INTRODUCTION:

“Movement is a medicine for creating change in a person's physical, emotional and mental states.”¹

The health of the nation depends on the health of women. Women is having the soul authority in keeping the human species alive, by the help of a process known as reproduction.

Reproduction helps to continue one’s progeny and to give human immortality by giving birth to new ones, enabling the survival of the human species in the earth.²

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of reproductive disease or infirmity.³ The vital organ that helps in the process of reproduction is the womb, literally called ‘the uterus’. The function of the uterus is to shelter the fetus during pregnancy. It prepares for receiving the fertilized ovum each month and following pregnancy it expels the product of consumption.⁴

There are several factors which adversely affect the normal physiological function of an uterus and thus hindering the normal reproductive health. The main factors are developmental defect, alteration in hormonal level, obesity, malnutrition and occupational and environmental exposures during the reproductive years. There are also several medical indications that result in the removal of the uterus such as pregnancy catastrophe, uterine fibroid, severe infection, operative complications, benign and malignant cancer, chronic pelvic pain, abnormal uterine bleeding and in extenuating circumstances such as sterilization, cancer prophylaxis etc.⁵

Hysterectomy is the operative procedure done for the removal of uterus. Depending on the indication for the removal of the uterus, hysterectomy can be performed using different methods such as abdominal hysterectomy and vaginal hysterectomy. Abdominal hysterectomies are performed when the fibroid size is too large, that does not allow for vaginal excision of the uterus. On the basis of the extent of removal of the uterus and the adjacent structures, hysterectomy can be classified as total hysterectomy, subtotal hysterectomy, pan hysterectomy, extended hysterectomy and radical hysterectomy.⁶

Hysterectomy is the best option to save the life of the women in gynecological conditions. It is having many complications such as hemorrhage, pain, deep vein thrombosis, urinary incontinence, wound dehiscence and anesthetic hazards. In some women the removal of the uterus will result in sexual dysfunction and emotional disturbances such as depression, sadness, anxiety, stress and mental trauma.⁷

The most important management after hysterectomy is to administer pain medications, especially narcotic analgesics for pain. The patients are advised to avoid all heavy activities.⁸ In the recent years there has been increasing pressure on the health service for faster return to normal activity following major surgical procedures, including hysterectomy. Demand for these changes has been driven not only by economic considerations but also by the health care needs of working population. In order to ensure a safe and quick recovery after surgery, effective preoperative preparation and post-operative exercises are essential and it is important that the patient play an active role in this pathway.⁹

Traditionally, hysterectomy patients were maintained on bed rest, because it was believed that the conservation of energy would be beneficial for recovery. The adverse effects of bed rest are now well known. The greater the degree of immobility and the longer the periods of immobilization, the greater the risk for development of adverse outcomes like deep vein thrombosis, decreased muscle tone etc. The sedative agents and pain medications that are administered to patients after hysterectomy can contribute to prolonged sedation and inactivity. As a result, complications such as skin breakdown, delirium and weakness can occur. Progressive mobilization for hysterectomy patients has become a new standard of care to regain baseline mobility function in the very early phase of post-operative period.¹⁰

Progressive mobilization is a series of planned movement done in a sequential manner to improve the physical activity. Various exercises like passive range of motion exercises, lateral rotation therapy, active range of motion exercises and ambulation are done to reduce stiffness and build muscle strength, particularly in the abdomen, arms and legs. An increasing number of studies have demonstrated that progressive mobilization in the hysterectomy patients are feasible, safe, and beneficial in improving patients physical function. Progressive mobilization is also having secondary benefits such as improving socialization and reducing the use of heavy sedation, which can impair physical and mental activity level of the patient. The superiority of progressive mobilization lies in the fact that it produces early and quicker recovery and the patients can resume their activities of daily living at the earliest.¹¹

The challenges to mobilizing hysterectomy patients are numerous. Factors to consider include the safety of the tubes and lines, pain level, patient’s size, personnel and equipment resources available for mobilization, sedation practices, and the ability to hemodynamically tolerate the movement are the most significant factors. In the first and second days of minimal movements, patients are advised to undergo slow mobilization within their limit, thereafter the duration and frequency in doing the exercises are prograssivelly increased.¹²

During the obstetrics and gynaecological nursing clinical posting the researcher noticed numerous hysterectomy patients suffering from pain, decreased muscle strength, lack of self-esteem, pain and joint stiffness after the surgery. So the researcher felt a need to undertake an effective therapy to improve post-operative recovery after hysterectomy.

