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Fırat University Medical Journal of Health Sciences
2023, Cilt 37, Sayı 3, Sayfa(lar) 227-231
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Cerrahi Kliniklerde Yatan Hastaların Solunum Egzersizi Yapma Durumlarının Uyku ve Kaygı Düzeyine Etkisi
Dilek GÜNEŞ1, Nur Özlem KILINÇ2, Fatoş UNCU2, Gamze KIRKIL3
1Fırat University, Faculty of Health Sciences, Department of Surgical Nursing, Elazığ, TÜRKİYE
2Fırat University, Faculty of Health Sciences, Department of Public Health Nursing, Elazig - TURKIYE
3Fırat University, Faculty of Medicine, Department of Chest Disease, Elazig - TURKIYE
Anahtar Kelimeler: Solunum egzersizi, uyku, kaygı, hemşirelik
Özet
Amaç: Bu araştırmanın amacı, hastaların solunum egzersizlerinin uyku ve kaygı düzeylerine etkisini belirlemektir.

Gereç ve Yöntem: Bu araştırma tanımlayıcı tipte yapılmıştır. Araştırmanın evreni Üniversite Hastanesi Genel Cerrahi Kliniklerinde ameliyat olan tüm yetişkin hastalardan oluşmaktadır, araştırma örneklemi 200 hasta olarak belirlenmiştir. Veriler, Kişisel Bilgi Formu, Richards-Campbell Uyku Ölçeği (RCSQ) ve Durumluk Sürekli Kaygı Envanteri (STAI) kullanılarak yüz yüze görüşme yoluyla toplanmıştır.

Bulgular: Hastaların yaş ortalaması 48.26±18.92’dir. Ayrıca %93.5'i hemşirelerden solunum egzersizi eğitimi aldığını, %63'ü solunum egzersizi eğitimi veren kişinin hem egzersizi uyguladığını hem de hastalara yaptırdığını belirtmiştir. Solunum egzersizini öğretme değişkeni ile RCSQ toplam puanı arasında anlamlı bir fark olduğu bulunmuştur. RCSQ (p=0.001) ve durumluk kaygı ölçeği (p=0.001) sıra ortalamaları dikkate alındığında, fark ameliyat öncesi solunum egzersizi yapılan grup lehinedir.

Sonuç: Solunum egzersizleri öğretilen hastaların uyku kalitelerinin arttığı ve durumluk kaygılarının azaldığı bulundu. Hastaların tedavisinin etkinliğini artırmak için etkili solunum egzersizi önerilebilir.

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    Although the success of surgery in terms of patients is thought to depend on advanced surgical techniques, knowledge, and skills, it is also known to depend on preoperative preparation and postoperative care1. Post-operative breathing complications are frequently seen. Impaired breathing muscle integrity due to incision of chest wall and abdomen, pain in the incision site, phrenic nerve dysfunction, associated diaphragm dysfunction, and other systemic effects reduce the depth of breathing. Decreased breathing depth causes complications such as hypoxemia, atelectasis, and infection. In preventing these complications, it is important for patient care to teach breathing exercises to the patients and make them apply them before surgery, and continue these exercises after surgery2,3. The goals of nursing care consist of accelerating patient recovery by performing breathing exercises that will oxygenate the blood, and increase lung volume1,2. Breathing exercises increase the amount of oxygen in the cells, improve gas exchange, stimulate surfactant production and reduce the development of complications3,4. In addition, it increases the patient's adaptation to treatment and reduces the length of hospital stay and the use of painkillers, so the patient returns to his normal life in a shorter time1,5. A nurse performs this process by using the role of educator in addition to the role of caregiver. Breathing exercises are just one of the nursing practices that improve the patient's quality of life. In this context, having knowledge and practicing it improves the quality of nursing care6,7.

    Sleep is a physiological process that affects many systems of the body. Sleep consists of the REM (Rapid Eye Movements) phase, where mental rest occurs, and the NREM (nonREM) phase, where physical rest occurs8. Sleep increases the body's resistance to infections by affecting various immune parameters, accelerating healing. Sleep is therefore an important factor in wound healing, especially in surgical patients9. In addition to improving breathing, exercises improve the quality of sleep by relaxing the patient, reducing anxiety, and increasing the speed of recovery4,8,10.

    Surgical intervention is a cause of great anxiety for a patient, while the hospital environment, being away from his/her family, fear of obscurity, the treatment process, and less providing of physiological requirements cause anxiety10. A high level of anxiety experienced before surgery increases physiological signs such as breathing rate, heart rate, and blood pressure and leads to an increased need for painkillers and analgesics after surgery11,12. Quality nursing care should be planned from a holistic point of view and should be individual-specific based on realistic goals. Data collection, objective interpretation of data, planning, and implementation constitute important stages of patient care13.

