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

---- ----------~---"-------~--~---.------- --·---~~-----------"--

.....

17

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

REFERENCE

Hickey J.V., (2003) The c/inicalpractice of Neurological and Neurosurgical Nursing,

(5th ed). USA: Lippincott Williams and Wilkins.

Klopfenstein, C. E., Forster, A., Van Gessel, E. (2000), Anesthetic assessment in an

outpatient consultation clinic reduce preoperative anxiety. Can J Anaesth, 47(6),

511-5.

Cooke, M., Chaboyer, L.N., Schluter, P., Hiratos, M. (2004). The effect of music an

preoperative anxiety in day surgery. J. Adv. Nur, 68 (5), 362-70.

Lin, LY., Wang, R.H. (2005). abdominal surgery pain and anxiety preoperative nursing

intervention. J. Adv. Nurs 51 (3): 252-60.

Stergiopoulou., A., Birbas, K., Katostaras, T., Mantas, (2005). The effect ofinteractive

multimedia on preoperative knowledge and post operative recovery of patients

undergoing laparoscopic cholecystectomy; Neurocrit care, 60 (2), 505.

Logan, DE., Rose, JB., (2005), IS post operative pain and patient- controlled analgesia

use among adolescent surgical patients. J Pediatr psycho/, 30 (2)

187-96.

Carr, E., Brock bank, K., Allen, S., Strike ,P. (2006). Patterns and frequencyofanxiety

in women undergoing gynaecological surgery. J Clin Nurs, 15 (3),

341-52.

Deyirmenjian, M., Karam, N., Salameh, P.(2006) Preoperative patient education for

open heart patient source of anxiety. Patient Educ couns, 62 (1), 111-7.

29

Reuber, M., Andersen, B., Elger CE. (2004), Depression and anxiety before and after

temporal lobe epilepsy surgery. Patient educ couns, 13 (2), 129-35.

Kiyohara, LY., Kayano, LK., Oliveira, L.M., Younamoto, M.U. (2004) Surgery information

reduces anxiety in the pre operative period. J,Anesth, 59 (2), 51-6.

Rymaszewska, J., Kiejna, A.(2003) Depression and anxiety in coronary artery bypass

grafting patients.J Neurosurgery, 18 (4) 155-60.

Cardoso, A.C., Fernandes, Y.B., Ramina, R., Borges, G., (2007) Acoustic neuroma

(vestibular schwannoma) . Surgical results on 240 patients operated on dorsal

decubitus position. Arq Neuropsiquiatr, 65(3A) 605-9.

Thibult, M.; Girard, F., Moumdijian, R., Chouinard, P., Boudreault, D., Ruel, M. (2007)

Br J Neurosurg, 54 (7), 544-8.

Rocha- Filho, P.A., Fujara, F.J., Gherpelli, J.L., Rabello, G. D. (2007) The long term

effect of craniotomy on temporalis muscle function. Arq Neuropsiquiatr, 70 (2)

505-5.

APPENDICES

a roo (J)l <n» 6 6> s <lml cru 6 ru ru6 t2lO mfl 6Tl.lm.L>6> r;HS 6 cmm l<n» J o, 630 c.1::1ao ril::lm 12lJ O'Bo.JJ o o.J1CTB o.JJ

12lJ~ 00 mcrul.e, <lmlCllmill o.J rol auoo wl.BG> J <m<U>l mo<n> 6 o <lml<U>16> e.J ao.Jo roo a$' t2lc&uB nQ)6>cm

n.Jo61U'IID 6 12lmrw1 e.~od36>1 <U>ro 6 cm<U>lm~ o Gro>ocro nJl<8GpJI2lO<I» J o cru/Zl2l <U>l.oo ~em 6· @an 63(!) J n.Jol

((ll'O)amJ>16)~ t50(J)£2lO<I»om). @'D o.Jom<mmlm aru6llS1 6TIDocro crun.Oc&..ro1~J6>c&o~o6>t2lm5 <TUIZI2l

(()) 1.86) 6 (ffi 6'

THE STATE TRAIT ANXIETY INVENTORY

(ADOPTION AND TRANSLATION OF SPEILBERGER'S

STATE TRAIT ANXIETY INVENTORY)

ruw<'h\1 ......................................................... ..

<rUvrn"lfn.~&«>&rii:::I<'ID ............................................... .

00t3_,\0f'!~Ocru OCDJO(I)~(O) ...................................... ..