MATERIAL AND METHOD:

Research Design:

Post-test only control group design.

Setting of the study:

The study was conducted at Matha Hospital, Kottayam, Kerala. It is a 500 beded Maternity hospital with all modern facilities.

Sample size:

The sample of the study consisted of 60 women who had undergone abdominal hysterectomy in Matha Hospital at Kottayam District. Out of the 60 samples, the first 30 samples were taken as the control group and the next 30 samples were taken as the experimental group.

Inclusion Criteria:

The criteria that specify the characteristics of the subjects in the population are referred to as the inclusion criteria.⁵⁷

Patients who are :

· Undergoing abdominal hysterectomy in a selected setting.

· Undergoing surgery under spinal or general anesthesia.

· Willing to participate in the study.

· Completed 8 hours of surgery.

· Able to understand English and Malayalam.

Exclusion Criteria:

Patients who are :

· Having surgical complications and contraindicated for progressive mobilization.

· Undergoing vaginal hysterectomy.

· Operated at emergency conditions.

· Having Doctor’s order for strict bed rest.

Hypothesis:

H₀₁: There will be no significant difference in the post-test level of post-operative recovery between the experimental group and control group.

H₀₂: There will be no significant association between post-test level of post-operative recovery and selected socio - demographic variables in the control group.

H₀₃: There will be no significant association between post-test level of post-operative recovery and selected socio - demographic variables in the experimental group.

H₀₄: There will be no significant association between post-test level of post-operative recovery and selected clinical variables in the control group.

H₀₅: There will be no significant association between post-test level of post-operative recovery and selected clinical variables in the experimental group.

Operational definitions:

Effectiveness:

In this study, effectiveness refers to significant improvement in the post-operative recovery after progressive mobilization, twice daily for five days, among women who had undergone abdominal hysterectomy, in the experimental group.

Progressive Mobilization:

In this study, progressive mobilization refers to teaching and demonstration of series of suggested steps preoperatively, and application of those procedures post-operatively twice daily for five days, to accelerate the ability of the post hysterectomy patients to move or walk in a shorter period of hospitalization, by providing step by step procedures of slow deep breathing exercise, selected passive range of motion exercises, continuous lateral rotation therapy and sitting 8 hours after the surgery, followed by walking and range of motion exercises after 24 hours of surgery.

Abdominal Hysterectomy:

In this study, abdominal hysterectomy refers to a surgical procedure for removal of whole uterus or a part of it, through an abdominal incision.

Post-operative recovery:

In this study, post-operative recovery refers to restorations of patients after abdominal hysterectomy, to their normal or near to normal condition, in terms of physical symptoms, physical functions, psychological, social and activity level of the patients as measured by using post-operative recovery profile questionnaire.

Assumption:

· Progressive mobilization may be effective in early post-operative recovery

Tools and Techniques:

Tool 1 (section - A): Socio demographic variables:

Socio demographic variables included 12 items such as age, religion, educational status, occupation, monthly income, marital status, type of family, dietary pattern, body weight, menstrual cycle, number of surgeries and previous history of surgery. The purpose of this was to determine the association of degree of post-operative recovery with selected socio demographic variables.

The technique for administering this tool was structured interview schedule.

Tool 1 (Section – B): Clinical variables:

Clinical variables included 5 items such as indication for hysterectomy, type of anesthesia, maximum doses of sedatives, maximum doses of pain medications and type of abdominal hysterectomy. The researcher collected the values of clinical variables from the investigation report which was available in the patient hospital record after the abdominal hysterectomy.

The technique for administering this tool was by Dairy method.

