characteristics of and factors related to …

Kitakanto Med.J.

48 ( 4 ) : 289•`295, 1998

289

CHARACTERISTICS OF AND FACTORS RELATED

TO PREOPERATIVE ANXIETY OF ADULT

AND ELDERLY CRANIOTOMY PATIENTS

Mayumi Ito, Mitsuko Sagehashi*, Seiko Ishizaka*

Department of Nursing, School of Health Science, Faculty of Medicine, Gunma University

* Division of Nursing, Gunma University Hospital

Abstract : The author interviewed and observed 14 patients in the neurosurgery ward to elucidate

characteristics and factors related to preoperative anxiety of craniotomy patients and obtained the

following results :

(1) Six common preoperative anxiety of craniotomy patients are : fear of change and collapse of

personality, fear of physical disability due to complications, fear of lost or altered role in the

society, fear of change in body image caused by tonsure, fear of postoperative death, fear of

ambiguity and something unknown.

(2) These fears are related to their past experience of operations, subjective symptoms, sufferings,

triggers of their decision to have operation, expectation from the surgery, awareness of expected

complications as well as their understanding of neurology.

Key words : Perioperative nursing, Anxiety, Adult and elderly patients, Neurosurgery, Psychologi-

cal adaptation

(Kitakanto Med.J. 48 (4) : 289•`295, 1998)

INTRODUCTION

It is a serious event for a person to have some

neurological disability. Craniotomy patients present

different preoperative reactions and anxiety because

they are expected to have some damage to their brain

which is the center of body and mind.

There have been reports on anxiety of craniotomy

patients and on psychological and social support using

crisis model and adaptation theory1•`4) and case study

based on the concept of body image5). But there have

been no report focusing on the neurosurgery patients to

identify their anxiety and related factors.

The author studied to identify anxiety of neurosur-

gery patients because we believe it will give me a better

idea for perioperative nursing care.

PURPOSE

The purpose of this study is to identify the charac-

teristics of and the factors related to preoperative

anxiety of craniotomy patients to prepare a preoper-

ative nursing care guideline.

METHOD

1. Subjects

Subjects were 14 adult and elderly patients of craniotomy in the neurosurgery ward. The subjects

were selected based upon their state of consciousness, verbal communication and informed consent to the

participation in this study. Table 1 shows the outline of the subjects. 2. Method

In order to have holistic understanding of the

patients and to elucidate factors related to anxiety,

qualitative and descriptive study methods were used. 1) Identification of preoperative anxiety of

craniotomy patients Semiconstitutive interview was made on 9 patients

(patient 1 through 9) 4 to 1 day prior to surgery to collect data on preoperative fear, degree of anxiety, organ image of brain and nerve systems and acceptance

of surgery and disease. Interview was tape recorded

Received : May 20, 1998

Address : MAYUMI ITO

Department of Nursing, School of Health Science, Faculty of Medicine, Gunma University

3-39-15 Showamachi, Maebashi, Gunma, 371-8514, Japan

290

Ito, Sagehahsi, Ishizaka

with the patients' consent and transcribed. All the

words and behavior related to preoperative anxiety of craniotomy patients were extracted from the record and categorized by four researchers.

2) Characteristics of and factors related to

preoperative anxiety of patients and perioper-ative change in anxiety state

Five patients (patient 10 through patient 14) were interviewed semiconstitutively twice (3 to 1 day before

surgery and 7 to 14 day after surgery) based on the

previously extracted 6 anxiety categories. In the pos-toperative interview, anxiety expressed before the sur-

gery was confirmed and patients were asked to add anxiety verbally unexpressed before the surgery. Nurses observed the patients between admission to the

14th postoperative day and recorded their observation in the field note.

Characteristics and factors for these five patients

were analyzed based on the interview and observation.

RESULTS

1. Preoperative anxiety of craniotomy patients

(patients 1 through 9) Table 2 summarizes 6 preoperative anxieties of

craniotomy patients based on the analysis of their interview.

