RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA, BANGALORE.

ANNEXURE - IIPROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the candidate

and address(in block letters)

Mrs. BINCY THOMAS

SAHYADRI COLLEGE OF NURSING,

SAHYADRI CAMPUS, NH-48, ADYAR,

MANGALORE-575007.

2 Name of the institution SAHYADRI COLLEGE OF NURSING,

SAHYADRI CAMPUS, NH-48, ADYAR,

MANGALORE-575007.

3 Course of study and subject M.Sc. NURSING, MEDICAL SURGICAL NURSING

4 Date of admission to course 04/07/2011

5 Title of the topic:

EFFECTIVENESS OF FOOT AND HAND MASSAGE ON PAIN AND SELECTED

PHYSIOLOGICAL PARAMETERS OF POST OPERATIVE PATIENTS AT

SELECTED HOSPITALS IN MANGALORE.

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6 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Pain and death are part of life. To reject them is to reject life itself ”

-HAVELOCK ELLIS

Safety is one of the basic needs of human life. Physical safety is the most

sensitive aspect for anyone. When there is threat to ones physical safety that may result

in physical injury and pain, man becomes less efficient and this is reflected in all

dimensions of human activities. Pain is common unpleasant feeling as a result of tissue

injury. This might be the reason for people to hesitate various surgical treatments inspite

of its potential advantages. Physiological responses to pain create harmful effects that

prolong the body's recovery after surgery. Patients routinely report mild to moderate

pain even though pain medications have been administered postoperatively.

Complementary strategies based on sound research findings are needed to supplement

postoperative pain relief using pharmacologic management. Foot and hand massage has

the potential to assist in pain relief. Massaging the feet and hands stimulates the

mechanoreceptors that activate the "no painful" nerve fibers, preventing pain

transmission.

6.1 NEED FOR THE STUDY

The word abdomen is derived from the Latin abdere , meaning concealed or

un-seeable. Abdominal surgery includes a variety of surgical procedures performed on

the organs and conduits of the digestive system. These procedures include the repair,

removal, or resection of the esophagus, liver, stomach, spleen, pancreas, gallbladder,

colon, anus, and rectum. In 2010, Data monitor estimates that there were 7.4 million

major abdominal surgeries. This number is not expected to change significantly,

growing to 8.1 million surgeries in 2020.1

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According to recent study findings, a small minority of patients undergoing

abdominal surgery are at high risk for postoperative complications that may lead to

prolonged hospital stays. In a study of 235 patients who underwent abdominal surgeries,

47% had at least one postoperative complication majority related to pain, with the length

of hospital stay at 11 days compared to those without complications with length of stay

at six days.2

Despite improvements in perioperative care, major surgical operations are still

followed by sequelae such as pain, organ dysfunction and prolonged convalescence. It

has been assumed that sufficient pain relief will improve the surgical outcome with

reduced morbidity, need for hospitalization and convalescence, and there is a common

consensus that optimal (dynamic) pain relief is a prerequisite for early postoperative

recovery. The availability of analgesic drugs and pain relieving techniques has not been

much effective and pain remains a common problem and a significant fear for the

patients in postoperative period. Instead of unimodal treatment, a multimodal effort has

been proposed to include effective control of postoperative pain as it is caused by

interaction of a number of physiological and psychological factors. As the patient is

confined to bed passive exercises and massages are relieving factors for the post

operative pain. Foot and hand massage are considered as therapies that provide some

benefits and they have no side effects as compared to the side effects of pain

medications

Inadequate pain relief, particularly upper abdominal surgery, may cause pulmonary

dysfunction and an increase in postoperative pulmonary complications. Involuntary

spinal reflex responses to the noxious stimulus from the injured area result in reflex

muscle spasm in the immediate region of the injury as well as the surrounding muscle

groups, which prevents movement in this area (ie, splinting), with subsequent

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hypoventilation and hypoxemia. In addition, pain can cause diaphragmatic dysfunction,

which further impairs ventilation. After upper abdominal surgery, vital capacity

decreases by 40% to 60%, with a greater decline in the elderly than in younger patients.

Increased sympathetic activity from severe pain increases gastrointestinal secretions and

smooth muscle sphincter tone while also decreasing intestinal motility. This partly

accounts for the gastric stasis and paralytic ileus, particularly after abdominal surgery.