.a. &SJo6l'l.IOo(f)6US~J6'>S o{l)opJo .............................. ..

ailruoon1(0)( o&) 1 ~o.nruoon1(0)( em) ........................................ ..

l n.J(l))1mo cru cB:> ;~ s ;so 6l'l.l ru ro ,l 00 mo ............................................... .

mmltB tnJcNIIDOQJ(T) li3(0'l.ooQJllll11jl ~c~~o tli'LBG>QJ:)Ol o om w 0

~C~l~~

1. oQ>mW UOO<mHID ('9l3(nJ$Ql6l~SJ<'mJR 1 2 3 4

2. oa>m1t.GE5 O'UJ0<9.!:f1!l»<<DJo <:<!DO<mJ<mJri 2 3 4

3. oa>m1~ r:acmo<n>amm~o @GmO.a.oaJri 2 3

4. oQ>o1lt.GE5 ~oo.rocruo cro>O<mJ<m&ri 1 2 3 4

5. n4)m1cBG) amcru.KTU.Oro> <f.mmJiinJ6l~S~<mJn 1 2 3 4

6. OKmJOA..I00QlJ<m ml<&SOUll61m6l@.OOJ01-2JJ~

~cB.Je.l.o..flmn n(j)oilc86l1C~ O<IDO<mJ<mJR 1 2 3 4

7. n4)m1cBI5 ofltool2lo e.~rs1~ano<n>1

<mCOJiinJ6l(,tj$J<m l~• 1 2 3 4

8. n4>mW fl«f1.&6l"{So <f.mmJ~ru6lrus&<m~GI'E 1 2 3 4

9. n4)m1.aGJ <TUJ6l.Jo C<IDO<mJ<mJri 2 3 4

10. oQ>m1.aGJ ~arr:anfl~m>o

<mCOJfSQ.I6l(,tjSJ<mJW 1 2 3 4

11. n4)m1t.GE5 <f.m6l6lill;o\0lo cro>o<mJ<mJri 2 3 4

12. n4)m1.BG) nll011llJO JcB6>o {'9l3ffiJfin16>~J<m&ri 2 3 4

13. n4Jo1l.aGl nflt(Jl)0o <f.mmJiinJG>tHs~<m~ri 1 2 3 4

14. n4)oil~ cruoa».\nJ<IDl cro>ocmJ<mld 1 2 3 4

15. n(t)m1~ o1lmooo o<IDoonJ<m~ri 2 3 4

16. lil'O)O<i& 6lnJ6l§tm ofl.a.000~01S«mn1m

<mS1Q)6)c,t:ISJ<mJtil'E 1 2 3 4

17. oQ)ml.aGJ ~mmo O<mo<mJcmlri 1 2 3 4

18. n4)m1cBG) LnJ<ru<mro> cro>om>~cm.lri 1 2 3

J

m1~cg®G~Mu3

(j)(j)<Jffios1m m1nfl(1J)(l)lll)lafll «D<nJ<iCli6>~SOOJail .a..ileJ cOJOa)l Gmu3 (1J)OfJ)IPfJ)c86lOSJanm1co1.ooJanl.

ClmCY\)0(.l)OC06Jl><DlOtnll m1ti?JB(I3dJ5} nmt.(U)Cam»OOo <ma<nJti<lJ6)~JcmJfJ)OJOl)ml ~4ii(1J)IDO<Dl(1J)1<nlC<nfJ)CO

X<tmS<DIO~anm1ell6>S C~6l.f6)~SJClJimlcOJ,

mm.tro ln.lmJ CO>OOJfiJ Q(OlsQQJ~1211il C'lJ'jlO~lO 12!'lca6>nJ001o nG)'fijOIDC<,HO!I>6o

