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Proposed Anesthesia Scoring Criterias for Video Assisted Thoracic Surgery at Lung Center of the Philippines

Submitted by:Surgical Intensive Care Unit/Post-Anaesthesia Care Unit/Operating Room

Allan Flores, RN Dahlia Galinato, RN Nurse II Nurse II Lourdes Liza Sales, RN Nurse II

Adviser:Rosario M. Cristi, RNNurse IV

Co-advisers:

Zenaida B. Gaspe, RN Marilyn A. Aro, RNSICU/PACU Head nurse OR Head nurse

APPROVAL SHEET

Rosario M. Cristi RNAdviser

Approved by the Committee on Oral Examination with the grade of _________.

Glenda L. Picardal RN, MAN, MM, MPA, PhDDivision Chief II Nursing Training and Research Division

Elvira N. Baura RN, MANDepartment Manager II Nursing Service

ACKNOWLEDGEMENT This study is sincerely dedicated to our patients who underwent Video Assisted Thoracic Surgery who was discharged safely at the Post-Anaesthesia Care Unit. To the Anaesthesiologist and nurses that gave their best to render high quality service. We would like to extend our deepest gratitude to the following: Our adviser, Theresa Alcantara, MD, who continuously guides and boosts our morale during the research. Our in-house adviser, Rosario M. Cristi RN, for tirelessly lending us a hand in every step of the way. Our head nurses, Mrs. Zenaida Gaspe, RN and Mrs. Marilyn A. Aro RN, who keeps on finding ways to adjust the staffing in order to give way to our schedule. To the Nursing Training and Research Staff headed by Ms. Glenda Picardal RN, MAN,MM, MPA, PhD, Mrs. Edna Formaran RN, MAN, Mr. Leonardo Macaraan, RN and Emmanuel Caab Jr. RN, for their unwavering patience and understanding. To our fellow staff from Surgical Intensive Care Unit, Post Anesthesia Care Unit and Operating Room for giving insights and enthusiastically participating in our research. To the Lord Almighty for giving the strength, knowledge and confidence in our endeavour.

DEDICATION

This study is sincerely dedicated to our patients who underwent Video Assisted Thoracic Surgery who were discharged safely at the Post-Anaesthesia Care Unit. To the Anaesthesiologist and Nurses who gave their best to render high quality service.

TABLE OF CONTENTS

Title Page 1Approval Sheet 2Acknowledgement . 3 Table of Contents ....... 5List of Table and Figures ........7Chapter I The Problem and Its Background 8 Introduction Statement of the Problem Significance of the Study Scope and Delimitation of the Study Hypothesis Conceptual Framework Paradigm of the Study Definition of TermsChapter II Review of Related Literature and Studies .. 13 Chapter III The Research Design .. 15Methods of ResearchRespondentsSettingResearch Proceedings and InstrumentsStatistical TreatmentChapter IV Presentation, Analysis and Interpretation ..... 23Chapter V Summary, Conclusions and Recommendations .. 33SummaryConclusionRecommendations Bibliography Appendices Curriculum Vitae

LIST OF TABLESTables 1 Assessment of Nurses on the Over-All Condition of Patients in PACU Based on Post-Anaesthesia Scoring System Four Hours after Video Assisted Thoracic Surgery. 2Assessment of Nurses on the Condition by Criteria of Patients in PACU based on Post-Anaesthesia Scoring System Four Hours after Video Assisted Thoracic Surgery. 3Assessment of Nurses on the Over-All Condition of Patients in PACU Based on Post-Anaesthesia Scoring System Eight Hours after Video Assisted Thoracic Surgery. 4Assessment of Nurses on the Condition by Criteria of Patients in PACU Based on Post-Anaesthesia Scoring System Eight Hours after Video Assisted Thoracic Surgery. 5Assessment of Doctors on the Over-All Condition of Patients in PACU Based on Post-Anaesthesia Scoring System Eight Hours after Video Assisted Thoracic Surgery. 6Assessment of Doctors on the Condition by Criteria of Patients in PACU Based on Post-Anaesthesia Scoring System Eight Hours after Video Assisted Thoracic Surgery 7Summary of Persons r-Coefficient of Correlation Test Result to Determine the Significant Relationship Between the Nurses and Doctors Assessment on the Condition of Patients in PACU

CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Introduction:

