FACTORS PREDICTING POSTOPERATIVE FATIGUE AMONG …
Transcript of FACTORS PREDICTING POSTOPERATIVE FATIGUE AMONG …
FACTORS PREDICTING POSTOPERATIVE FATIGUE AMONG PATIENTS WITH
CLOSED FRACTURE OF LEG UNDERGOING INTERNAL FIXATION
SURGERY IN KHANH HOA GENERAL HOSPITAL, VIETNAM
NGUYEN THI THUY TRANG
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
AUGUST 2015
COPYRIGHT OF BURAPHA UNIVERSITY
This master thesis has been supported by the master and doctoral thesis
support grant from Burapha University,
fiscal year 2015
ACKNOWLEDGEMENT
Throughout my study as well as the completion of this thesis, there are many
people that I would like to express my gratitude. I would like to express my deep
appreciation to my major advisor, Assistant Professor Dr. Niphawan Samartkit for her
patience, unending guidance, support, encouragements and believing in me. I am
indebted to my co-advisor, Assistant Professor Dr. Pawana Keeratiyutawong for her
countless influential supports. I would like to offer my special gratitude to thesis
examination committee members for providing their suggestions and enriching my
thesis.
I extend my deeply felt gratitude to The South Central Coastal Region
Project for granting me the scholarship for a full time study in master of nursing
science in Thailand. Special thanks to the head nurse and staff of the Traumatology –
Orthopedic department, Khanh Hoa General Hospital for their great contributions.
Without their willingness to share their experiences with me, this thesis would not
have been successful. I am also very grateful to those people who participated in this
study, for taking their time to complete the questionnaires at the hospital.
My sincere thanks also go to colleagues at Khanh Hoa Medical College who
had to take on my responsibilities during my absence from work to study abroad. I
also would like to thank all Faculty members for their academic guidance and staff for
their warm hospitality during my study period here in the Faculty of Nursing, Burapha
University. My special acknowledgement also goes to all of my Vietnamese,
Indonesian, Bhutanese, Thai friends for their supports throughout my study in
Thailand.
Lastly, I am totally indebted to my parents, my parents in law, my younger
sister, my brothers and sisters in law for their strong prayers and blessings during my
two years away from home. My heartfelt thank you goes to my husband for his
support, encouragement and love. I will always remember the sacrifices he made for
me.
Nguyen Thi Thuy Trang
v
56910109: MAJOR: NURSING SCIENCE; M.N.S.
KEYWORDS: CLOSED FRACTURE OF LEG/ POSTOPERATIVE FATIGUE/
PAIN/ ANXIETY/ UNCERTAINTY
NGUYEN THI THUY TRANG: FACTORS PREDICTING
POSTOPERTIVE FATIGUE AMONG PATIENTS WITH CLOSED FRACTURE
OF LEG UNDERGOING INTERNAL FIXATION SURGERY IN KHANH HOA
GENERAL HOSPITAL, VIETNAM. ADVISORY COMMITTEE: NIPHAWAN
SAMARTKIT, Ph.D., PAWANA KEERATIYUTAWONG, Ph.D. 120 P. 2015.
This study was conducted to explore pain, anxiety, uncertainty and
postoperative fatigue as well as to investigate influences of pain, anxiety and
uncertainty on postoperative fatigue among patients with closed fracture of leg
undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam.
The Theory of Unpleasant Symptoms (TOUS) provided a conceptual framework for
this study. A simple random sampling technique was used to recruit 80 samples with
closed facture of leg undergoing internal fixation surgery patients from the
Traumatology – Orthopedic department at Khanh Hoa General Hospital, Vietnam.
Data collection took place during March to April 2015 by using the Patient’s Profile
Record Form, Numeric Pain Rating Scale to measure pain, Hospital Anxiety and
Depression Scale to measure anxiety, the Mishel Uncertainty in Illness Scale to
measure uncertainty and the Identity – Consequence Fatigue Scale to measure fatigue.