In addition, opioid analgesics may also contribute to decreased intestinal motility.

Unrelieved pain can increase the incidence of postoperative nausea and vomiting.4

The postoperative patients need some interventions that can be useful

along with pain relieving medications or other than pain relieving medications. Foot

and hand massage are considered as one of the complementary therapy for pain. So this

method can be implemented for the postoperative patients who have genuine pain. As

pain management is one of the challenging responsibility of nursing care, there is an

obvious need for giving no pharmacological management such as foot and massage for

reducing post operative pain and stabilizing physiological parameters among patients

undergone abdominal surgeries.

A study was conducted to assess the effects of foot massage on the cancer

pain. Eighty seven patients participated in the study and each received a 10 minute foot

massage 5 minutes on each foot. The results revealed that the treatments produced a

significant and immediate effect on the patients’ perceptions of pain and relaxation

when measured with a visual analog scale [ p<0.1].3

As the patients undergoing surgery were experiencing many side effects due to the

inevitable use of analgesics post surgery the investigator felt the need to provide non

pharmacological measures such as foot and hand massage as a measure for pain

management.

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6.2 REVIEW OF LITERATURE

A study using pretest post test design was done to investigate whether a 20

minute foot and hand massage (5 minutes to each extremities) which was provided 1 to

4 hours after a dose of pain medication would reduce pain perception and sympathetic

responses among post operative patients. A convenience sample of 18 patients rated

pain intensity and pain distress using numeric rating scale. They reported decrease in

pain intensity from 4.65 to 2.35(t=8.154,p<0.01) and in pain distress from 4.00 to 1.88.

Statistically significant decreases in sympathetic responses to pain that is heart rate and

respiratory rate. Thus pain was reduced by the intervention showing that foot and hand

strategy for postoperative pain management3

A randomized control study was conducted to assess the efficacy of foot

reflexotherapy as adjuvant therapy in revealing pain and anxiety in postoperative

patients with gastric cancer and hepatocellular cancer. Sixty one patients were randomly

selected for intervention [n=30] or control [n=31] group. The patients received usual

pain management measures along with 20 mins of foot reflexology during postoperative

day 2,3 and 4. Patients in the control group received only usual pain management. Using

generalized estimated equations and controlling for confounding variables less pain

[p<0.05] and anxiety [p<0.05] overtime were reported by the intervention group

compared with the control group. In addition patients in the intervention group received

significantly less opiod analgesics than control group [p<0.05]. thus showing the

effectiveness of foot reflexology.4

A randomized controlled experimental study was conducted to determine the

efficiency of foot and hand massage on reducing postoperative pain in patients who had

cesarean operation. The result was reported that the reduction in pain intensity was

significantly meaningful in both intervention groups when compared to the control

group. It was also noted that vital findings were measured comparatively higher before 5

the massage in the test groups, and they were found to be relatively lower in the

measurements conducted right before and after the massage, which was considered to be

statistically meaningful. Foot and hand massage proved useful as an effective nursing

intervention in controlling postoperative pain.5

A study conducted in Germany found reflexology to be as helpful to patients

with headaches as medication (flunarizine). In a blind random trial,25 women and 7

men randomly assigned to two groups. One group was given a placebo and received of

medeflexology treatments two times a week for two or three months, The other group

received Flunarizine treatment and massage of a non -specific area twice a week for 12

sessions. Patients were evaluated at the end of the study and again three months after the

study. It was concluded that the reflexology treatment was effective as the Flunarizin

treatment and may be classified as an alternative non-pharmacological therapeutic

treatment that would be particularly appropriate to those patients that were unable to

follow pharmacological treatment.6

A randomized-controlled study examined the effects of foot massage on patients'

perception of care received following surgery. The sample of 59 women who underwent

laparoscopic sterilization as day case patients were randomly allocated into two groups.