The impetus for this research was to have a good post anesthesia scoring criteria because since time immemorial Lung Center of the philipines, the post anesthesia care unit dont have any criteria on how to discharge patient. The intent of this research was to improve the flow of patients through the recovery process, in an effort to contain or reduce cost while still maintaining high quality patient care standards, thus it shown a decreased in patient length of hospital stay without increase in reports of post-operative complications. The favourable outcomes of the use of this scoring have led to its implementation after a protocol discussion. The time immediately following a general anaesthetic. Is a critical period for patients recovery, requiring intensive observation to enable early detection of complications from surgery. Since its introduction in 1923, the Post Anaesthesia Care Unit is the preference location for the immediate recovery to the Post Operative Patient. The patient length of stay in Post Anaesthesia Care Unit is dependent upon a number of factors, including pre-operative health status, surgical procedure, type of anaesthetic and the stability of vital signs. It has been common practice for PACU discharge policies to stipulate a minimum length of stay with a patient readiness for discharge traditionally relying upon nursing relying assessment of normality and stability of physiological parameters. A patient condition can deteriorate quickly and much work has been carried out to develop tools to assist the identification of deteriorating vital signs. Utilization of such tools has been associated with a reduction in adverse events in ward. Based since advent of day procedure surgical units there has been an increasing trend towards the use of similar objective scoring systems to aid decision making and quality patient readiness for discharge from Post-Anaesthesia Care Unit. Post-Anaesthesia assessment guidelines are often focused on the rule of an Anaesthesiologist, however due to nurse central role in the management of patience in the Post-Anaesthesia Unit setting, Anaesthesiologist often delegate the responsibility for evaluation of patient availability for discharge to the Post-Anaesthesia Care Unit nurse. Basing nursing practice an evidence is fundamental to optimal and effective care. Even experienced nurse face a dilemma about a right time to transfer or discharge patients.Statement of the Problem: The study aimed to develop a clinically based objective scoring system to assess and to measure the readiness of patient who underwent Video Assisted Thoracic Surgery (VATS) at Lung Center of the Philippines. Specifically it sought to answer the following questions:1. What is the assessment of the nurses on the condition of patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System four eight hours after Video Assisted Thoracic Surgery?2. What is the assessment of the doctors on the condition of the patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System eight hours after Video Assisted Thoracic Surgery?3. Is there a significant difference in the assessments of nurses and doctors of patients who underwent Video Assisted Thoracic Surgery?4. Is there a significant difference in the assessment of the nurses and doctors on the condition of patients in post anesthesia care unit using Post anesthesia scoring criteria four to eight hours after Video Assisted Thoracic Surgery?

Significance of the Study: The following are deemed to benefit from the study:1. To the institution, Lung Center of the Philippines, the study will for the development of institutional policy on how to assess and discharged/ transfer out patient from Post anesthesia care unit.The Healthcare team, this study aims to develop an instrument that will serve as basis for proper assessment to patient whether it is suitable to be discharged and transferred to ward or to be retained in Post-Anaesthesia Care Unit.2. The Patients/Clients will received utmost care as nurses becomes updated and enriched with knowledge and skills on post anesthesia care unit..3. The Family/Relatives will become satisfied with their love ones attention and care received from health team members. They themselves will be diretly involved in their patients management..4. The Researchers- will conduct similar study on similar local to generate a more expanded conclusion and recommendations.

Scope and Limitations: The study was conducted at Lung Center of the Philippines for the period of 2 months from July to August of 2014.The respondents are Nurses and Anesthesiologist assigned at Post Anesthesia Care Unit and take care patients with pulmonary disease and underwent Video Assisted Thoracic Surgery .Excluded from the study are outside Lung Center of The Philippines non lung center nurses and doctors and patients who underwent non thoracic surgery.

Hypothesis: This study tested at 0.05 level of significance the null hypothesis that there is no significant correlation between the assessment of nurses and doctors on the condition of patients in the Post Anesthesia care unit based on post anesthesia scoring system after video assisted thoracic surgery. Theoretical Framework: The Nursing Theory utilized was the Self Care Theory of Dorothea Orem. The theory explained that nursing is an extend regulatory force that acts to preserve the organization and integration of the client behaviour at the optimal level those condition in which the behaviour contributes a threat to physical or social level of health in which illness develops. Nursing has a special concern to mans needs for self-care and action. Self-care is requirement on every person, man, woman and child. When self-care is not maintained illness, diseases and death will occur. The above theory is paralleled to nursing as a unique situation and dedication in one hand. It is the product of a scientific method of analysis which studies humans as a bio-psychosocial being on the other hand; nursing dedication to health is forcing the profession to view humans from a holistic point of view. This dichotomy creates frustration at times. But one basis for uniqueness of nursing is believed to reside in viewing man from a concept of holism to promote health.

Paradigm of the Study:

Nurses 4 to 8 hours Post-Anaesthesia Scoring Criteria Assessment of patients who underwent Video Assisted Thoracic Surgery.Doctors 4 to 8 hours Post-Anaesthesia Scoring Criteria Assessent of patients who underwent Video Assisted Thoracic Surgery.

