.10. Organization of the report
Chapter II - Review of Literature
2.1
2.2
Studies for reducing anxiety by pre-operative education
Studies on Craniotomy
Chapter Ill- Methodology
3.1. Research approach
3.2. Research design
3.3. Settings
3.4. Sample and sampling technique
3.5. Inclusion criteria
3.6. Exclusion criteria
3.7. Development of tool
3.8. Description of tool
1-6
1
1
3
4
4
4
5
5
6
6
7-12
7
12
15-18
15
15
15
16
16
16
16
17
3.9. Pilot Study
3.10. Data collection
3.11. Plan of Analysis
3.12 . Summary
. Chapter IV - Analysis and Interpretation of data
4.1. Distribution of sample according to the demographic
variables
4.2 Mean, standard deviation and P. value of pre operative
and post operative state anxiety.
4.3. Mean and standard deviation of pre operative and post
operative Trait anxiety.
4.4. Summary
Chapter -V - Summary Conclusions , Discussion
and Recommendations
5.1. Summary
5.2. Major findings
5.3. Limitation
5.4. Discussion
5.5. Recommendations
5.6 Conclusion
Reference
Appendix
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.....
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18
18
18
19-25
20
22
23
24
25-27
25
26
26
26
27
27
28-29
Vlll
LIST OF TABLE
Page Nos
2,1 Key terms used for literature search 14
4.1 Distribution of sample according to sex 20
4.2 Distribution of sample according to age 21
4.3 Mean, standard deviation and P value of pre operative and post operative State Anxiety Score 22
4.4 Distribution of mean and standard deviation of the preoperative and post operative Trait Anxiety 23
ix
LIST OF FIGURES
4.1 Distribution of sample according to sex
4.2 Distribution of sample according to age
4.3 Mean, standard deviation and P value of preoperative and post operative State Anxiety score
4.4 Distribution of mean and standard deviation of the preoperative and post operative Trait Anxiety
Page Nos
20
21
23
24
X
LIST OF APPENDICES
·A Consent
B. Questionnaire
C. Health Education
STAI
NSICU
NMICU
XI
ABBREVIATIONS
State Trait Anxiet Inventory
Neuro Surgical Intensive Care Unit
Neuro Medical Intensive Care Unit
-
1.1. Introduction
1
CHAPTER-I
INTRODUCTION
· A craniotomy is the surgical opening of the skull to gain access to intracranial structures.
This procedure is done to remove a space-occupying abnormality such as tumor, cyst
or vascular malformation. This procedure may also be needed on an emergency basis
to evacuate a hematoma, relieve intracranialpressure and reverse a herniation
syndrome. In' this procedure, a skin incision is made, the bone flap is elevated, dura is
opened, and the tumor is subjected to biopsy or resection. (Hickey, 2003).
Craniotomy is indicated for the diagnosis or treatment of intracranial lesions
demonstrated by neuroradiology, where there is adequate clinical indication with modern
diagnostic facilities, truly exploratory procedures will rarely be needed.
Contra-indications may be the nature of lesion, the speed of progression of symptoms
and also the patient's age and fitness. The few absolute contraindications include
overwhelming infection or abnormalities of blood coagulation. Poor neurological
condition of the patient need not be a contraindication, since surgical treatment of an
intracranial mass will usually be required before improvement can occur.
1.2. Background of the study
There are many reasons for performing a craniotomy. It may be done as an emergency
following a head injury or brain hemorrhage. This is to remove blood clots; which are
-.
2
pressing on the brain. As a planned procedure, a craniotomy may be essential to
remove a tumor or to clip an aneurysm. All operations carry some risks. Proper
assessment of the postoperative status of the patient requires an awareness of the
patient's symptoms so that a comparison may be made between the preoperative and
postoperative conditions. In case of craniotomy the complications occurs intra
operatively, during the immediate and late postoperative period. The complications
after craniotomy includes increased intra cranial pressure, vasospasms, cerebral
infarction, hydrocephalus, pneumonia, pulmonary embolism, diabetic insipidus,
syndrome of inappropriate anti diuretic hormone, wound infection meningitis, seizure,
cranial nerve damage and functional disability. The late postoperative complication
includes wound infections, seizure, meningitis, and functional disabilities. Most of the
patients are very much anxious due to complications. So reduction of pre operative
anxiety is widely accepted as part of nursing care. (Johnson 1971)
SCTIMST is one of the major center in India where craniotomy is done successfully.