Tool 2: Post-operative recovery profile questionnaire:

Post-operative recovery profile questionnaire developed and prepared by the researcher, for assessing post-operative recovery among women who had undergone abdominal hysterectomy. Post-operative recovery is assessed in terms of physical symptoms, physical functions, psychological, social and activity level of the patients. It consist of 23 multiple choice questions and has 4 choices. This is a four-point rating scale prepared by the researcher.

To interpret the level of post-operative recovery scores are arbitrarily distributed as follows:

Table 1: Interpretation of Knowledge Score

Sl. No	Score	Score %	Level of knowledge
1	0 – 18[	≤ 25%	Not Recovered
2	19 – 36[	26 - 50%	Slightly Recovered
3	37 – 54[	51 - 75%	Partially Recovered
4	55 – 69	> 75%	Fully Recovered

Plan for data analysis:

The data obtained was planned to be analyzed by both descriptive and inferential statistics based on the objectives and hypothesis of the study.

Comparison of level of recovery between experimental and control group.

Figure 1: Bar graph shows the comparison of level of recovery between experimental and control group.

Figure 1 shows that in the experimental group a very small (3.30 %) percentage had partly recovered and a vast majority (96.70 %) were fully recovered while in the control group more than three fourth (76.70 %) were slightly recovered and less than one fourth (23.30 %) were partly recovered.

Table 2: Mean, S.D. and ‘t’ value to compare the difference in post-operative recovery among women between the experimental group and control group. (N = 60)

Group

Mean

Recovery

S.D.

Difference

between

means

Experimental group

57.5

3.14

25.4

28.94**

Control group

32.1

3.64

**Significant at 0.01 level

Table 2 shows that unpaired t- test was used to compare the post-test level of post-operative recovery between experimental and control group. The mean post-test level of post-operative recovery score 57.5 with SD =3.14 in the experimental group was significantly higher than the mean post-test level of post-operative recovery score 32.1 with SD = 3.64 in the control group with a mean difference of 25.4.

The calculated t value (28.94) was more than the table value (2.02) at 0.01 level of significance at 58 degrees of freedom. So there was a significant difference in the post-test level of post-operative recovery between the experimental and control group. Hence the null hypothesis (H₀₁) was rejected and the research hypothesis (H₁) was accepted. From this it can be concluded that progressive mobilization was effective in improving the post-operative recovery among women who had undergone abdominal hysterecto.

RESULT:

Demographic variables:

In experimental group, half (50.00%) of women belonged to the age group of 55 - 65 years and in the control group, more than one fourth (26.60%) of women belonged to the age group between 35 – 45 years. In the experimental group, more than half (53.40%) and in the control group, 40.0% of the women were Hindus. In the experimental group, one third (33.40%) of women were having primary education where in the control group, more than one third (43.40%) of women were having high school education. In the experimental group 40.00 % were house wife and in the control group 36.60% of the women were private employee in the experimental group, more than one fourth (36.60%) of the women and in the control group, more than one third (33.40%) of the women had income ranging between Rs. 15, 001 - 20, 000/- month. In the experimental group more than three fourth (76.60%) and in the control group a vast majority (90.00%) of the women were married. In the experimental group 93.40% and in the control group 96.60% of women belonged to the nuclear family. In the experimental group, a vast majority (96.60%) of the women and in the control group, more than three fourth (93.40 %) of the women were non-vegetarian.

Clinical Variables:

· Majority in the experimental group (80.00%) and (70.00%) in the control group had fibroid uterus.

· Majority in the experimental group (86.60%) and control group (93.40%) had spinal anesthesia.

· A majority in the experimental group (80.00%) and control group (73.30%) used only one sedative.

· 60% in the experimental group used three to four doses of pain medication and 53.3% in the control group used five to six doses of pain medications.

· 40.00% in the experimental group and more than half (53.20%) in the control group had subtotal hysterectomy.

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Received on 23.11.2020 Modified on 10.12.2020

Int. J. of Advances in Nur. Management. 2021; 9(1):22-26.

DOI: 10.5958/2454-2652.2021.00007.X