Figure I: Paradigm of the Study to Determine The Significant Difference on the Nurses And Doctors Assessment Of Patients After Video Assisted Thoracic Surgery.Definition of Terms:

Post-Anaesthesia Care Unit - sometimes referred to as Post-Anaesthesia Recovery (PAR) is a vital part of hospitals ambulatory care and other medical facilities. It is an area normally attached to operating theatre suite designed to provide care for patients recovering from anaesthesia whether it be general anaesthesia, regional anaesthesia or local anaesthesia.Video Assisted Thoracic Surgery - is a type of surgery that enables doctors to view the inside of the chest cavity after making only very small incisions. The doctor can examine the outside surface of the lung and the inner surface of the chest wall through a camera attached to the scope. Abnormal appearing areas on the lung surface can be biopsied.Nurses - to which surgical patients are taken for nursing assessment and care while recovering from anaesthesia. Vital signs, adequacy of ventilation, level of consciousness, surgical site, and level of pain are carefully monitored as the patient recovers consciousness.Anaesthesiologist- is a physician trained in anaesthesia and peri-operative medicine.CHAPTER IIREVIEW OF THE RELATED LITERATURE AND STUDIES Postoperative patients must be monitored and assess closely for any deterioration in condition and the relevant postoperative care plan or pathway must be implemented. Postoperative patient are at risk of clinical deterioration, and it is vital that it is minimised. Knowledge and understanding of the key areas of risk will help reduce potential problem .When assessing the post-operative patients it is vital that the patient is observed for signs of haemorrhage, shock, sepsis. and the effects of anaesthesia and anaesthetic. Patients receiving intravenous opiates are at risk of their vital signs and consciousness levels being compromised if the rate of the infusion is too high. It is therefore imperative that the patients pain control is managed well, initially by the anaesthetist and then the ward staff to ensure that the patient has adequate analgesia but is alert enough to be able to communicate and cooperate with clinical staff in the postoperative period. Vital signs should be performed in accordance with the policies and compared with the baseline observations taken before surgery, during surgery, and in the recovery area. When assessing patients recovery from anaesthesia and surgery, these observation should not be considered isolation. The nurses should look at and feel the patient. Many trusts now insist that vital signs are performed manually to provide more accurate recording and assessment. The respiratory rate and function often the first vital signs to be affected if there is a change in cardiac or neurological state. It is therefore imperative that this observation is performed accurately. Nurses should observed and record the following, airway, respiratory rate, and respiratory rate, and respiratory depression, indicated by hypoventilation or bradypnea and whether opiate-induced or due to anaesthetic gasses. Oxygen is administered to enable the anaesthetic gasses to be transported out of the body. The oxygen saturation should be above 95% on air; unless the patient has lung disease; and maintained above 95%. Particular attention should be paid to the systolic blood pressure as a lowered systolic reading and tachycardia may indicate hemorrage and/or shock; although initially the blood pressure may not drop and will remain within normal limits as the body compensates. Tachycardia may also indicate that the patient is in pain has a fluid overload or is anxious. Hypertension can be due to the anaesthetic or inadequate pain control. Patients who have been in the theatre for a long period are at risk of hypothermia. Shivering can due to anaesthesia or a high temperature indicative of an infection, while a drop in temperature might indicate a bacterial infection or sepsis. Post-operative patients should respond to verbal stimulation, be able to answer questions and be aware of the surroundings before being transferred to the ward and throughout the postoperative period. A change in level of consciousness can be a sign that the patient is in shock. The nurse should observe and record on the fluid balance chart the nausea and vomiting, if necessary, administration of antiemitics should be checked. The peripheral venous catheter are checked daily as a minimum for signs of phlebitis redness, heat, and swelling. Patient can be discharged quickly only when they do not experience any postoperative complications, may of which can be avoided or identified with correct and thorough monitoring of signs and symptom. The Post Anaesthesia Care Unit must continually update their theoretical knowledge and clinical skills, can do this by relying less on electronic equipment and developing their ability to combine the use of assessment tools with good observational skills, feeling, listening for abnormal sounds and closely observing the patient. Recovery from anaesthesia can range from completely uncomplicated to life-threatening. It must be managed by skilled medical and nursing personnel. The Anaesthesiologist plays a key role in optimizing safe recovery from anaesthesia. Must be carried out in a well- planned and protocol based fashion. The Post-Anaesthesia Care Unit renders specialized care given to patients who have undergone anaesthetic management by a team of well trained professionals, in a specially designed, equipped and designated area of the hospital. Post-Anaesthesia Care Unit is provided to anyone who has undergone anaesthesia and all patients who have undergone surgery. The methods of anaesthesia have been available for more than 160 years the Post-Anaesthesia Care Unit has only been common for the past 50 years but one can trace it to Lady of the Lamp, Florence Nightingale. In 1920s and 1930s several Post-Anaesthesia Care Unit opened in the United States and abroad. It was until after World War II that the number of Post-Anaesthesia Care Unit increased significantly. This was due to the shortage of nurses in the United States. In 1947, a study was released that over an 11 year period, nearly half of the deaths that occurred during the 1st 24 hours after surgery were preventable. In1949, having a Post-Anaesthesia Care unit was considered as standard of care. The Post-Anaesthesia Care Unit Staffing involved 1 nurse to 1 patient for the 1st 15 minutes of recovery and then 1 nurse for every 2 patients. The Anaesthesiologist is responsible for the anaesthetic remains for managing the patient in the Post-Anaesthesia Care Unit. The Post-Anaesthesia Care Unit must be equipped with multi- parametric monitors (automated blood pressure, pulse oximeter and ECG) and intravenous supports should be located at each bed. The area for charting, bed-side supply storage, suction, and oxygen flow meter at each bed-side. Supply of immediately available emergency equipment, crash cart and defibrillator. All the post- anaesthesia patients may it general anaesthesia, regional anaesthesia or monitored anaesthesia care should receive Post-Anaesthesia assessment and management. The patient should be transported to the Post-Anaesthesia Care Unit by a member of the one anaesthesia care team that is knowledgeable about the patients condition. Upon arrival in the Post-Anaesthesia Care Unit, the patient should be re-evaluated and a verbal report should be provided to the nurse. The patient shall be evaluated continually in the Post-Anaesthesia Care Unit. The Anaesthesiologist, concerned is responsible for discharge of the patient.CHAPTER IIIRESEARCH METHODOLOGYResearch Method This study is used a descriptive correlational survey method of research which according to Calmorin (2008) determines the relationship between two variables (x) and (y), if the relationship is perfect, very high, high, moderate, slight or negligible. In this study the correlational survey method was used to determine the relationship between assessments of nurses and doctors in Post-Anaesthesia Care Unit on the condition patients four to eight hours after Video Assistant Thoracic Surgery based on Post Anaesthesia Scoring Criteria.Setting of the Study Lung Center of the Philippines is a non-stock and non-profit corporation that was established on January 16, 1981 by President Ferdinand E. Marcos under Presidential Decree no. 1823. Philippine Government Tertiary Medical Center for Respiratory and Thoracic Conditions, The Post Anaesthesia Care Unit has a sixteen bed capacity and the nurse patient ratio is one nurse to patient for the first fifteen minutes of recovery and one nurse for every two patients. It is a special area where surgical patients are afforded comprehensive and critical care. The unit is equipped with continuous monitoring device, ventilators, pipe in oxygen and suction device, defibrillators, resuscitation carts and emergency drugs, infusion pump and emerson pump, which will designed to meet any emergencies in surgical cases. It is also provided with specialty trained staff nurses and doctors for the effective delivery of such care.Sampling Design The respondents of the study are nurses and doctors with a total census sampling of 20 patients all are in patients admitted in the post-anesthesia care unit in the duration of study.Respondents The respondents in this study are the nurses and anesthesiologist who are assigned in the Post-Anaesthesia Care Unit of Lung Center of the Philippines on the duration of the study. Research Instrument The researchers used a modified questionnaire in gathering data for this study. They modified the Discharge Criteria for Phase I & II Post Anaesthesia Care by the Joint Standards of Post Anaesthesia Nursing Perspective (1991 2002) and Post-Anaesthetic Discharged Scoring System to assess patient recovery and discharge after colonoscopy by Lucio Trevisani, Viviana Cifala, et. Al (2013). For this study, a patient should get a total score of 27 to be discharged from Post-Anaesthesia Care Unit.Validation of the Instrument The modified instrument was submitted to Ms. Glenda L. Picardal RN, MAN, MM, MPA, PhD, for content validation. Their comments and suggestions were considered before it was administered for pilot study which is .359 low reliability as shown in Appendix B. The instrument was further analysed and improved through the assistance of the research adviser and statistician. It was further analysed and improved into a rubric form where criteria, condition delineation and indicators included. The revised instrument having a reliability index of 0. 843 with a verbal description of very high reliability as shown in Appendix B was in this study.Data Gathering Procedure Using the revised instruments, the researcher asked permission from the head of Post Anaesthesia Care Unit to gather data from Post Anaesthesia Care Unit to the patient who underwent Video Assisted Thoracic Surgery. The researchers requested the nurses and doctors assigned/on duty on Post Anaesthesia Care Unit to use the instrument in assessing the patients using their instruments. The filled-up instruments were then collected and submitted to a statistician for data analysis. A letter of communication was sent prior to distribution and collection of data and its takes two months to sum it up.