More than hundred craniotomy cases were done in a month.
Johnson (1971) suggested that accurate pre operative information builds accurate
expectation of surgery which will intact reduce emotional arousal during surgery. Anxiety
is one of the most common emotions seen in health care setting. Care of anxious client
is one of the greater challenges as nurses.
Anxiety is a universal experience and an unavoidable aspect of everyday life. Mainly
anxiety is three types that are mild, moderate, and severe. The responsibility for giving
3
preoperative information to reduce anxiety is recognized as a necessary and ongoing
responsibility of the nurse as a source of emotional support (Oakely1984 ).
Anxiety is one of the major problem in psychology and result in considerable functional
impairment. State and trait anxiety is one of the most common features of anxiety.
State anxiety refers to emotional reaction characterized by subjective conscious feeling
of tension, apprehension, nervousness and worry. In contrast, Trait anxiety deals with
individual difference in the dangerous, and in the frequency that state anxiety is
experienced. Statistics vary widely but most agree that anxiety disorders are more
common in women than in men. Medical illness and invasive procedure are often
associated with anxiety.
The most commonly used psychometric self-report inventory is probably Speilberger's
State Trait Anxiety Inventory (STAI-Speilberger etal., 1970). State and trait anxiety are
analogous in certain respect to kinetic and potential energy. People who differ in trait
anxiety will show corresponding difference in state anxiety depending on the extent to
which each of them perceives a specific situation as psychologically dangerous or
threatening and this is greatly influenced by each individual's past experienced.
1.3. Need and significance of the study
Patients who are admitted for craniotomy are found to be more anxious about the
outcome of surgery. These patients also fear about the complications and are in high
emotional stress before surgery. The patient's anxiety level is an indication of
postoperative problem.
4
Preoperative anxiety increases the chance of postoperative pain, analgesic
consumption, and also hospital stay and recovery. In this situation preoperative teaching
plays an important role in relieving anxiety and reducing anxiety related complications.
Cochran ( 1984) found that surgical patients who were emotional support and information
about the procedure generally had a smoother operative course and recovery and
showed greater compliance with treatment. It has been known for many years that
preoperative information reduce anxiety (Greeve, 1999, Spalders, 2004). The patients
ask too many questions about surgery, ICUstay, complication, follow-up, recovery etc.
Hence the investigator felt the need to conduct the study about the effectiveness of
preoperative teaching on anxiety
1.4. Statement of the problem
A study to assess the effectiveness of preoperative teaching on the anxiety level of
patients undergoing craniotomy.
1.5 Objective
1. To assess preoperative anxiety of patients undergoing craniotomy.
2. To assess the effectiveness of preoperative teaching on the anxiety level of patient
Undergoing craniotomy.
1.6. Operational Definition
Pre operative teaching:- in this study preoperative teachings describes an interactive
process of providing in formations and explanations about surgical process, expected
_,'
5
patients behaviour and anticipated sensations and providing appropriate reassurance
and therapeutic listening to patients who are about to undergo surgery.
Anxiety: - it is a state of emotion and is measured by using Speilberger's State Trait
Anxiety scale.
Craniotomy: -is a surgical opening of the skull to provide access to the intracranial
content for reasons such as removal of a tumor, clipping of an aneurysm, or repair of a
cerebral injury, relieve elevated ICP, evacuate a blood clot and control hemorrhage.
1. 7. Methodology
Settings: -Neuro SurgicaiiCU and NeuroSurgical Ward in Sree Chithra Tirunallnstitute
for Medical Sciences and Technology
Study design:-one group pre test-post test design.
Pre test is given on the day of admission followed by health education.
Post test is done on the first postoperative day.
Sampling technique: -consecutive sampling.
Exclusion criteria: -children below the age of 18yrs.
1.8 Tool
The investigator assessed the anxiety level of patient by using Speilberger's state
trait anxiety inventory starndardized Malayalam version . After assessing the anxiety
6
level the investigator gives health education by using self-prepared pamphlet. The
content of health education includes the disease condition, surgery, need for surgery,
outcome, ICUstay and follow-up. The experts in neurology department in SCTIMST
validated this content.