19. ng)ID1~ 0<Y>O'UJ6Uo C<m::>OT>OOJri 2 3 4

20. n@ffilcOO 6)nJ6>acm .a.9:fl6mo C<m::><m::>OJri. 2 3 4

21. n@m1<£MS c£b06'ffi<D>6JT>6)12lrr0 cano<moo &ri 1 2 3 4

22. 12lg,l~OJ6>mc~6>e.J crucmnon!J:il~to1o:66)::>mJ~

~tWnDo nQ)ffilcB6>J~ 2 3 4

23. 6ln.J6)3rr0 <ID1i'OJI2lO<Y>6tJB<J8 n4)SJ.B6)JOJO<T&

Cl1.lOW'lcoo::>am»<mJI2lle.Jo nJe.J mn!l;is60B~Uo

nq>m1d96>J61"80c&..OOJ6'18'. 1 2 3 4

24. n4)ffi1.aoJ nflt.(R)0o !Gla<Y>JiiOJ6>~SOOJri 1 2 3 4

25. nQ)m1cB6l O'UJ<ru..o<m<D>~o <RJornn<m<D>Jo

!mffi.}@Cl16>c;HSOO .}~ 2 3

26. nQ)m1cB6l nflt\9::1W<mc£b<J8 ru0ru>1.a6>Jc&..(D)Jo

tmCJ6><D> <ma>6JT>o 6).QJ~JOJO<T& .a.!9l<D>00<tn<D>.lo

01000Jom 1 2 3 4

27. m1q~p«>c£b::>0l6!JB6>@d96>J01~ 6Ta)o<l&

.!l.fi(lll)Oc&..Je.I<Y>Oc&..OOJri 1 2 3 4

28. nQ)ffikOO (I'\)<JrnJ')Oo!t::1QlJorB 2 3 4

29. OUOW006ffi c&..Oi'O.,\fitJBuD .a.o1m00<D>l0aS~d:)QJOT>

lnJ<l.l6m<m n4)ffilcB6>~ 1 2 3 4

30. n@mlcBfS O'UJ0cBil:fl®®Jo C<tnO(TT)OOJri 1 2 3 4.

31. n4)()")'lcB6) mlcoo·(R) @61"80¢hOOJ~ 1 2 3 4

32. n4)m1cB6l auo<mlrJ<m1 ccmocrnonJri 1 2 3 4

33. (9T1JtnJWOffi00<D> .!l.ile.J !Ulm».a.<J8 n4)6lcm

nfln!1:1121lc;H1cB6>00 Jri 2 3 4

34. m,nfl®6>6>ffii'OOC/0.,\6tJBuD (J)'!,100JnJlc8C]J-

6ll2lSJo:66)Jc&..Ol>Jo. 0m't\11Co'8 rrilan <maOJ6l(D) 1 2 3 4

l2lOg.laJO<T& .a.w1~::>o1~

35. a:uo10Ailt'Olm<D>.l~ OI.,\&KQ)lCDJ06TOJ 6tO'>Oa3 1 2 3 4

36. «!mSJ.rotmJc&..Oe.lt'OlmJ nQ)01 ffi)o0@6tJB6>@

c&Jol~Jo <m::>eJnJ0.,\6tJB6>@cS6lJ01~Jo 2 3 4

~Ce.JOAflcB6>JOOlJOuD nQ)ffil.a6>J /il<JffiO

<ruam0~12llGrn:Oca.JOl>J.

N.B: "4)~0 C!:IJOB.,\<mmlmJo @rot!J)0o n4)1PJ<ml<D>laJ061"80 oQ)rrO rnmlcS6lCo'8ce6>lS1 nJm1c<RJoWlo:66)JcEb.

Speilberger's State - Trait Anxiety Invetory

Score of State Anxiety

Sl.No. 6lG>1ut<iU~JltD1fjJ O.lfitC«M()'Plo CDlcOQOJ()OlO D3J~iJ:><I»c: tl.lOt'lo

1. 4 3 2 1

2. 4 3 2 1

3. l 2 3 4

4. 4 3 2 1

5. 1 2 3 4

6. 1 2 3 4

7. 4 3 2 l

8. 1 2 3 4

9. 4 3 2 1

10. 4 3 2 1

ll. l 2 3 4

12. 1 2 3 4

13. 4 3 2 I

14. 4 3 2 I

15. 1 2 3 4

16. 1 2 3 4

17. 4 3 2 1

18. 4 3 2 1

1 I

Score of Trait Anxiety

SLNo. 6l<a1c86leJ~IB~

19. 4

20. 1

21. 1

22. 1

23. 1

24. 4

2.5. 4

26. 1

27. 1

28. 4

29. 1

30. 4

31. 1

32. 4

33. 1

34. l

35. 4

36. 1

Cll'iJC~I'~o tB1c86l<ll00lO nO'Jfi!:JUCtUOt>lo

3 2 1

2 3 4

2 3 4

2 3 4

2 3 4

3 2 t

3 2 1

2 3 4

2 3 4

3 2 1

2 3 4

3 2 1

2 3 4

3 2 1

2 3 4

2 3 4

3 2 1

2 3 4

r

ng)~O <J(l)O(J)1db<J8ca6>lo (fl)mll®ldb1CD> ng)CTTll <JdbWcB6>l<Jm.IO<J8 <fm>e.J§6CTTl dbOro~Ql06YT) <Jn..JS1<D>lo

<m0(fl)IBl<D>l o. (fl)mllCIDldb 1<D>CD>l6'>S <m00J(fl)~&ffi u8 CD>LDOldbQlmm>1am n.J06Tlm5>l6'>db0Sl arm> om& 63rol

n..Jrn1u5l<1..16)(l) <Jn.JS1CD>lo ~(fl)!BlCD>lo dblOa»'cB6>000 crun.DO<D>lcB6>lCTTll. CID06'>Wn.JOCD>lcm dbOro~&mu8

m1&m®,6)S ~crodb6YT)o dblOcB6>ocm crun.DoCD>1cB6>lo.