The following are guidelines to score the Post-Anaesthesia Scoring Criteria:1. Muscle Activitya) A score of 3 is assigned when the patient is able to move all the extremities on command, or motor activity has returned to the patients pre-operative status (if a deficit exist).b) A score 2 is assigned when the patient is able to move only 3 extremeties.c) A score of 1 is assigned when the patient is able to move only 2 extremeties.d) A score of 3 must be achieved before discharge unless specified in writing by the anaesthesiologist.e) For patients with regional nerve block a score of 3 may be acceptable with a discharge order by Anaesthesia.2. Respirationa) A point score of 3 is assigned when the patient is able to breathe deeply and cough.b) A point score of 2 is assigned when the patient exhibit signs of dyspnea or has difficulty breathing and clearing secretions or requires supportive measures to maintain airway patency.c) A score of 1 is assigned when the patient is apneic or requires assisted ventilation.d) A score of 3 must be achieved and maintained in this category for a minimum of one-half hour before discharge.3. Consciousness a) A point score of 3 is assigned when the patient is fully awake, able to answer questions and call assistance. If the patient had an altered level of consciousness before surgery, the patient will receive a point score of 3 when he or she is at preoperative consciousness level.b) A point score of 2 is assigned when the patient is drowsy but respond easily to verbal commands.c) A point score of 1 is assigned when no response is elicited to verbal commands. Painful stimulation is not employed to elicit a response.d) The minimal score of 2 must be achieved in this category before discharge.4. Circulationa) Score of 3 is assigned when the blood pressure (systolic) reading is (+) or (-) 20mmHg the pre-anesthetic level.b) A score of 2 is assigned when the blood pressure (systolic) reading is (+) or (-) 35 mmHg of the pre-anesthetic level.c) A score of 1 is assigned when the blood pressure (systolic) reading is greater than (+) or (-) 50mmHg of pre- anesthetic level.d) Patients with a systolic blood pressure 200mmHg, or exhibiting a blood pressure other than their baseline pre-anesthetic blood pressure, must be evaluated by an anesthesiologist prior to discharge.e) A minimum score of 2 must be achieved and maintained for at least three consecutive readings at 15-minute intervals before discharge. The measurement parameters defined in d must be met.5. Oxygen Saturationa) A score of 3 is assigned when the SpO2 meets or exceeds the anesthesiologists parameters on room air.b) A score of 2 is assigned when the SpO2 meets or exceeds the anesthesiologists parameters on supplemental 02.c) A score of 1 is assigned when the minimum Sp02 level as established by the anesthesiologist cannot be maintained.d) A score of 2 or higher must e achieved before discharge.6. Heart Ratea) A score of 3 is assigned when the heart rate is (+) or (-) 20 beats/ minute of the pre-ansthetic level.b) A score of 2 is assigned when the heart rate is (+) or (-) 40 beats /minut of the pre-anesthetic level.c) A score of 1 is assigned when the heart rate is (+) or (-) 50 beats /minute of the pre-anesthetic lvel.d) Patients with a heart rate of 110beats /minute, or exhibiting a cardiac rhythm other than their baseline pre-anesthetic rhythm must be evaluated by an anesthesiologist prior to discharge.e) A score of 2 or higher must be achieved and maintained for three consecutive measurements at 15-minute intervals before discharge. The parameters defined d must be met.7. Paina) A score of 3 if pain is acceptable with the patient without pain medication.. b) A score of 2 if pain is controlled by opoid analgesic.c) A score of 1 if pain is uncontrolled even with opoid analgesic.8. Nausea and Vomitinga) A score of 3 is assigned if minimal nausea and vomiting perceive by the patient and without anti emetic medication.b) A score of 2 is assigned if with moderate relived with intravenous or intramuscular medication.c) A score of 1 is assigned if with severe nausea and vomiting and there is a continuous repeated treatment.