1.9. Delimitations
1. The patients who speaks Malayalam.
2. The patient who are conscious, oriented and co-operative.
1.1 0. Organization of the Report
Chapter I deals with introduction, background of the study, need and significance of
the study, statement of the problem, objectives, operational definition, methodology
and delimitations. Chapterll deals with review of literature, chapterlll details the
methodology, and chapteriV presents analysis and interpretation of data and chapterV
include summary, discussion, conclusion and recommendation, reference and
appendices are given towards the end.
7
CHAPTER II
REVIEW OF LITERATURE
Review of literature is an important aspect of any research project from beginning to
end. It gives character insight into the problem and helps in selecting methodology,
developing tool and also analyzing data. With these in view an intensive review of
literature has been done.
The review of literature relevant to this study is presented in the following sections:-
2.1 Studies for reducing anxiety by pre-operative education.
2.2 Studies on craniotomy
2.1 Studies for reducing anxiety by pre-operative education.
Kolpfenstein et al.(2000) conducted a studyto compare the level of preoperative anxiety
in patient assessed in an out patient consultation clinic with the anxiety level of those
assessed by anesthesiologist after entering the hospital . This study included two
group of 20 patients who underwent elective trasurethral prostate or bladder resection.
Group A having the anesthestic assessment between one .,..two week before
hospitalization, group 8 having this assessment the evening before surgery after
entering the hospital .Two different methods used to assess the anxiety level that is
multiple Affect- Adjective check list and visual analogue scale of anxiety. The anxiety
score were lower in group A than in group 8, suggesting that an anesthetic assessment
--~---c--~--------~-----------------C--------------. .
8
in an out patient consultation clinic reduce preoperative anxiety compared with an
assessment on the evening before surgery ..
Cooke et al. (2004) conducted a randomized controlled trial design to assess anxiety
before and after listening to patient preferred music participants were allocated to an
intervention (n =60) and control group (n =60). Pre-post test measures of anxiety were
carried out using the state trait anxiety inventory. Music significantly reduced the state
anxiety level ofthe music (intervention) group. The finding supported the use of music
as an independent nursing intervention for preoperative anxiety in patient having day
surgery.
Lin and Wang (2005) conducted a study examining the effect of preoperative nursing
intervention for pain on abdominal surgery, pre-operative anxiety and attitude to pain
and post operative pain . Randomized controlled study conducted between January to
August (2001 ). Patients were assigned to an experimental (n=32) control group (n=30).
The experimental group received routine care and postoperative nursing intervention
for pain, while the control group received routine care only. A structured questionnaire
including an anxiety scale, pain attitude scale and brief pain inventory was used to
assess the result. Participants in the experimental group experienced pain attitude.
They also had statistically significantly lower post operative pain intensity forfour hours
after surgery and lower highest pain intensity with in the. 1st 24 hrs after surgery.
Perceived pain interference during position change, deep breathing and coughing and
movement of emotion in the experimental group was statistically significantly lower
-·'
9
than that of Control group. Preoperative nursing rntervention for pain had positive
effects for patients undergoing abdominal surgery.
Stergiopoulou et al. (2007) conducted a study to evaluate the impact of a multimediaCD
on preoperative anxiety and postoperative recovery of patients undergoing elective
laparoscopic cholecystectomy. Sixty consecutive candidates for elective laparoscopic
cholecystectomy were randomly assigned to four group. Group A included 15 patients
preoperatively informed regarding lapraroscopic cholecystectomy through the
multimedia CD presented by a registered nurse. Patients in group 8 (n=15) were
informed through a leaflet. Patients in group C. (n=15) were informed verbally from a
RN. Patients in a group D (n=15) were informed by the attending surgen and anesthetist.
Evaluation of preoperative anxiety was conducted using APAIS scale. Post operative
pain and nausea score were measured using an RNS scale. The result showed that
those patient in group A,B andC achieved a higher knowledge score, less preoperative
anxiety score and less postoperative pain and nausea, compared to group D. Informative
sessions using MCD was an effective means of improving preoperative knowledge
and reducing preoperative anxiety.
