Assessment of the Effects of Early Ambulation on Activities of Daily Living in Patients Undergoing Abdominal Surgery

Introduction

Abdominal surgery is a very common surgical procedure. A national survey in the United States reported that operation on the digestive system is one of the three most frequent surgical procedures (DeFrances, Lucas, Buie, & Golosinskiy, 2008). Problems related to the digestive system are one of many reasons for surgeons to open up the abdominal cavity. The prevalence rate of intraabdominal surgeries in patients aged ≥60 years is 43.8% (Nunoo-Mensah, Rosen, Chan, Wasserberg, & Beart, 2009). This rate increases with age, and is found to be significantly higher in women than men (Nunoo-Mensah et al., 2009; Primatesa & Goldacre, 1994; Steiner, Bass, Talamini, Pitt, & Steinberg, 1994).

Ramachandran (1972) conducted a descriptive, comparative study on the effects of structured and unstructured preoperative teaching on early ambulation following elective abdominal surgery. The study was conducted at the Christian Medical College and Hospital, Vellore. The tools used consisted of an observational checklist on the ability to perform activities of daily living (ADLs) in postoperative patients up to the seventh day of the surgery, and the interview guide on early ambulation. The statistical analysis of the descriptive and nonparametric results revealed a significant difference in the structured and unstructured preoperative teaching on early ambulation among the control and study groups.

The objectives of the study were to evaluate the effectiveness of modified early ambulation on the ADLs in patients who had undergone abdominal surgery, and to determine the correlation between the demographic variables and ADLs, functional activity, and psychological well-being of the patients.

Our study was based on the following two hypotheses with regard to the effect of modified early ambulation on the ADLs:

a) Hypothesis 1 (H1): There is a significant difference in the ADLs in patients who availed the intervention than those who did not.

b) Hypothesis 2 (H2): There is no significant difference between the selected variables and ADLs.

Literature Review

Deepa M (2007) studied the effectiveness of early ambulation on postoperative recovery of patients following abdominal surgery at the railway hospital in Chennai. It was a quasi-experimental, nonequivalent, control group, post-test-only study design. It was conducted in postoperative ICU, surgical wards (male and female) and included 60 patients who had undergone abdominal surgery, divided into two groups – experimental (n=30) and control (n=30). The investigator helped the patients in the experimental group to ambulate 24 h after surgery, until they were able to do so independently. The hospital’s regular regimen was followed for the control group. The level of dependency in performing the ADLs was assessed using the observational checklist while the level of comfort was evaluated through a structured interview. The patients in the experimental group showed a highly significant decrease in the level of dependency in performing activities of discomfort following early ambulation (P<0.001), in comparison to patients in the control group.

Hardy et al (2005) conducted a study on the factors associated with recovery of independent ADLs among community-dwelling elderly people who had undergone a major abdominal surgery. The aim of their study was to assess the time required and the duration of recovery of independent ADL function in this population. The study included 754 persons <70 years old. The investigators studied 420 participants who experienced at least 1 episode of disability involving 1 or more key ADLs such as bathing, dressing, walking, or transferring during a median follow-up of 53 months. The results showed that regular physical activity was an important factor for achieving independent ADL function in this group.

Materials And Method

The study site was the Kempegowda Institute of Medical Sciences, Bangalore. This center has 750 beds, 300 surgical beds (for both male and female patients), and 5-7 major abdominal surgeries per day are performed here. The study was conducted in the male and female surgical wards and surgical intensive care unit of the hospital. It included randomly selected patients who had undergone a major abdominal surgery. The patients were enrolled in the preoperative phase, to avoid dropouts and postoperative exclusions. Patients who could be ambulated in the 16th hour of surgery were selected for the study group, with simultaneous selection of subjects for the control group.

A total of 150 patients were selected (75 each for the study and control groups, respectively) to achieve a comfortable sample size. Both male and female patients who: were aged between 40 and 75 years; could speak Tamil/Kannada/English; had undergone only general anesthesia; had been approached on day-1 before surgery during the preoperative period; had few issues related to postoperative recovery of ADLs, functional activities, and sense of well-being; and had medical illness such as: diabetes, hypertension, bronchial asthma, cardiac problems and renal problems, were included in the study. Patients who were unconscious and disoriented, or had undergone laparoscopic abdominal surgeries were excluded.

Study Design

An experimental research design was used to determine the effectiveness of modified early ambulation on the ADLs, functional activity, and psychological wellbeing among these patients. A simple, random sampling was performed by using the lottery method to assign the selected study participants to the study and control groups. Equal number of lots (75 each for the study and control groups) were made and kept in a box, and the participants were asked to pick from the box.

The study tool consisted of two sections: Section I – Demographic and co-morbidity variables and Section II – Observation schedule for restoration of ADLs. Section I consisted of demographic variables such as age, gender, education, exercise, sources of knowledge, and co-morbidities. These data were collected through the verbal responses of the patients. Section II comprised factors related to the restoration of ADLs such as oral hygiene; nutritional needs; and ability to eliminate body waste (urination and defection), comb hair, change clothes, and take bath, in the postoperative patients. This information was collected by observing the patients every 24 h after the surgery. The reliability of the tool was established by test/re-test method and the calculated correlation coefficient was 0.83.