    Our aim in the study is to investigate the influence of breathing exercises on the anxiety levels and sleep of patients.

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    Research and Publication Ethics: Necessary permission to conduct the research was obtained from the Fırat University non-interventional research ethics committee (2021/02 -27). At all stages of the research, the articles of the Helsinki declaration were taken into account. Informed written consent was obtained from each study participant. They were also informed of their full right to refuse, withdraw, or completely reject their part in the study. Confidentiality was guaranteed by keeping the secret of personal identification and keeping questionnaires and results in a well-secured area.

    Research Design and Sampling: This descriptive research was carried out between February 2021 and May 2021 at the Fırat University Hospital General Surgery Clinics. All adult patients who underwent surgery in the hospital's surgical clinics formed the population of the research. All patients were included, regardless of the type of surgery. In general surgery clinics, approximately 375 operations are performed in a year. By power analysis with 0.08 effect size, 0.05 error level, and 0.95 ability to represent the population, the sampling amount of the study was assigned as 200. The data were collected by the researchers by face-to-face interview technique on the 2nd postoperative day from patients who were hospitalized in general surgery wards for at least 72 hours. The data were selected by random sampling. Based on the inclusion criteria patients were selected and were randomly allocated into two groups; Preoperative the status of learning the breathing exercises, postoperative the status of learning the breathing exercises.

    Breathing exercise: 'Sit on the edge of the bed or lie on your back and bend your knees to relax your abdominal muscles. Place your hands on the sides of your abdomen. Continue breathing through your nose until your upper abdomen bulges outward. Slowly blow air through your mouth, contracting your abdominal muscles.' It is a routine practice taught in the form of

    Data Collection: A Personal Data Form, The State-Trait Anxiety Inventory (STAI), and The Richards-Campbell Sleep Questionnaire (RCSQ) were used to collect data.

    Personal Data Form: It was developed to collect introductory information about patients who volunteered to take part in this research. It includes information about age, gender, profession, marital status, level of education, the state of learning the breathing exercises, who teaches breathing exercises, and how breathing exercises are taught.

    The Richards-Campbell Sleep Questionnaire (RCSQ): The scale, originally called the Richard-Campbell Sleep Questionnaire (RCSQ), was revealed in 1987by Richards. RCSQ refers to a 6-item scale that assesses the time to fall asleep, the depth of night sleep, the time to stay awake when you wake up, the frequency of waking up, the level of noise in the environment, and the quality of sleep. Using the visual analog scale technique, each item is scored from 0 to 100 on a chart. A score of "0-25" on the scale indicates very poor sleep, while a score of "76-100" suggests excellent sleep. The scale's total score is calculated using 5 items; the sixth item, which assesses the noise level in the surroundings, is removed from the total score calculation. Patients' sleep quality improves as their scores on the scale rise. The scale created by Richards was found to have a Cronbach's alpha value of 0.8214. But, Cronbach's alpha was found 0.94 in the present study. Its reliability and validity investigation was carried out by Karaman Özlü and Özer15.

    The State-Trait Anxiety Inventory (STAI): The Turkish reliability and validity of the scale created by Spielberger et al16 were made by Öner and Le Compte17. This scale consists of 40 items, the first twenty questions measure the patient's level of state anxiety, and the other twenty questions measure the level of trait anxiety. Reliability values were observed to range from 0.83 to 0.87 for trait anxiety and from 0.83 to 0.92 for state anxiety in the Turkish-adapted scale. Cronbach's alpha value of this study was found to be 0.79 for state anxiety and 0.89 for trait anxiety. Eighty and above points taken from the scale are evaluated as panic, 60-79 points as severe anxiety, 40-59 points as moderate anxiety, 20-39 points as mild anxiety, and 0-9 points as no anxiety16,17.

    Statistical Analysis: The Statistical Package for Social Science 22.00 (SPSS) program was used to analyze the study's data. When reviewing study data, the normality test was performed using the Shapiro-Wilk test in addition to descriptive statistical methods (percentage, number, standard deviation, average). In comparisons between the two independent groups, the Mann-Whitney U test was employed since the normal distribution was not observed in the collected data. The significance level was accepted as p<0.05.