Logan and Rose (2005) conducted a study to explore relationships among anxiety,
anticipated pain coping style, postoperative pain and patient controlled analgesia use
among adolescent surgical patients and their parents. This study included 65 surgical
patients who underwent surgery with postoperative PCA pain management between
the age group 12 to 18yrs old. Pain and coping style were assessed with in 48 hrs after
surgery, with pain score and PCA use recorded through the end of the second
10
postoperative day. Findings are interpreted as suggesting a self-fulfiiling prophecy in
adolescents postoperative pain experience where in teens who expected to have high
levels of postoperative pain ultimately reported more pain and used more opioid PCA
medication than those who reported lower levels of pain.
Carr et al. (2006) conducted a study to identify the patterns and frequency of anxiety in
women undergoing gynecological surgery. The study used a mixed method approach.
Anxiety was assessed using the state trait anxiety inventory. Trait anxiety was measured
at the time of recruitment. State anxiety was assessed at six-time point during the pre
and postoperative periods. State anxiety rose steadily from the night before surgery to
the point of leaving the ward to go to theater. Anxiety then increased sharply prior to
anesthetic, decreasing sharply after wards. Patient with higher level of trait anxiety
were more likely to experience higher levels of anxiety through out their admission.
This study found higher rate of anxiety than previously reported and anxiety levels
appeared raised before admission to hospital.
Deyirmenjian et al. (2006) conducted a study on preoperative patient education for
open-heart patients. The selected Lebanese clients were randomly assigned to an
experimental (n =57) and a control group (n=53). Anxiety was assessed using the
Beck anxiety inventory scale. The patients in the experimental group received a special
educational session on their admission day and had a tour of the cardiac surgery unit.
The control group followed the routine hospital protocol, which encompassed almost
no pre operative education or a tour. Borderline statistical significance was noted for
the experimental group in terms of preoperative and postoperative anxiety. Unlike most
11
studies published previously, which noted the benefits of preoperative patient education,
this study with the Lebanese clients, failed to support earlier findings. This study
suggested that patient education should not be initiated before assessing the patient's
cultural and social background.
Reuber et al, (2004) conducted a study on depression and anxiety before and after
temporal lobe epilepsy surgery. This study included 94 TLE patients for epilepsy surgery,
76 underwent a resective procedure, 18 continued on medical treatment alone ..
Depression was assessed by using the Beck depression inventory and anxiety was
assessed by using Self-rating anxiety scale during presurgical evaluation (T1) and
after a mean of 16months (T2) or 12 months after surgery. At T1 depression and anxiety
score were higher in patients with TEL than scores in published normal populations .At
T2, depression but not anxiety scores were significantly lower than at T1. Results
showed that depression improved, not because of epilepsy surgery perse, but because
of improved seizure control. This is more commonly achieved by surgery than medical
treatment.
Kiyohara et al (2004) evaluated the anxiety level on the day before surgery as related
to the information known by the patients regarding the diagnosis, surgical procedure
or anesthesia. The Spielbergre's State-Trait Anxiety Inventory was used to measure
patient's anxiety level. The sample included 82 females and 38 males who were
interviewed. The state anxiety levels were alike for males and females. Trait anxiety
levels were higher for women. Unfamiliarly with the surgical procedure raised State
anxiety levels (P=0.021) A lower state anxiety level was found among patients who did
12
not know the diagnosis but knew about the surgery. Increased knowledge of patient
regarding surgery, they are about to undergo might reduce their state anxiety level.
Rymaszewska and kiejna et al. (2003) conducted a study to offer a prospective view
on the incidence and cause of self reported depression and anxiety in CABG patients.
In this study 53 patients who submitted to CABG were examined a few days before and
after operation and three months after the surgery. In this study Spiel Berger's Anxiety
questionnaire and Beck depression inventory were used. Approximately 55%of the
patients had high levels of anxiety preoperatively than postoperative periods. High
preoperative depression, state and trait anxiety scores appear to be predictors of
postoperative psychological out come. Preoperative assessment can identify patients
at risk for clinical levels of postoperative anxiety and depression.