The ADLs were measured based on the scores obtained. The minimum score was 7 and the maximum score was 21.

Data Analysis and Interpretation

The collected data were carefully coded and analyzed using the SPSS package (v11.5). The modified early ambulation intervention was measured using the observational checklist and interview schedule, at the 15th h (pre-test). The intervention was done at the 16th h after surgery for the study group. Data pertaining to 75 subjects each in the control and study groups were included for the final analysis. The results were organized and presented under the following sections.

Section I: Distribution of demographic variables.

As depicted in Table 2, the majority of the participants were aged 51-60 years (35%) and 41-50 years (37%); and 56% and 57% of them were male in the study and control groups, respectively. With regard to education, 19 (25%) and 21 (28%) of them had completed primary school in the study and control groups, respectively. It was observed that 39 (52%) patients in the study group and 42 (56%) subjects in the control group were not doing regular exercise. The knowledge about early ambulation was acquired through friends by 20 (27%) patients in the study group and 26 (35%) subjects in the control group. There were 18 (24%) known cases of hypertension in the study group and 19 (25%) known cases of hypertension and respiratory diseases in the control group.

Section II: Effectiveness of modified early ambulation on ADLs in the two groups.

Table 3 presents the mean scores, SD, and t-test values of ADLs among the study and control groups at regular intervals of 24 h after surgery.

The reported pre-test mean score was 7 in both the groups with the standard deviation of zero (0), suggesting no difference in the ADLs before intervention through modified early ambulation. The post-test mean scores and SD reported in the study group at regular intervals of 24 h surgery were 12.96 (1.14), 17 (0.9), 20.51 (0.83), 20.95 (0.23), and 21 (0) which were higher than the pre-test values. The mean scores and SD reported in the control group were 7.72 (1.03), 10.56 (1.71), 13.88 (1.68), 16.98 (1.42), and 19.6 (1.03), respectively.

The obtained t-values between study group and control group post-test ADLs scores at regular interval of 24 h after surgery were t=29.54 (p<0.01), 32.22 (p<0.01), 30.64 (p<0.01), 23.9 (p<0.01), and 11.77 (p<0.01) were highly significant.

Therefore, the null hypothesis H 01 was rejected and the research hypothesis H1 was accepted. There was a significant difference in the post-test ADL scores between the two groups in relation to modified early ambulation. The post-test mean scores of ADLs were higher in the study group than the control group. Also, the modified early ambulation made a significant difference in the restoration of ADLs.

Table 4 shows the differences in the ADL scores from pre- and average post-test values between the study and control groups. The average post-test mean score was significantly higher than the pre-test score in the study group. Modified early ambulation made a significant difference in the restoration of ADLs in this group.

Section: Assessment and comparison of the effect of demographic variables on the ADLs in the study and control groups.

Table 5 reveals mean, SD, and t-values of demographic variables and post-test ADLs scores in study and control group.

Regarding age, the post-test ADLs mean scores and SD in the study group were 15.7 (1.07), 15.5 (0.72) and 16.0 (1.31). The obtained F-ratio was 0.721 not significant. In the control scores were 12.8 (0.42), 12.4 (0.45), 12.9 (0.19) and 12.7 (0.18) the obtained F-ratio was 1.6252 not significant.

Regarding sex, the post-test ADLs mean scores and SD in the study group were 16.0 (1.27), 15.0 (0.79), the obtained t-value was 1.13 (p=0.273) not significant.

In the study group scores 12.8 (0.28), 12.5 (0.40). The obtained t-values was 0.027 (p=0.058) not significant.

Regarding education the post-test ADLs mean scores and SD in the study group were 15.7 (.87), 16.3 (.183), 15.0 (.75), 16.0 (1.31), the obtained F-value was 1.62 (p=1.328) not significant. In the control group scores were 12.4 (0.04), 12.9 (0.19), 12.7 (0.18), 12.8 (0.42), 12.4 (0.45), the F-value was 1.752 (p=0.243) not significant.

Regarding exercise the post-test ADLs mean scores, SD in the study group was 15.7 (0.79), 16.0 (1.27), the obtained t-value was 1.24 (p=0.283) not significant. In the control group scores 12.7 (0.40), 12.8 (0.28), the obtained t-value was 0.029 (p=0.059) not significant.

Regarding source of knowledge the post-test ADLs mean, SD in the study group were 15.7 (0.87), 15.4 (0.79), 16.0 (1.31), 16.3 (0.12), 16.0 (1.31), the obtained F-values was .731 (p=.564) not significant. In the control group scores were 12.4 (0.45), 12.9 (0.19), 12.8 (0.33), 12.7 (0.18), 12.9 (0.19), the F-test was 1.723 (p=0.224) not significant.

Regarding co-morbidity the post-test ADLs mean, SD in the study group were 15.7 (0.73), 16.4 (1.42), 16.2 (0.34), 16.1 (0.65), 15.2 (1.9) the obtained F-value was 0.724 (p=0.543) not significant. In the control group scores were 12.1 (0.31). 12.9 (0.42), 12.7 (0.28), 12.6 (0.41), 12.4 (0.23), the F-test was 1.645 (p=0.346) not significant.

Conclusion

There was a significant improvement in the ADLs of patients who had availed the modified early ambulation intervention than those who had not.

Conflict of Interest

None.