EFFECTIVENESS OF PREOPERATIVE PATIENT ASSESSMENT

BY PERIOPERATIVE NURSES IN PREPARATION FOR

SURGICAL INTERVENTION

AT STUDY AT KENYATTA NATIONAL HOSPITAL, NAIROBI,

KENYA

OMONDI LILIAN ADHIAMBO

MScN, BScN, KRPoN

A PROPOSAL SUBMITTED IN PARTIAL FULFILMENT FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY OF UNIVERSITY OF

NAIROBI.

JUNE, 2010

DECLARA TION

This thesis proposal is my original work and has not been presented in any other

institution for examination

Sign ~ .

IS'H -ju rv £ ~ 0 I 0Date .

CERTIFICATE OF APPROVAL

The proposal has been developed under supervision and approval ofthe following

Supervisors;

1. Dr. Grace Omoni.

Senior lecturer School of Nursing Sciences, University of Nairobi

..~ .

2. Dr. Mary Wangari Kuria. (PhD, Psychiatry UoN, MMed Psych UoN, MBChb UoN).

Lecturer, School of Medicine, department of psychiatry, University of Nairobi,

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DEDICATION

This work is dedicated and to my family for their continuous support and to the honor of

the late Professor Joyce Musandu for her inspirations.

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ACKNOWLEDGEMENT

I am very grateful to my supervisors Dr. Omoni, Professor Ogendo and Dr. Wangare for

their devotion, moral and academic support.

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TABLE OF CONTENT

DECLARATION ii

CERTIFICATE OF APPRO VAL ii

DEDICATION iii

ACKNOWLEDGEMENT iv

TABLE OF CONTENT v

LIST OF FIGURES vii

OPERATIONAL DEFINITIONS viii

ABBREVIATIONS xi

ABSTRACT xii

CHAPTER 1: INTRODUCTION 1

Background Information 1

CHAPTER 2: LITERATURE REVIEW 4

Problem Statement 11

Justification 12

Research questions 13

Research hypothesis 13

Aim 14

Specific Objective 14

Theoretical frame work of the study 15

Conceptual Frame work of Nursing Perspective of Surgical Care 19

Flow of the Study 20

CHAPTER 3: STUDY METHODOLOGY AND MATERIALS 21

Phase One: Formulation of preoperative patient assessment tool 21

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Phase 2: Evaluating the formulated tool for effectiveness 27

Phase 3: Testing the designed tool in enhancing anxiety reduction as a surgical

outcome 30

BUDGET 39

GANTT CHART 40

REFERENCES 41

APPENDIX 1: GUIDING QUESTIONS FOR THE WORKSHOP .45

APPENDIX 2: PREOPERATIVE CHECK LIST 46

APPENDIX 3: GORDON'S TYPOLOGY OF 11- FUNCTIONAL HEALTH 47

PATTERNS GUIDE LINES 47

APPENDIX 4: A DAMMY OF THE PREOPERATIVE ASSESSMENT TOOL 48

APPENDIX 5: AUTHORITY TO CONDUCT STUDy 51

APPENDIX 6: QUESTIONNAIRE EVALUATING THE DESIGNED

PREOPERATATIVE ASSESSMENT TOOL 52

APPENDIX 7: CONSENT EXPLANATION FORM 56

APPENDIX 8: FORM YA KIELELEZO CHA KIBALI 57

APPENDIX 9: PATIENT ANXIETY EV ALUATION 58

APPENDIX 10: APPENDIXMASWALIYASEHEMUYATATUYA UTAFITI; 62

UKAGUZI KUHUSU JINSI MGONJW A HANA VYOJIHISI KUHUSU HOFU YA

UP ASU AJI 62

APPENDIX 11: AMSTERDERN PREOPERATIVE ANXIETY INFORMATION 65

SCALE 65

APPENDIX 12: MAP OF KENYATTA NATIONAL HOSPITAL 66

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LIST OF FIGURES

Figure 2.1: Study Flow Chart , '" 20

Figure 2.2: Flow Chart 21

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OPERA TIONAL DEFINITIONS

Amsterdam preoperative Anxiety and Information Scale a designed tool for

measuring situational worries of a surgical patient related to the surgical procedure,

anesthesia and desire for more information regarding the surgical process measure on a

five dimensional linkert scale. Modification of the tool includes component of hospital

bill repayment and family role play to suit the local situation.

Anesthesia is a deliberate creation of painless and muscle relaxation state by the

anesthetist to a surgical patient with or without loss of consciousness achieved by use of

drugs to ease the surgical process. Anesthetist is a medical doctor a nurse or a clinician

trained to administer anesthesia.

Anxiety is an emotional reaction elicited by stress, fear and worry of surgery. In the

study context, anxiety will be measured by the patient's perception of his/her anxiety

related to hospitalization, surgery and surgical outcome and the effect thereof on his/her

family using modified Amsterdam preoperative Anxiety and Information Scale (AP AIS).

Assessment in this context refers to preoperative evaluation of a surgical patient during

preoperative ward visit or upon reception to the operating room by the perioperative

nurses in order to complete the preoperative preparation while gathering data pertinent to

the planning of actual surgical care of the patient and documentation of such evaluation.