9. Surgical Bleedinga) A score of 3 is assigned if there is minimal bleeding. No dressing change required.b) A score of 2 is assigned if there is moderate bleeding wherein dressing change up 2 times.c) A score of 1 is assigned if there is severe bleeding and 3 or more dressing change required.10. Activitya) A score of 3 is assigned when the patient is able to move all 4 extremities on command, or motor activity has returned to the patients preoperative status (if deficit exists).b) A score of 2 is assigned when the patient is able to move only 3 extremities.c) A score of 1 is assigned when the patient is able to move only 2 extremities.d) A score of 3 must b achieved before discharge unless specified in writing by the anesthesiologist.e) For patients with regional nerve block, a score of 3 may be acceptable with discharge order by Anesthesia.

Statistical Treatment of Data Data were summarized using Microsoft Excel, analysed and interpreted using Statistical Package for Social Sciences (SPSS) version 21. To answer question 1and2, Weighted Mean and Frequency were used to determine the Assessment of nurses on the condition of patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System four eight hours after Video Assisted Thoracic Surgery.To answer question 3, Pearson Product Moment of Correlation was used to determine the significant correlation between assessments of nurses and doctors on the condition of patients in Post-Anaesthesia Scoring System after Video Assisted Thoracic System.Percentage Frequency DistributionA percentage frequency distribution is a display of data that specifies the percentage of observations that exist for each data point or grouping of data points. It is a particularly useful method of expressing the relative frequency of survey responses and other data. Many times, percentage frequency distribution s are displayed as tables or as bar graphs or pie charts. The process of creating a percentage distribution involves first identifying the total number of observation to be represented; then counting the total number of observations within each data point or grouping of data points ;and then dividing the number of observations within each data point of grouping of data point.

Formula P= F x 100 NWhere: P= percentageF= frequencyN= Total number of PatientPearsons Product Moment of correlationIt is also known as the Product Moment Correlation Coefficient which is to be used only in determining the strength of correlation between two or more interval data.FormulaR p = (n-1) (Sdx) (Sdy)

Where:R p = Pearsons coefficient correlationEdxdy = the sum of the product deviation of doctors and nurses variablesSdx = Standard deviation of doctorsSdy = Standard deviation of nursesN = number of patieentWhere: = Pearsons coefficient of correlation = the sum of the product of the deviation of doctors and nurses variables = standard deviation of doctors = standard deviation of nurses = number of patient

Computed r value Interpretation0.0 to +0.10 No correlation+0.11 to +0.25 Negligible correlation+0.26 to +0.50 Moderate correlation+0.50 to +0.75 High correlation+0.76 to +1.0 Very high perfect positive /negative correlation