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    The participants in the study were 48.26±18.92 on average. Also, 53% (n=106) of the subjects of the research group were women and 75.5% (n=151) were married; 69.5% (n=139) of the participants received breathing exercise training before surgery and 30.5% (n=61) after surgery. Again, 93.5% stated that they received breathing exercise training from nurses, and 63% said that the person who taught breathing exercise training both practiced the exercise and made the patients practice it (Table 1).


    Büyütmek İçin Tıklayın
    Table 1: Socio-Demographic Characteristics of the Patients Involved in the Study

    According to Mann-Whitney U-test outcomes, there is a significant difference between the overall score obtained from the RCSQ and the variable of teaching the breathing exercises. When RCSQ (p=0.001) and state anxiety scale (p=0.001) are taken into account, the difference is in favor of the group taught breathing exercises before surgery. This also coincides with the high positive attitude outcomes of preoperative breathing exercise training for sleep and anxiety in general terms.

    There were no statistically significant differences between the patients' preoperative and postoperative breathing exercise training and their trait anxiety levels (p=0.672) (Table 2).


    Büyütmek İçin Tıklayın
    Table 2: Distribution of Total Scores of RCSQ, State Anxiety and Trait Anxiety Scales of Patients Taught Breathing Exercise (n=200)

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    In order for patients to get clinical benefits in the postoperative period, one of the interventions that can be performed during the pre-operative period is breathing exercises18. Ghorbani et al.19 conducted a study on patients who underwent coronary artery bypass graft, it was determined that deep breathing exercises enhance the duration and quality of postoperative sleep. A study conducted on patients with lung transplantation found a positive correlation between the regulation of patients' breathing and sleep efficiency20. It was also determined in another study that breathing exercise training in patients improved sleep quality21. Breath training led by a supportive-trainer nurse was found to reduce anxiety and sleep disturbance in patients who underwent graft coronary artery bypass22. Methodological studies that tested many training strategies and interventions, such as breath training, showed significant improvement in sleep evaluations of patients after cardiac surgery23.

    In our study, patients who performed breathing exercises had high sleep quality (RCSQ score between 76-100 indicates very good sleep) and there was a significant difference between both variables. Our results are similar to the literature.

    As a result of the work of Spielberger et al, the concepts of “state anxiety” and “trait anxiety” were identified for the first time, and the distinction between anxieties was made. According to this, state anxiety is a subjective fear that a person feels due to a distressed state, problems, or pressure that they experience at that moment, and trait anxiety is the individual's perception of living conditions as stressful mostly and a tendency toward anxiety16,17.

    According to our research findings, patients who performed breathing exercises had low state anxiety scores, and the difference between these variables is significant statistically. But there were no significant differences between breathing exercise-making status and trait anxiety levels. The reason for this may be that breathing exercise reduces the troubles momentarily, so people relax more.

    Deep breath exercise therapy is effective in alleviating postoperative pain and anxiety levels in orthopedics patients24. A study that examined the effect of breathing exercises on anxiety levels showed a decrease in anxiety levels25. A study conducted on patients undergoing heart surgery found that state anxiety decreased in patients who performed breathing exercises following preoperative training26. A study conducted on patients with mastectomy surgery found that breathing exercise causes a decrease in patients' anxiety27.

    As a result, in our study it was found that breathing exercises increased patients' sleep quality and decreased trait anxiety. By doing this exercise effectively, the effectiveness of treatment of patients may increase, and postoperative complications can be prevented. It is recommended to set standards for breathing exercises and make them part of nursing practices and care in a systematic and planned way.

    Limitation of the study, the results of the study can only be generalized to this group.

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    1) Moradian ST, Heydari AA, Mahmoudi H. What is the role of preoperative breathing exercises in reducing postoperative atelectasis after CABG? Rev Recent Clin Trials 2019; 14: 275-279.

    2) Girard NJ. Clients having surgery: Promoting positive outcomes. In: Black JM, Hawks JH. (Editors). Medical Surgical Nursing-Clinical Management for Positive Outcomes. 8th Edition, Saunders: Elsevier, 2009: 193-194.

    3) Thybo Karanfil EO, Møller AM. Preoperative inspiratory muscle training prevents pulmonary complications after cardiac surgery - A systematic review. Dan Med J 2018; 65: A5450.

    4) Wang YQ, Liu X, Jia Y, Xie J. Impact of breathing exercises in subjects with lung cancer undergoing surgical resection: A systematic review and meta-analysis. J Clin Nurs 2019; 28: 717-732.

    5) Cavalheri V, Granger C. Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database Syst Rev 2017; 6: CD012020.

    6) Stamenkovic DM, Rancic NK, Latas MB, et al. Preoperative anxiety and implications on postoperative recovery: What can we do to change our history. Minerva Anestesiol 2018; 84: 1307-1317.