Checklist is a list of reference to verify specific items of preoperative preparation of a

surgical patient. It is usually filled in the surgical ward and completed when the patient is

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finally handed over to the theatre nurse receiving the patient. The list varies from hospital

to hospital although the key concepts are the same according to World Health

Organization (WHO) standards.

Collaborative health care refers to all healthcare personnel contributing their expertise

towards the care of a surgical patient for example, a radiographer and a plaster technician

in orthopeadic surgery.

Effective means ability to meet holistic need of the surgical patient and the entire surgical

team within a specified time frame and standard of care.

Elective surgery is scheduled or planned surgery.

Elective Cases are a category of patients scheduled for elective surgery

Emergency Surgery refers to surgery for a category of patients for immediate surgical

remedy failure to which morbidity or mortality ensues and preoperative preparation

protocol can be breeched.

Perioperative nurses are nurses working in theatre who care for the patients during the

three phases of surgery; preoperatively from the time patients are received in theatre and

before induction of anesthesia; intraoperatively from induction of anesthesia, during the

actual surgical procedure until the patient leaves the operating table; and postoperatively

from the time the patient leaves the operating table to Post Anesthetic Care Unit (PACU)

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until discharge to the ward or from the operating table and transfer to Critical Care Unit

(CCU).

Preoperative assessment tool is the assessment tool succinct to perioperative patient

care that will be designed by the peri operative nurses guided by perioperative objectives

for such assessment; the Association of peri-Operative Nurses (AORN) standards of

practice and practical experience. The tool will serve as a documentary evidence for such

assessment.

Preoperative visit is ward visit by a number of perioperative nurses usually done a night

or moments before elective surgery or in the receiving area of the operating theatre in

emergency cases. The aim is to allay anxiety through acquaintance and patient orientation

to the operating room, evaluate patients' readiness for surgery, assessing actual surgical

needs for effective planning of perioperative care, and for effective collaboration with the

significant surgical care delivers. The assessment information is disseminated to the rest

of the nurses during the shift reports.

Surgical team members are nurses in the operating room, the surgeon, assistant surgeon

and the anesthetist who primarily participate in the actual surgical procedure.

Collaborating members include the radiographer and theatre technicians among others.

Succinct preoperative assessment preoperative patients' assessment focused to

perioperative nursing care of an individual patient during a surgical intervention.

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ABBREVIA TIONS

APAIS

AORN

ISO

JeAHO

KRPoN

KNH

NANDA

NATN

NNAK

NPs

OR

OT

PACU

SOPs

SPSS

WHO

Amsterdam Preoperative Anxiety and Information Scale

Association of peri- Operating Room Nurses

International Standard of Operations

Joint Commission of Association of Health Care Organizations

Kenya Registered Peri-Operative Nurse

Kenyatta National Hospital

North American Nursing Diagnosis Association

National Association of Theatre Nursing.

National Nurses Association of Kenya

Nurse Practitioners

Operating Room

Operating Theatres

Post Anesthetic Care Unit

Standard Operation Procedures

Scientific Package for Social Sciences

World Health Organization

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ABSTRACT

The perioperative nurses play important role in care delivery of surgical patients

preoperatively, intraoperatively and post operatively. The nurses coordinate collaborative

activities during surgery and are directly concerned with preparation of the operating

room. Preoperative patient assessment by perioperative nurses is critical in planning,

preparation and implementing individualized patients' surgical care for safe and quality

surgical outcomes. The busy theatre schedules do not permit an objective ward visit to

perform such assessment. Perioperative nurses plan for surgical procedures using theatre

list and relying on preoperative patient assessment by non theatre personnel to verify

preoperative preparation using a preoperative checklist. Checklists and theatre lists do not

adequately address the actual procedural needs of the nurse and the patient. The result is

fragmented nursing care, cancellation of surgery in theatre due to excessive anxiety; .

intraoperative surgical delays related to preparation omissions and reduce cost

effectiveness to the patient and the institution. Postoperatively, some patients still harbour

surgical myths clarified during the assessment.

The aim of the study is to enhance the quality of surgical outcomes such as anxiety

reduction by promoting the practice of preoperative patient assessment by peri operative

nurses in planning individualized patients' surgical care. A preoperative assessment tool

will be formulated to standardize assessment and as a documentary evidence. The tool

will complement theatre list and preoperative checklists for effective surgical intervention

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The study setting will be at National Nurses Association (NNAK) building complex

(phase one) and Kenyatta National Hospital (KNH) operating theatres (phase Two) at and

KNH general surgery wards (phase 3).

The design will be descriptive cross sectional (phase one and two) and controlled trial

(phase three). Study phase one will be formulation of the assessment tool through

perioperative nurses workshop to be organized through NNAK Theatre Chapter. Study

phase two will be evaluating the tool practically. Phase three will be evaluating the tool

on surgical outcome of anxiety.

Instruments for the study will be focused group discussions (phase one) structured

questionnaires.

Data analysis will be done usmg Scientific Package for Social Sciences (SPSS).

Descriptive statistics will be used. Paired sample T- test and Independent sample T- test

will be used for testing mean differences between the experimental and control groups.

The Chronbach's alpha will be set at 0.05 corresponding to 95% confidence limit.

Ethical considerations will be observed and authority to conduct the study sought from

KNH Ethics and Research Committee.

The study will take duration of three years at a cost of approximately Ksh. 454,960.00

(four hundred and fifty four thousand, nine hundred and sixty Kenyan shillings).

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