1) Fear of change and collapse of personality Many patients expressed their fear of loosing their

original personality by surgical invasion of the brain. Their expression of this fear includes, "become fool", "get demented" and "personality will change" .

2) Fear of physical disability due to complications

This is a type of anxiety patient experience after being told of the surgery. Doctors give them descrip-

Table 1 Outline of patients

Table 2 Preoperative anxiety of craniotomy patients

291

Characteristics Of And Factors Related To Preoperative Anxiety Of Adult And Elderly Craniotomy Patients

292


tion of complications of systemic anesthesia, of

craniotomy and of surgical maneuver and operation

sites. Patients expressed their anxiety like "loss of mobility of extremities" and "get bed bound".

3) Fear of lost or altered social role In relation to the previous two types of anxieties,

the patients also expressed their fear of losing their role

in the family and society as well as their dependence on carers.

4) Fear of change in body image due to tonsure Patients especially female patients worried about

the change in body image caused by tonsure and some

psychological effects of this. 5) Fear of postoperative death

Since they perceive brain as the center of life

maintenance, they worried if they could survive the surgery and whether surgery would be successful.

6) Fear of ambiguity and something unknown Though the surgery was described and they made

informed decision, they were still not very sure of the

complicated brain and nerve functions, of their own

postoperative disability and of treatment. They also have some vague fear of head incision and some of them cannot find any words to express their fear.

2. Case study

Table 3 shows what five patients (patients 10 through 14) were informed and how they perceived the

operation. All these five patients were informed of their surgery with their families with diagnostic images and other data. They were informed of histology,

surgical procedure, scope of operation, surgical approach, expected complications and expected time required for surgery etc. in detail. Case 13 had previ-

ous surgery for brain tumor excision 7 years ago and the recurrence was identified during follow-up. The

patient had no subjective symptoms and pain. All patients except patient 14 were advised to have

operation by a doctor. Patient 12 could not verbally express expectation of surgery. No patients showed

their perception of such complications following gen-eral anesthesia and craniotomy like spasm and hemor-

rhage. Case 14 showed his only perception of infec-tious complication as "bacteria entering into my

body". He said he had surgery because this is what his son agreed to the doctor.

Table 4 summarizes characteristics of fear of each

patient classified with the framework of I through VI "preoperative anxiety of craniotomy patients" .

Case 10 had symptoms of hemiplegia and amnesia at the time of admission with some difficulty in her

daily living. Her preoperative anxiety was concen-trated in I, II and III. Case 11 had decrease in right

sight and was informed of postoperative eye complica-

tions. Since he was going to marry, his anxiety was concentrated in II and III. Case 12 was informed of meningioma before admission. She believed her dis-

ease was not serious because diagnosis was not brain tumor. She was in the same room with a post

craniotomy patient who had conscious disorder bed bound. Her anxiety was concentrated in I, II and III

and expressed her fear with such words as vegetative state and sequela. Case 13 had second craniotomy.

She was informed of the change in her life from mother of two infants and the heart of a large family to an

individual possibly with crutches. Her anxiety was in II and III and expressed her fear using such words as "walk" and "run" . Case 14 had hemiplegia and articu-lation disorder. He was informed of the disease and

surgery with his son. He expressed his fear in V and VI with such expression as "getting into a coffin" and "something uncomfortable" . He, however, expressed no other fears preoperatively.

DISCUSSION

Six categories of characteristic preoperative anxiety were extracted from the interview of 9 patients (Case 1 through Case 9) and confirmed with interview and

observation of other 5 patients. Fear of change and collapse of personality was

triggered by "observation of other patients losing

consciousness", "being told of recovery of other craniotomy patients" as well as by their vague idea of "neurosurgery equals dementia" . This fear threatens the essential existence and leads to loss of self esteem as

described by Patient 10 who said "I will be a useless waste". Such low self esteem will affect their compre-

hension of preoperative orientation, progress, and decision on surgery. It is therefore necessary to assist

the patients to promote their understanding that decrease in the level of consciousness and object nam-ing is transient and a part of the normal process of

recovery. We also have to communicate with the

patients more thoroughly on the cause of such miscon-ception. A patient rooms have to be carefully selected to avoid unnecessary fear.