Cronsbachs AlphaIf the response in the items are not scored high versus wrong as in some essay test where more than one answer is possible to determine the internal consistency of the instrument the alpha coefficient method should be used.It will be used only if the responses are not continuous or non-dichotomous data. Further, coefficient alpha does not require the assumption that all items are of equal difficulty although it is more difficult to calculate computer programs for doing so are commonly available.Formula:

Where;K= the number of items in the tests = the sum 0 variances of individual items = the variances of scores on the test

CHAPTER 4PRESENTATION, ANALYSIS AND INTERPRETATION OF DATAThis chapter includes the presentation, analysis and interpretation of data gathered from the patients by the nurses and doctors who perform the assessments. It comprises tabular and textual presentations to facilitate the discussion and interpretation of the results.Table 1Assessment of Nurses on the Over-All Condition of Patients in Post-Anaesthesia Care Unit Based on Post Anaesthesia Scoring System Four Hours after Minor Operation

ScoreFrequencyPercent

22.00210.0

23.0015.0

24.00210.0

26.0015.0

27.001050.0

28.00210.0

29.00210.0

Total20100.0

Table 1 show the assessment of nurses on the over-all condition of the patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System four hours after minor operation. These reveal that first in rank is a score of 27 with 10 out of 20 (50%) patients, second is 29, 28, 24 and 22 with 2 out of 20 (10%) patients each. All the obtained scores are higher than the cut off score of 27 as shown. Table 2Assessment of Nurses on the Condition by Criteria of Patients in Post-Anaesthesia Based on Post Anaesthesia Scoring System Four Hours after Minor Operation

CriteriaConditionDelineationWeightedMean

Verbal Description

Muscle Activity164002.80Very GoodAble to move 3-4 extremities voluntarily on command

Respiration155002.75Very GoodAble to breathe deeply; able to cough freely

Consciousness200003.00ExcellentFully awake

Circulation146002.70Very GoodBP up to 20mmHg of pre-anaesthetic level

Oxygen Saturation173002.85Very GoodMeets or exceeds >92 % on room air

Heart Rate173002.85Very GoodWithin 20 beats/min of Pre-operative Baseline

Pain317002.15GoodAcceptable with the patient with intravenous medication

Nausea & Vomiting713002.35GoodModerate*(with intravenous and/or intramuscular medications

Surgical Bleeding155002.75Very GoodMinimal * No dressing change required

Activity119002.05GoodAble to ambulate with assistance*Steady gait but with dizziness*Unsteady gait but no dizziness

Weighted Mean12.57.5002.625Very Good

Legend: 1 1.49 Poor 1.50 2.49 Good 2.50 2.99 Very Good3.00 Excellent

Table 2 on the other hand indicates the assessment of nurses on the condition of patients of Post-Anaesthesia Care Unit by criteria indicated in the Post Anaesthesia Scoring System four hours after Video Assisted Thoracic Surgery. It reveals that the patients collectively got a weighted mean of 2.05 -3.0 from the rating scales of 1-3 with a grand weighted mean of 2.62 meaning very good. Consciousness got a perfect score of 3 meaning the patients are fully awake when they were assessed four hours after minor operation. Both oxygen saturation and heart rate got a weighted mean of 2.85 meaning very good which indicates that they meet or exceed more than 92 % on room air and Within 20 beats/min of Pre-operative Baseline respectively. In terms of muscle activity, patients got a weighted mean of 2.80 which signifies they were Able to move 3-4 extremities voluntarily on command respiration. In terms of respiration and surgical bleeding, the group had a weighted mean of 2.75 meaning very good because they were Able to breathe deeply and able to cough freely and no dressing changed was required. In terms of circulation, they were very good with a weighted mean of 2.70 meaning their BP was up to 20mmHg of pre-anaesthetic level. Patients were good in terms of pain (2.15) since they find pain acceptable with intravenous medication, good in vomiting and nausea (2.35) since they can do it with intravenous and/or intramuscular medications and good also in activity since they were able to ambulate with assistance meaning its either they have Steady gait but with dizziness, or Unsteady gait but no dizziness.

Table 3Assessment of Nurses on the Over-All Condition of Patients in Post-Anaesthesia Care Unit Based on Post Anaesthesia Scoring System Eight Hours after Minor Operation

ScoreFrequencyPercent

22.00210.0

23.00210.0

24.0015.0

25.00210.0

26.00315.0

27.00840.0

28.00210.0

Total20100.0

Table 3 show the assessment of nurses on the over-all condition of the patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System eight hours after minor operation. These reveal that first in rank is a score of 27 with 8 out of 20 (40%) patients, second is 28 with 3 out of 20 (15%) patients, followed by 28, 25, 23 and 22 with 2 out of 20 (10%) patients each, and the last is 24 with only 1 out of 20 (5%) patients. All the obtained scores are higher than the cut off score of ______ as shown.