2.2 Studies on Craniotomy
Cardosa et al. (2007) conducted a study on the surgical treatment of vestibular
schwannoma operated in dorsal decubitus (mastoid position). This study included 240 ·
patients with vestibular schwannoma who underwent a retro sigmoid craniotomy for
tumor resection in dorsal decubitus position. Complete tumor removal was achieved in
99 percent of the cases, with a mortality of 1.6 percent. The facial nerve function was
preserved in 85 percent of cases and hearing in 40 percent of the patients (with
preoperative hearing) with tumors of up 1.5cm in diameter. The incidence of
cerebrospinal fluid leak was 5.8 percent and meningitis 2.9 percent. Venous air embolism
was registered in 3 percent of cases; it was not associated to mortality. The study .
showed that the surgical removal of vestibular schwannoma in dorsal position has
13
several advantages; the morbidity and mortality were very low.
Thibault et al. (2007) conducted a study to assess the intensity of postoperative pain
in relation to the location of craniotomy. The pain was assessed by collecting scores
obtained using an 11-point verbal rating scale. Data were compared according to the
craniotomy location. In this study 299 patients were taken for analysis. Postoperative
use of steroids, gender and presence of preoperative pain were not statistically. linked
to postoperative pain intensity. This study showed that the intensity of postoperative
pain in neurosurgery was affected by the site of craniotomy. Frontal craniotomy patients
experienced the lowest pain scores and required significantly less opioid than patients '
undergoing posterior fossa interventions.
Rocha -Filho et al. (2007) conducted a study about a long-term effect of craniotomy on
temporalis muscle function. This study was to evaluate jaw movements and the
masticatory muscle in patients who underwent craniotomy for treatment of cerebral
aneurysm. This study included 71 patients who were evaluated between 4 and 6 months
after craniotomy. Their mean age was 45.3 yrs. 34 patients complained of headache
during dental evaluation. 20 patients reported pain during normal jaw movement.
Patients with post craniotomy headache had more masticatory muscle tenderness on
palpation than those without post craniotomy headache. This study showed that
headache was the complaint in 47.9% of the sample. Jaw movement was found to be
a pain-precipitating factor. Patients who suffered from post craniotomy headache had
more masticatory muscle tenderness.
14
The Key Terms used for literature search, http://www.ncbi.nlm.nih.gov is given in Table
2.1
Table 2.1
Key terms used for literature search
Key Terms No. of articles Preoperative
anxiety of patient undergoing surgery 128
CraniotorllY_ 10135 Preoperative
anxiety of patient undergoing
laminectomy 53
15
CHAPTER Ill
METHODOLOGY
This chapter deals with research approach, research design, setting, the sample and
sampling technique, development of tool, description of tool, pilot study, data collection
and plan of analysis.
The aim of the study was to find out the effectiveness of health education on anxiety of
patients undergoing craniotomy.
3.1.Research approach Pre experimental study
3.2. Research Design
For fulfilling the objective of the study one group pretest -post test was used. The
schematic representation is shown in figure 3.1. In this figure 01 represents pretest, x
is the health education and 02 is the post test.
01 X 02
Figure 3.1 One-group pretest -posttest design
3.3.Settings
The study was conducted in the neuro surgical ICUand neuro surgical ward at Sree
Chitra Tirunallnstitute for Medical Sciences and Technology; Trivandrum.The rationale
16
for selecting this hospital was that this is one of the superspeciality hospital in lndja
doing craniotomy. In this hospital on an average, 100 craniotomy cases are done every
month on a regular basis. More over, the investigator was familiar with this hospital.
3.4. Sample and sampling technique: -
Consecutive sampling technique was used for selecting the sample. All the patients
who met the inclusion criteria were selected. The total duration of the study period
was August .,..Qctober 2007.
3.5. Inclusion criteria :
Both male and female patients undergoing craniotomy
Those patient who are co operative, conscious and oriented.
Those patients who know Malayalam.
3.6. Exclusion criteria
Children below the age of 18 years.
3. 7 Development of tool :
An extensive review and study of literature helped in preparing a health education
pamphlet and it was scrutinized and approved by experts in Sree Chitra Tirunallnstitute
for Medical Sciences and Technology. In this study the investigator used standardized
Malayalam version of Speilberger's State Trait Anxiety Inventory for assessing pre
operative anxiety and to assess post operative anxiety which contain 36 question.
17
3.8. Description of tool :
The tool used in present study consists of the following parts.
Part- I
This part contains demographic data including age, sex ,educational status, occupation.