The experimental group received a foot massage and analgesia post-operatively, whilst

the control group received only analgesia post-operatively. Each participant was asked

to complete a questionnaire on the day following surgery. The 76% response rate was

comparable with other patient satisfaction studies following day-case surgery. Statistical

analysis showed no overall significant difference in the pain experienced by the two

groups; however, the mean pain scores recorded following surgery showed a

significantly different pattern over time, such that the experimental group consistently

reported less pain following a foot massage than the control group.7

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Twenty-two adults with wrist/hand arthritis were randomly assigned to a massage

therapy or a standard treatment control group. The massage therapy group was

massaged on the affected wrist/hand once a week for a 4-week period and were also

taught self-massage on the wrist/hand that was to be done daily at home. The group by

repeated measures MANOVA was conducted on the of pre–post session measures on

the first and last day including the self-reported pain, grip strength and

anxiety/depression mood state measures. The significant MANOVA (F ¼ 23.14, Po.01)

was followed by ANOVAs on each of the dependent measures. Interaction effects

revealed by ANOVAs were as follows: (1) reduced pain, F ¼ 5.89, Po.01; (2) increased

grip strength, F ¼ 4.11, Po.05; (3) lower anxiety, F ¼ 4.26, Po.05; and (4) lower

depressed mood levels, F ¼ 5.13, Po.01. Post hoc Bonferroni tests indicated significant

changes for the massage group on all of these measures after the first and last sessions

and by the end of the study.8

A quasi-experimental research study in which a five-minute foot massages was offered to 25

patients (68 sessions in total) as a stress-reduction intervention. Repeated measures design was used

to collect data before, during and after the intervention. Physiological data (heart rate, mean arterial

blood pressure, respirations and peripheral oxygen saturation) were obtained from the patient bedside

monitoring system. Repeated measures analysis of variance indicated a significant decrease in heart

rate, blood pressure and respirations observed during the foot massage intervention. Results indicated

foot massage had the potential effect of increasing relaxation as evidenced by physiological changes

during the brief intervention administered to critically ill patients in intensive care.9

6.3 PROBLEM STATEMENT

EFFECTIVENESS OF FOOT AND HAND MASSAGE ON PAIN AND

SELECTED PHYSIOLOGICAL PARAMETERS OF POST OPERATIVE PATIENTS

AT SELECTED HOSPITALS IN MANGALORE.

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6.4 OBJECTIVES OF THE STUDY

The objectives of the study are –

1. assess the pretest and posttest pain and physiological parameters of

postoperative patients in experimental and control group.

2. determine the effectiveness of foot and hand massage on pain and selected

physiological parameters of postoperative patients.

3. find an association between pretest level of pain, physiological parameters and

selected demographic variables of postoperative patients.

6.5 OPERATIONAL DEFINITIONS

1) EFFECTIVENESS

In this study effectiveness refers to the extend to which foot and hand massage

reduce pain as measured by numerical pain scale and stabilize selected physiological

parameters such as pulse rate, respiratory rate and blood pressure of postoperative

patients.

2) FOOT AND HAND MASSAGE

The scientific manipulation by the investigator using fingers over the sole of foot

and palm of hand through stroking, rubbing, kneading or tapping for a duration of 20

minutes twice daily for the first three post operative days in order to improve muscle

tone and to relax the patient.

3) PAIN

Subjective unpleasant feeling due to surgical procedure experienced by the

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patients during the first 3 postoperative days as measured by scores of numerical pain

scale.

4) SELECTED PHYSIOLOGICAL PARAMETERS

In this study it refers to respiratory rate and peripheral pulse rate of patients

during first three days of postoperative period.

5) POSTOPERATIVE PATIENTS

Male or female subjects undergone open abdominal surgeries as a treatment modality

for abdominal disorder.

6.6 ASSUMPTIONS

The study assumes that –

pain is one of the major issue experienced by the patients in the postoperative

period.

postoperative pain needs adjuvant therapeutic interventions along with

analgesics.

pain influences patients’ physiological parameters.

6.7 DELIMITATIONS

Study is confined to selected hospital of Mangalore, Karnataka.

Study is confined to only patients who have undergone open abdominal surgery.

6.8 HYPOTHESES (All hypotheses will be tested at 0.05 level of significance.)

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H1: The post test score of pain and physiological parameters will be significantly less after foot and hand massage than pretest score among post operative patients

H2: There will be a significant reduction in pain and stabilization of physiological

variables among patients those who receive foot and hand massage than who do not

receive foot and hand massage.

H3: There will be significant association between pretest level of pain, selected

physiological parameters and demographic variables.

7. MATERIAL AND METHODS

7.1 SOURCE OF DATA

Data will be collected from patients who have undergone abdominal surgeries in

selected hospitals in Mangalore, Karnataka.

7.1.1 RESEARCH APPROACH AND RESEARCH DESIGN

Quantitative research approach will be used for this study.