Table 4Assessment of Nurses on the Condition by Criteria of Patients in Post-Anaesthesia Care Unit Based on Post Anaesthesia Scoring System Eight Hours after Minor Operation

CriteriaConditionDelineationWeighted MeanVerbal Description


Respiration137002.65Very GoodAble to breathe deeply;able to cough freely

Consciousness191002.95Very GoodFully awake





Nausea & Vomiting515002.25GoodModerate *(with intravenous and/or Intramuscular medications

Surgical Bleeding128002.60Very GoodMinimal * No dressing change required

Activity118102.00GoodAble to ambulate with assistance*Steady gait but with dizziness*Unsteady gait but no dizziness

Over-All Mean2.57Very Good

Legend: 1 1.49 Poor1.50 2.49Good2.50 2.99 Very Good3.00 Excellent

Table 4 on the other hand indicates the assessment of nurses on the condition of patients of Post-Anaesthesia Care Unit by criteria indicated in the Post Anaesthesia Scoring System four hours after minor operation. It reveals that the patients mutually got a weighted mean of 2.05 -3.0 from the rating scales of 1-3 with a grand weighted mean of 2.57 meaning very good. Consciousness got the highest score with a weighted mean of 2.95 meaning the patients are fully awake when they were assessed four hours after minor operation followed by heart rate with a weighted mean of 2.85 meaning patients are within 20 beats/min of pre-operative baseline. Both oxygen saturation and muscle activity got a weighted mean of 2.80 meaning very good which indicates that they meet or exceed more than 92 % on room air and able to move 4 extremities voluntarily on command respectively. In terms of respiration and circulation they both got the weighted mean of 2.65 meaning very good since they are able to breathe deeply and cough freely whose BP is up to 20mmHg of pre-anaesthetic level. Patients were good in terms of pain with a waited mean of (2.15) since they find pain acceptable with intravenous medication, good in vomiting and nausea with a waited mean of (2.25) since they can do it with intravenous and/or intramuscular medications and good also in activity with a waited mean of (2.00) since they were able to ambulate with assistance meaning its either they have Steady gait but with dizziness, or Unsteady gait but no dizziness. Table 5Assessment of Doctors on the Over-All Condition of Patients in PACU Based on Post Anaesthesia Scoring System Eight Hours after Minor Operation

FrequencyPercent

25.00420.0

26.00735.0

27.00840.0

28.0015.0

Total20100.0

Table 5 show the assessment of doctors on the over-all condition of the patients in Post-Anaesthesia Care Unit based on Post Anaesthesia Scoring System eight hours after minor operation. These reveal that first in rank is a score of 27 with 8 out of 20 (40%) patients, second is 26 with 7 out of 20 (35%) patients, followed by 24 with 4 out of 20 (20%) patients, and the last is 28 with only 1 out of 20 (5%) patients. All the obtained scores are higher than the cut off score of ______ as shown. Table 6Assessment of Doctors on the Condition by Criteria of Patients in Post-Anaesthesia Care Unit Based on Post Anaesthesia Scoring System Eight Hours After Minor Operation

CriteriaConditionDelineationWeighted MeanVerbal DescriptionVerbal Description

3210


Respiration1732.85Very GoodAble to breathe deeply; able to cough freely

Consciousness1822.90Very GoodFully awake





Nausea & Vomiting7132.35GoodModerate *(with intravenous and/or Intramuscular medications

Surgical Bleeding8122.40GoodModerate* Up to 2 dressing change required

Activity4162.20

GoodAble to ambulate with assistance*Steady gait but with dizziness*Unsteady gait but no dizziness

Over-All002.63Very Good

Legend: 1 1.49 Poor1.50 2.49Good2.50 2.99 Very Good3.00 Excellent

Table 6 on the other hand indicates the assessment of doctors on the condition of patients of Post-Anaesthesia Care Unit by criteria indicated in the Post Anaesthesia Scoring System four hours after minor operation. It reveals that the patients mutually got a weighted mean of 2.05 -3.0 from the rating scales of 1-3 with a grand weighted mean of 2.57 meaning very good. This is the ranking of the assessment of the doctors: First is muscle activity with a weighted mean of 2.95 meaning the patients are able to move 3-4 extremities voluntarily on command. Second is consciousness with a weighted mean of 2.90 indicating that they are fully awake during assessment period. Third is respiration with a weighted mean of 2.85 meaning they are able to breathe deeply and cough freely. Next are circulation and oxygen saturation both with a weighted mean of 2.80 indicating that their BP up to 20mmHg of pre-anaesthetic level and that they meet or exceed more than 92 % on room air. It is followed by heart rate with a weighted mean of 2.70 which means Within 20 beats/min of Pre-operative Baseline. The criteria with good ratings are surgical bleeding (2.40), pain (2.30), nausea and vomiting (2.35) and activity (2.20). These indicate that the patients required up to 2 dressing change, pain is Acceptable with the patient with intravenous medication, nausea and vomiting is moderate with intravenous and/or Intramuscular medications and they are able to ambulate with assistance; either with steady gait but with dizziness or unsteady gait but no dizziness.Table 7

Summary of Pearsons r- Coefficient of Correlation Test Result to Determine the Significant Relationship Between the Nurses and Doctors Assessment on the Condition of Patients in Post-Anaesthesia Care Unit

r- valueVerbal Descriptionp-value DecisionConclusion

0.532Moderate relationship0.0160.05Reject HoThere is a significant moderate relationship between the nurses and doctors assessment.