Data were analyzed using descriptive statistics and multiple regression analysis.
The results revealed that mean scores of pain, anxiety, uncertainty and
postoperative fatigue were 5.09 (SD = 1.71), 12.29 (SD = 3.78), 82.06 (SD = 10.57)
and 86.58 (SD = 15.06), respectively. Multiple regression analysis indicated that
42% of variance in postoperative fatigue was significantly predicted by pain, anxiety
and uncertainty (R2= .42, p < .001). Pain explained most variance in postoperative
fatigue (β = .35, p < .01), following by anxiety (β = .30, p < .01), and uncertainty
(β = .19, p < .05) respectively. The results provide important information to develop
effective nursing intervention for reducing fatigue among patients with closed
fracture of leg undergoing internal fixation surgery.
CONTENTS
Page
ABSTRACT ............................................................................................................... v
CONTENTS ............................................................................................................... vi
LIST OF FIGURES ................................................................................................... viii
LIST OF TABLES ..................................................................................................... ix
CHAPTER
1 INTRODUCTION ............................................................................................. 1
Background and significance ..................................................................... 1
Research objectives .................................................................................... 7
Research hypothesis ................................................................................... 7
Scope of the study ...................................................................................... 7
Conceptual framework ............................................................................... 7
Definition of terms ..................................................................................... 9
2 LITERATURE REVIEWS ................................................................................ 11
Overview of closed fracture of leg ............................................................. 12
Concepts of postoperative fatigue .............................................................. 21
The theory of unpleasant symptoms ......................................................... 29
Factors predicting postoperative fatigue among patients with closed
fracture of leg ............................................................................................ 32
Conclusion ................................................................................................. 36
3 RESEARCH METHODOLOGY ....................................................................... 37
Research design ......................................................................................... 37
Population and sample ............................................................................... 37
Setting of the study .................................................................................... 39
Research instruments ................................................................................. 40
Translation of the instruments ................................................................... 43
Validity and reliability of the instruments ................................................. 43
Protection of human subjects ..................................................................... 44
Data collection procedure .......................................................................... 44
Data analysis .............................................................................................. 45
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CONTENTS (cont.)
CHAPTER Page
4 RESULTS .......................................................................................................... 46
Description of sample characteristics including demographic
characteristics and medical information of the sample .............................. 46
Description of the studied variables including pain, anxiety, uncertainty
and postoperative fatigue ........................................................................... 49
Influence of pain, anxiety and uncertainty on postoperative fatigue among
patients with closed fracture of leg ............................................................ 52
5 CONCLUSION AND DISCUSSION ................................................................ 54
Summary of the study ................................................................................ 54
Discussion .................................................................................................. 56
Implications and recommendations ........................................................... 62
REFERENCES .......................................................................................................... 65
APPENDICES ........................................................................................................... 79
APPENDIX 1 ..................................................................................................... 80
APPENDIX 2 ..................................................................................................... 88
APPENDIX 3 ..................................................................................................... 97
APPENDIX 4 ..................................................................................................... 99
APPENDIX 5 ..................................................................................................... 102
APPENDIX 6 ..................................................................................................... 106