Fear of physical disability due to complications

became clear after information was provided by a

doctor. The doctor described general complications following general anesthesia and craniotomy but a

patient tends to be attentive to the information related to their own lesion and procedure. Their fear is often described as the paralysis of extremities and bed-bound

state. The factors related to the anxiety is : They are discouraged with the fact that some symptoms or

disabilities would be there because they decided to

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294


have operation with the expectation of improvement. They are given some information from their peer

patients. It is necessary to start rehabilitation prior to surgery if the patients have some physical symptoms or

sufferings and we have to plan a rehabilitation pro-

gram with patients. We also have to discuss about the involvement of OT/PT and have repeated conversation between a patient and a doctor if the former have some

concerns. Fear of the loss of social roles tend to appear with

the above mentioned categories of fear. Patients in the same generation as Cases 10 and 12 generally have

concerns of lo!ering physical functions and aging. People in this generation tend to be afraid of being

bed- bound and dependent on others. This type of

general fear was amplified with craniotomy. Patients with some preoperative physical disability and this

type of fear needs discussion on the use of social resources after discharge and family meeting with

nursing staff. We have to consider family intervdntion to deal with preoperative fear. Cases 11 and 13 had

issues related to the development of families. Intenional and focused information gathering is need-

ed as well as identification of personality and family development. Fear of body image change by tonsure is considered

to be less serious among the subjects as their expres-sions are concerned. Body image, however, is one of

the elements composing self concept and shows wide interpersonal and intersexual difference. Tonsure is

performed at the final preparatory stage of operation and signals a patient that he/she has to be ready for

operation. If they are not fully determined, tonsure will trigger greater anxiety. Even those who are deter-mined would start worrying the eyes of families and

others. We have to appreciate their determining to have tonsure and provide family education so that the

family and significant others intentionally express that the personal value of the patient was not affected by

the loss of hair. It is necessary of the family or nurses to accompany patient during tonsure if the person is so concerned.

Fear of postoperative death is often found among the patients who would be on systemic anesthesia or

would have long operation. Craniotomy patients show simila tendency to patients of open heart sur-

gery6). It is, however, reported that the fear is less evident among neurosurgery patients, especially tran-snasal hypophysectomy7).

Fear of ambiguity and something unknown is often

found among craniotomy patients probably because of

the characteristics of the diseases and surgical proce-dure. Patients see brain and nerves as "a control tower

which should not be touched" On the other hand, many patients do not have ebjective understanding of

the system even after information is given. It is oftes the case that doctors leave something ambiguous in

their explanation by telling them that final decision of the scope and duration of operation would be made after intraoperative histology examination. Since the

postoperative treatment plan depends on the result of histology examination, it is also difficult for patients to

have some idea of post operative sufferings and life style. It is difficult for them to see their life after

discharge. As preoperative orientation is provided around the time doctors will give information surgery,

patients are apt to be confused with such fears of change in personality and of physical disability. We

have to carefully plan the preoperative orientation, timing and content, based on the degree and types of fear of each patient.

CONCLUSION

Characteristic preoperative anxiety of adut and

elderly craniotomy patients are "fear of the change and collapse of personality", "fear of the physical disability

due to complications", "fear of change and loss of social roles", "fear of body image change due to ton-sure", "fear of postoprative death" and "fear of ambi-

guity and something unknown". It is necessary to design and utilize a guideline of

preoperative nursing care based upon the results. It is also necessary to study the effectiveness and validity of the guideline.

This study was financially suppported by Kimura Foundation for Nursing Education.

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