Table 7 shows the summary of Pearsons r- coefficient of correlation test result to determine the significant relationship between the nurses and doctors assessment on the condition of patients in Post-Anaesthesia Care Unit. The r- value = 0.532 indicates a moderate relationship and the p-value 0.016 is lower than the set 0.05. Thus, the null hypothesis is rejected. It means that there is a significant moderate relationship between the assessments of nurses and doctors eight hours after a minor operation. It reveals that the patients who received a high rating from the nurses are also the patients who got high ratings from the doctors; although they did not give exactly the same ratings.CHAPTER 5SUMMARY OF FINDINGS AND RECCOMENDATIONS

Summary of Findings The study focused on developing Rubrics for Clinically-Based Objective Scoring System which can be used by attending nurses in assessing the condition of patients in Post-Anaesthesia Care Unit as a Post Anaesthesia Scoring System from four to eight hours after minor operation. In establishing its validity and reliability, the following data were obtained:1. The patients utilize in this study as subject of the research are equally distributed in terms of gender but mostly elderly in terms of age.2. The nurses successfully used the Rubrics for Clinically-Based Objective Scoring System as their instrument in assessing the condition of the patients under study four-eight hours after Video Assisted Thoracic Surgery.3. The doctors successfully used the Rubrics for Clinically-Based Objective Scoring System as their instrument in assessing the condition of the patients under study eight hours after Video Assisted Thoracic Surgery.4. The research instrument, Rubrics for Clinically-Based Objective Scoring System, is a reliable instrument in assessing the condition of the patients eight hours after Video Assisted Thoracic Surgery. The tool was adopted from Stanford Hospital and Clinics discharge criteria for Phase 1 and 2 Anaesthesia Care.5. There is a significant moderate correlation between the assessments of nurses and doctors on the conditions of the patients under study eight hours after Video Assisted Thoracic Surgery.ConclusionsFrom the findings of the study, the following conclusions were made:1. That the Rubrics for Clinically-Based Objective Scoring System, is a reliable instrument in assessing the condition of the patients under study eight hours after Video Assisted Thoracic Surgery.2. That there is no significant difference on the assessments of nurses and doctors on the condition of the patients under study eight hours after Video Assisted Thoracic Surgery.3. That the study offers insights on the researchers experiences as nurses monitors patients condition from time to time in the post Anesthesia Care Unit. RecommendationsIn the lights of the findings and conclusions of this study, the following recommendations are being offered:1. That the research instrument, Clinically-Based Objective Scoring System, be used as a tool in assessing the condition of the patients eight hours after Video Assisted Thoracic Surgery.2. That the nurses assessment maybe considered as part of the standardized procedure in discharging patients from Post-Anaesthesia Care Unit who underwent Video Assisted Thoracic Surgery.3. Future researchers may conduct a follow up study to improve the validity and reliability of the instrument.

References:1.Lucio Trevisani,Viviana Cifal,Giuseppe Gilli,Vincenzo Matarese,Angelo Zelante, andSergio Sartori. (2013) Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy. World Journal of Gastrointestinal Endoscopy2.Laurentina Paler-Calmorin & Ma. Lauremelch Calmorin-Piedad. (2008) Nursing 3.Research. National Bookstore, Mandaluyong City4. Statistics for research by Pablo E. Subong5. Truong, LJL Moran and P.Blum, Post Anesthesia Care Unit Discharge, A clinical Scoring System Versus Traditional Time Based Criteria. Anesthesia and Intensive 2004- (page 33-42).6. National Institute for Health and Clinical Excellence Acutely III Patients in Hospital.Recognition of and Response of Acute Illness in Adult in Hospital 2007 London (UK) Clinical Guideline No. 50 Retrieve on March 15, 2010.7. Aldrete JAN and D.Kroulik -: A Post Aneasthetic Recovery Score , Anesthesia and Analgesia 1970 pp924-934.8.Aldrete JAN Modification to the Post Anesthesia Score Use in Ambulatory Surgery Journal of Peri Anesthesia Nursing 1998 #13 pp 148-155.9. Department of Health (2011) High Impact Intervention No. 2 ,Peripheral Intravenous Cannula Care Bundle,London DH10.Royale College of Nursing (2011)Standards for assessing, Measuring, and Monitoring Vital Signs in Infants, Children, and Young People.London RCN,11. Harvard Health Publications Harvard Medical School August 11,2014.12. Use of a Modified Post anesthesia recovery score in phase II perianesthesia period of ambulatory surgery patients. Lisa M. Saar Lt Nc Msn Cpom.

Appendix B

Reliability of the Instruments during Pilot Study

Cronbachs Alpha No. of items

0.359 10

Interpretation: Low Reliability

vats

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