    7) Hanada M, Kasawara KT, Mathur S, et al. Aerobic and breathing exercises improve dyspnea, exercise capacity and quality of life in idiopathic pulmonary fibrosis patients: Systematic review and meta-analysis. J Thorac Dis 2020; 12: 1041-1055.

    8) Perez-Pozuelo I, Zhai B, Palotti J, et al. The future of sleep health: a data-driven revolution in sleep science and medicine. NPJ Digit Med 2020; 3: 42.

    9) Su X, Wang DX. Improve postoperative sleep: what can we do?. Curr Opin Anaesthesiol 2018; 31: 83-88.

    10) Doan LV, Blitz J. preoperative assessment and management of patients with pain and anxiety disorders. Curr Anesthesiol Rep 2020; 10: 28-34.

    11) Zarei B, Valiee S, Nouri B, Khosravi F, Fathi M. The effect of multimedia-based nursing visit on preoperative anxiety and vital signs in patients undergoing lumbar disc herniation surgery: A randomised clinical trial. J Perioper Pract 2018; 28: 7-15.

    12) Xu Y, Wang H, Yang M. Preoperative nursing visit reduces preoperative anxiety and postoperative complications in patients with laparoscopic cholecystectomy: A randomized clinical trial protocol. Medicine (Baltimore) 2020; 99: e22314.

    13) Fu S, Wang Q, Fan C, Jiang Y. The efficacy of nursing intervention to reduce preoperative anxiety in patients with total knee arthroplasty: A protocol of prospective randomized trial. Medicine (Baltimore) 2020; 99: e22213.

    14) Richards K. Techniques for measurement of sleep in critical care. Focus Crit Care 1987;14: 34-40.

    15) Karaman Özlü Z, Özer N. Richard-Campbell sleep questionnaire validity and reliability study. Journal of Turkish Sleep Medicine 2015; 2: 29-32

    16) Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory. CA: Consulting Psychologists Press, Polo Alto, 1970.

    17) Öner N, Le Compte A. State and Trait Anxiety Inventory Handbook. Istanbul: Boğaziçi University Publications, 1983:1-26.

    18) Lumb AB. Pre-operative breathing optimisation: an expert review. Anaesthesia 2019; 74: 43-48.

    19) Ghorbani A, Hajizadeh F, Sheykhi MR, Mohammad Poor Asl A. The effects of deep-breathing exercises on postoperative sleep duration and quality in patients undergoing coronary artery bypass graft (cabg): A randomized clinical trial. J Caring Sci 2018; 8: 219-224.

    20) Kruse F, Kleibrink BE, Rabis T, et al. Influence of sleep-disordered breathing on quality of life and exercise capacity in lung transplant recipients. Adv Exp Med Biol 2019; 1160: 25-33.

    21) Oz Alkan H, Uysal H, Enç N, Yigit Z. Influence of breathing exercise education applied on patients with heart failure on dyspnoea and quality of sleep: A randomized controlled study. International. Int J Med Res Health Sci 2017; 6: 107-113.

    22) Mousavi Malek N, Zakerimoghadam M, Esmaeili M, Kazemnejad A. Effects of nurse-led intervention on patients' anxiety and sleep before coronary artery bypass grafting. Crit Care Nurs Q 2018; 41: 161-169.

    23) Machado FS, Souza RCDS, Poveda VB, Costa ALS. Non-pharmacological interventions to promote the sleep of patients after cardiac surgery: A systematic review. Rev Lat Am Enfermagem 2017; 25: e2926.

    24) Yusuf A, Iswari MF, Sriyono S, Yunitasari E. The effect of combination of spiritual deep breathing exercise therapy on pain and anxiety in postoperative nonpatological orthopedic fracture patients. Eur Asian Journal of BioSciences 2020;14: 1625-1631.

    25) Chen YF, Huang XY, Chien CH, Cheng JF. The effectiveness of diaphragmatic breathing relaxation training for reducing anxiety. Perspect Psychiatr Care 2017; 53: 329-336.

    26) Kalogianni A, Almpani P, Vastardis L, et al. Can nurse-led preoperative education reduce anxiety and postoperative complications of patients undergoing cardiac surgery? Eur J Cardiovasc Nurs 2016; 15: 447-458.

    27) Parsa Yekta Z, Sadeghian F, Taghavi Larijani T, Mehran A. The comparison of two types of relaxation techniques on postoperative state anxiety in candidates for the mastectomy surgery: A randomized controlled clinical trial. Int J Community Based Nurs Midwifery 2017; 5: 61-69.

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