Quasi experimental design in which Non equivalent control group pre-test post-test design will be used in this study.

PRETEST TREATMENT POSTTEST O1 X O2

O1 _ O2

O1- Pretest assessment of pain using pain scale and selected physiological parameters.

X- Administration of foot and hand massage.

O2- Posttest assessment of pain using pain scale and selected physiological parameters.

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7.1.2 SETTINGS

Study will be conducted in selected hospitals of Mangalore,Karnataka.

7.1.3 POPULATION

Populations of the study include postoperative patients who underwent selected

abdominal surgeries.

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling procedure Non probability purposive sampling technique will be used to select the samples. Samples will be allotted to experimental and control group by non random bases.

7.2.2 Sample size

The sample size of the study is 40 in which twenty are in in the experimental group and

twenty in the control group.

7.2.3 Inclusion criteria for sampling

Post operative patients who underwent abdominal surgery

who are in age group of 20- 60 years

7.2.4 Exclusion criteria for sampling

Patients who are contraindicated for foot and hand massage.11

Patients who got disorders or deformities of upper or lower extremity.

Patients having altered level of consciousness.

Patients using any other non pharmacological interventions for pain.

7.2.5 INSTRUMENTS USED

Demographic proforma including age, gender, education, occupation, previous surgical history.

Numerical pain scale

Clinical proforma including respiratory rate and pulse rate.

7.2.6 DATA COLLECTION METHOD

Formal administrative permission will be obtained from concerned authorities of the hospital.

The nature and purpose of study will be explained.

Informed consent is obtained from patients.

Assess the pretest post operative pain using numerical pain scale and assess physiological parameters.

Administer the intervention of foot and hand massage for experimental group.

No interventions will be given to control group.

The pain is again assessed using numerical pain scale and assessing physiological parameters.

7.2.7 DATA ANALYSIS PLAN

Demographic data will be analysed using descriptive statistics-mean,median, 12

frequency, percentage and standard deviation. Effectiveness of foot and hand massage on pain and physiological variables will

be analysed by paired t’ test and independent t’ test.

Chi-square test will be used to find out association between pretest level of pain, physiological parameters and demographic variables.

7.3 Does the study require any investigation or interventions to be conducted on subject or other human or animals?

Yes, as a part of study foot and hand massage will be administered. on subjects who have undergone abdominal surgeries.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Ethical clearance will be obtained from concerned authorities.

Formal administrative permission is obtained from concerned authorities.

Informed written consent is obtained from subjects.

LIST OF REFERENCES

1. Health Statistics: Major abdominal surgery – A key risk factor for deep vein thrombosis and pulmonary embolism. Industry reports. 2011.

2. Lang, M. Outcome and resource utilization in gastroenterological Surgery. British Journal of Surgery. 2001; 88:1006–14.

3. Wang HL, Keck JF.Foot and hand massage as an intervention for post 13

operative pain. Pain management nursing .2004; 5(2):59-65.

4. Girish PJ, Babatunde O.Consequences of inadequate post operative pain relief and chronic persistent postoperative pain. Anesthesiology clinic of north America.2005; 7(4):2-36.

5. Grealish L, Losmania A, and Whiteman B. Foot massage a nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalized with cancer. Cancer nursing.2000; 23(3):237-43.

6. Tsay, Shiow L, Has OL. Effects of reflexology on acute postoperative pain and anxiety among patients with digestive cancer. Cancer nursing.2008; 31(2):109-11.

7. Degirmen N, Ozerdogan N, Sayiner D, Kosgeroglu N, Ayranci U. Effectiveness of foot and hand massage in post caesarean pain control in a group of Turkish pregnant women. Applied nursing research.2010; 23(3):153-8.

8. Olivia rosewood. Hand reflexology; a headache break. Healthy living newspaper.2011.

9. Hilme J, Waterman H Hillier VF. The effect of foot and hand massage on patients perception of care following laparoscopic sterilization as day care patients. Journal of advanced nursing.1999; 30(2):460-8.

10. Tiffany F, Miguel D, Maria HR. Hand arthritis pain is reduced by massage therapy. Journal of bodywork and movement therapy.2007; 11(1):21-24.

11. Hayes J, Cox C. Immediate effects of a five-minute foot massage on patients in critical care. Intensive Critical Care Nursing. 1999; 15(2):77-82.

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