Part -II
It consist of Speilberger's State Trait Anxiety Inventory which is a popular instrument
for measuring anxiety. It has been used previously in many researches to assess
emotional reaction to surgical procedure. This inventory consists of 36 self reporting
items and has two parts. The State anxiety and Trait anxiety.
Part- Ill
After assessing the anxiety level health education was given to the patients. The health
education pamphlet contains details about the disease condition, surgery, need for
surgery, ICU stay, and follow-up
3.9. Pilot study :
Pilot study was conducted form August 151h to 301h , 2007 . The aim of the study was to
assess the effect of health education on anxiety of patients undergoing craniotomy.
The study was conducted among five patients, both male and female between the age
group of 20 to 65 years. The tool used is State Trait Anxiety Inventory (STAI) with 36
questions. The questions were asked in Malayalam. Total time period required was 30
18
minutes for a patient. Pilot study revealed that posttest anxiety score was lower than
pre test anxiety. After making necessary correction in the scoring part of the tool the
main study was conducted.
3.1 0. Data Collection
For data collection formal permission was obtained form the authorities. Period of
data collection was from August 2007 to October 2007. Data was collected from patients
in the neurosurgery ward and Neurosurgery ICU.
The investigator first introduced herself and explained the need and purpose of study
to the patients. After getting consent from the patients, anxiety level of patients was
assessed with the help of Speilberger's State Trait Anxiety Inventory. After this, health
education was given to the patient using health education pamphlet. The patients
were also given the opportunities to clear their doubts.
On the 1st postoperative day, the level of anxiety were assessed by using the same
structured anxiety scale to find out the effectiveness of health education in reducing
the anxiety level.
3.11. Plan of Analysis
A plan of data analysis was developed by the investigator after the pilot study. A master
sheet was prepared with the scores obtained in the STAI. (Descriptive statistics is
used to analyse the data).
3.12. Summary
This chapter deals with research approach, the study design, setting of the study,
samples and sampling technique, development of tool, data collection and plan of
analysis. ·
19
CHAPTER IV
ANALYSIS AND INTERPRETATION OF DATA
This chapter presents the analysis and interpretation of data collected from 30 patients
who underwent craniotomy at SCTIMST, Trivandrum. Analysis is a process of organizing
and Synthesizing data in such a way that project elicit meaning from collected data.
The aim of the research study was to assess pre-operative anxiety of patients
undergoing craniotomy and to assess the effect of preoperative teaching on the anxiety
level of patients undergoing craniotomy.
Interpretation refers to the process of making sense of the results and of examining the
implication of the findings with in a broder content.
The data were coded, entered in microsoft excel and analysed using epi info version
3.2.
The finding of the study were arranged and analysed under the following section.
4.1. Distribution of sample according to the demographic variables
4.2. Mean, standard deviation and P. value of pre operative and post operative
state anxiety.
4.3. Mean, and standard deviation of pre operative and post operative Trait
anxiety.
20
4.1. Distribution of sample according to the demographic variables.
Table 4.1. Distribution of sample according to sex
Sex Frequency Percentage
Male 25 83.30%
Female 5 16.70%
Total 30 100%
The data given in Table 4.1. show that 83.3% of sample consisted of male.
The same data is shown diagramatically in Fig 4.1
• Male • Female
Fig 4.1 pie diagram showing the distribution of sample according to sex
21
The age of the sample ranged from 33 to 63 with a mean of 47.57+8.62, median 47.5
and mode 35. The age distribution of the sample is given in Table 4.2
TABLE 4.2
Distribution of sample according to age group
Category Frequency Percentage
33-38 6 20% 39-44 4 13.30% 45-50 7 23.40% 51-56 9 30%
>57 4 13.30%
Total 30 100%
The data given in Table 4.2 show that 23.4 percent of subjects belonged to the age
category of 45- 50% . The same data is given in Fig 4.2
33-38 39-44 45-50 51-56 >57
Fig 4.2
Bar diagram showing the distribution of sample according to age
22
4.2. Mean standard deviation & P value of pre operative and post operative state
anxiety.