cruoworoomm>om>1 (fl)mllCIDLdb1cn>c66) 63rola1rucruo Qllcmn.J am>cWQl1g 6'>.c..J~lo. ruodlcw1e.Jl~ ml9cru

m1&m <J8ce6) «3'f0(fl)ln.JLCID1 m1<D>Ql&m 6'>@a::JQ1 n..J06Tlm5>l crorolo. (fl)mlLCIDldb 1CD> 6'>.c..l~l em @0(J)6'>ams>

aroOQlo a>lcB6>dbCD>lo 6TlJ1gocw1cm ~n..J<JCD>O(J)1.oJ OJ~ams>1CD>OcB6>6db<ll>lo 6'>.c.J~lcm6. @®1mom>1

m16tm6'>~ ffiWCTUlo CTUn.DOCD>1CD>6o CTUnDOCD>1cB6>6o. roOtCID1 @cfW6Tnams>1m&<J(fl)n9::1o <JOJ6'>0

@cfW6Tn6tm<J§O 6'>0J~<IQlO dbW1cB6>000 n..JOS1~.

rn 0 OJ16'>e.J 6n.J1Q 0 (U)1 em ~n.JQ CD> 0 (J)1.oj nfl6ll'i 6 o db l @1cB6> l db. @em am> om l6ru OW CIDSCD> 000

CYUn.DO<D>1cB6>6CTTl6. am>cro1ml<Jcion9::1o <m0~6ruCJCD>0§1cB6>1~ 6'>SmlQ <JSOml @6TllllcfWOO m16tm®,6'>S

db~1am mamdblo. @6TllllcfWOO OJ.aj mlLQe.Jams)' 6'>.o.J001.aj1<Je.JO CIDS1Ca::JO ~6'>611'i&1am ml9cru1amoS'

n..JO<D>lc&.m1&m6'>@ 630it:I<JOn9::100 an1aCD>go1ce.JcB6)' QlOQlCTTl®60J6'>ro 6ruaw6cB6>@6o miP'crulo

m16lm§66)S dbl6'>S ~6ll'S00Jlo.

QlCD>cB6>6m> ccwocfb'sdl m1&m§66'>S db~1am db~Offile.J @S6c&CD>6o .c.J1e.J Qlro6CTTl6dbu8 croroldb<D>6o

6).o.J~6o. @aD m1&m6'>@ mcmoCD>1 ~06lmocm crun.DOCD>1cB6>6o. (fl)mllCIDLdb1@cB6>6 CJ(fl)n9::1o m1&m6'>@

NSICU ru1ae.JcB6)' Ql0Q6o.am>OJ16'>S m~ CYUoOJ1wom&m§6o Ln.J<JCID~dbo n.Jro1(fl)1e.Jmo e.J@1.aj

acwocfb'scf>morolo m19cru&QlOro6o ~6ll'i0db6o.

NSJCUru1as?,

~6mro~am.Jou8 m16tmu8 NSICU n.ne~om>1ro1cB6>~o m16tm~~6)S nD~B<IDQl1s1:J, 6'fll1nJl QlQ~o

<IDC>o1m>~ruomom>1 o.JeJ@o.Jc&Cb6m6tffi@~o m16tm@~6)S <JQlam ne.~s1ad1.cJl§.l~OCll~o. m1Eitmm6)s

ruom>1am Ul>Jcru1cB6>~cm<m1mom>1 63ro~ s~l6Yll' @~Om>1m1cB6>~o, <IDC><m1moas?, m1Eitmu8cB6)'

cruocruoro1cB6>ocro ~ru1~. m1Eitm u8c:B6)' <mm16)m> Ul>Jcru1c86> oo8 ~ <1..1~ em as>~ <1..16)Cb ~ s~ 6Tll'

m1&m@~6)S ruom>1as?, as>6)m> @~0<1..1~o. s~ml' QlOQ1 4-5 Ql6m1cB6>l01m~~1as?, m1Eitmu8cB6)'

db~S1c:B6)~<1..10ciD 6)ClJ~o as>Cb~o. <J<1..113ffi db~O<ID~ClJOffi~~ QlCb~m>~o m16m3u8cB6>~

croro~cmcroom>1ro1c86>~o.

63cm~roEill'i" a1rucruo c&\P16JmiDoas?, CT>16tm6)@ ruoc&cw1ae.JcB6)' QlOQ~o. oiD~O a1rucruru~o

m1&m m6)s~aa>O(J)~m1eJ6)<IDcB6>~01.cj6Tllm.o~ cB6><J@OS acwocibsc& cruocruoro1cB6>~ cmcroo6Yrl'.