The state anxiety was measured used Speilberger's State Trait Anxiety Scale score of
which ranges from 18 to 72. The pre operative state. anxiety of the sample ranged from
24 to 52 with a mean of 42.37 .:t. 8.22 and Post Operative state anxiety score ranged
from 23 to 52 with a mean of 32.57 .:t. 5,34. The details are given in Table 4.3
TABLE4.3
Mean, Standard deviation and P.value of Pre Operative and
Post operative state anxiety score
Type of anxiety Mean Standard deviation P. Value
Pre Operative state anxiety. 42.37 8.22
0.000
Post Operative state anxiety 32.57 5.34
A paired 't' test was done which showed that there was a statistically significant reduction
in the mean post craniotomy anxiety of the samples (p= 0.000)
23
The same data is given in Fig 4.3
Pre Operative state anxiety Post Operative state anxiety
Fig. 4.3 Bar diagram showing mean of pre operative and post operative state anxiety.
4.3 Distribution of mean and standard deviation of pre operative & post operative
trait anxiety.
Pre operative Trait anxiety of sample ranged from 27to 57 with the mean of 35.6_+ 5.56
and Post operative Trait anxiety ranged from 27 to 48 with the mean of 33. 93 + 4.07.
TABLE 4.4
Distribution of mean and standard deviation of the pre and
Post operative Trait anxiety
Type of Anxiety Mean SD
Pre Op Trait 35.6 5.56
Post OP Trait 33.93 4.07
The data given in Table 4.4. Show that there is not much change in trait anxiety score.
24
The same data is given in Fig 4.4
35.6
33.5-
35.5-
34.5
33
33.93
Pre Op Trait Post OP Trait
Fig 4.4. Bardiagram showing mean of Pre operative & Post operative state anxiety
4.4. Summary
This chapter deals with analysis and interpretation of data collected from 30 patients.
Descriptive statistics and inferential statistics were used for the analysis. Bar & pie
diagram were used to illustrate the findings of the study.
25
CHAPTERV
SUMMARY, CONCLUSIONS , DISCUSSION AND
RECOMMENDATION
A brief account of the study is given in this chapter which cover objectives, findings of
the study and possible application of the result. Recommendations for future research
and suggestions for improving the present study are also presented
5.1. Summary
The study was conducted with the objective to assess per-operative anxiety before
health teaching and to assess post operative anxiety. The structured state- Trait anxiety
inventory was used for collecting data from 30 samples.
A review of related literature helped the investigator to get a clear concept about the
project topic undertaken, as well as to develop tools, methodology of the study and
decide the plan for data analysis.
A standardized Speilberger's State Trait Inventory was used for assessing the anxiety
level of patients. After assessing the anxiety level of the patients with a standardized
questionnaire, health education on surgery , ICU stay, complication , outcome was
given.
The study was conducted in SCTIMST, Trivandrum, during the period Aug-Oct 2007.
The sample comprised of 30 patients, both male and female . Between the age group
of 33- 63 years. Tool used for data collection included patient demographic data,
26
Speilbergers State Trait Anxiety Inventory. State anxiety scale consisted of 18 questions
and trait anxiety scale consisted of 18 questions.
5.2 The major findings of the study
The study results showed that there was a statistically significant reduction in the
mean post craniotomy anxiety of the samples. And there is not much change in Trait
anxiety score.
5.3. Limitation
1. Study was limited to the SCTIMST, Trivandrum
2. Study was conducted in a single group of patients admitted for craniotomy.
3. The study was conducted only among patients who could read malayalam
5.4. Discussion
Assessment of anxiety level of patient who is undergoing craniotomy is very important,
because these patients are anxious about surgery, ICU stay, complication, outcome
etc.
According to cooke et al (2007) pre operative interventions decrease anxiety level of
patients post operatively.
According to Kolpfenstein et al (2007) cooke et al (2004) Lin and wang ( 2005)
preoperatively patients had higher level of anxiety than post operatively. The findings
of the present study is comparable to these results.
27
The present study showed that health education seemed to decrease the anxiety level
of patients post operatively
5.5. Recommendations
The following recommendations are made on the basis of the present study
• Similar study can be repeated by increasing the sample size
• True experimental study to asses the effectiveness of pre operative teaching on
anxiety level of patients before and after surgery can be done.
5.6 Conclusion
Based on the findings of the study, the following conclusions were drawn.
• With this limited number of patients it is not possible to generalize findings
• There is need for studies involving more number of patients that validate the
findings.
28
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505-5.
APPENDICES
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(ADOPTION AND TRANSLATION OF SPEILBERGER'S
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