APPENDIX 7 ..................................................................................................... 110
APPENDIX 8 ..................................................................................................... 115
BIOGRAPHY ............................................................................................................ 120
LIST OF TABLES
Tables Page
1 Frequency and percentage of samples’ demographic characteristic .............. 47
2 Frequency and percentage of samples’ medical information ........................ 48
3 Frequency and percentage of sample’s the level of pain in the first three days
after surgery ................................................................................................... 49
4 Frequency and percentage of sample’s level of anxiety in the third day after
surgery ........................................................................................................... 50
5 Range, mean and standard deviation of sample’s studied variables including
pain, anxiety, uncertainty ............................................................................... 50
6 Range, mean, standard deviation and mean percentage of samples’
postoperative fatigue classified by subcategories .......................................... 51
7 Pearson correlation coefficient of samples’ pain, anxiety, uncertainty and
postoperative fatigue ...................................................................................... 52
8 Multiple regression analysis for variables predicting postoperative fatigue . 52
9 Range, mean, standard deviation for each item of HADS ............................. 111
10 Range, mean, standard deviation for each item of MUIS .............................. 111
11 Range, mean, standard deviation for each item of ICFS ............................... 113
LIST OF FIGURES
Figures Page
1 Research framework of the study .................................................................. 9
2 The unpleasant symptom model .................................................................... 32
CHAPTER 1
INTRODUCTION
Background and significance
Lower extremity trauma is common and it is increasing as a result of our
increasing mobile society, high-speed driving, and the influence of alcohol and drugs
(Finkelstein, Corso, & Miller, 2007; Ignatavicius, 2013). In developing countries like
Vietnam, with the high frequency of using motorbike, the rate of lower limb fracture
from traffic accident is even more common. According to statistics from the National
Road Safety Commission (2013), traffic accidents alone contributed to around 30,000
injuries including orthopedic trauma victims in Vietnam. In a survey on traffic
accidents in Can Tho city, the result indicated that a half of the victim of trauma
included lower limb injury. The result also stated that, most of those patients with
lower limb injury were treated with operation (Giang et al., 2013).
It was reported that most of the lower extremity fracture cases occurred
among young age and males groups (Amin et al., 2011; Giang et al., 2013). An
investigation on the incidence of orthopedic surgery intervention in a level I urban
trauma center with motorcycle trauma, Amin et al. (2011) showed that the average age
was 35 years, with men compared to women at a ratio of 8:1. According to the
statistics from World Health Organization [WHO] (2012), the majority of injuries on
the roads in Vietnam are among those aged between 15 and 49 years - the main labor
resource in the family and the most economically active group. Surgical intervention
of lower limb patient is considered as an emergency situation beyond patient’s
preparation and prediction. Potential surgery and negative consequences after surgery
such as limited movement and role obligations of hospitalization directly affect
surgical patients (Karanci & Dirik, 2003). Moreover, lower limb injuries, even when
expertly treated, are known to induce a considerable effect on the patient’s physiology
with the potential to create long-term permanent disabilities (McCarthy & Mackenzie,
2001; McKoy & Hartsock, 2000; Mock et al., 2000; Ponsford, Hill, Karamitsios, &
Bahar-Fuchs, 2008). Many those patients require a variety of treatments and
rehabilitation, which affects their social psychology and impedes their full complete
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recovery even one year after trauma (Dischinger et al., 2004). Thus, delay in recovery
of post-operative surgery is an increasing burden to patient, family, health care
system, and the society.
Considering the period of time right after surgery, patients undergoing lower
limb surgery, particularly those who are treated with open reduction and internal
fixation (ORIF) operation, have to face with unpleasant symptoms such as pain,
dizziness, vomiting, dry mouth, headache, sleep disturbance, and fatigue (Adlin
Dasima, & Karis, 2013; Long, 2010; Mattila, Toivonen, Janhunen, Rosenberg, &
Hynynen, 2005; Pavlin, Chen, Penaloza, & Buckley, 2004). With high incidence and
longer duration than other symptoms, fatigue is considered as a factor delaying
surgical patient’s recovery in postoperative period (DeCherney, Bachmann, Isaacson,
& Gall, 2002). Postoperative fatigue is often expressed as a feeling of tiredness, strain
or exhaustion in the convalescence phase (Kennedy, 1988). Rubin, Hardy, and Hotopf
(2004 b) defined fatigue as ‘‘unpleasant and distressing symptoms associated with a
major impact on the patient’s quality of life”. Zargar-Shoshtari and Hill (2009)
asserted postoperative fatigue as a collection of physical and psychological symptoms
that delay return to normal activity after surgery. Moreover, postoperative fatigue is
also a kind of subjective feeling of discomfort and a condition with the loss of ability
to engage in normal work or daily life activities (Yu et al., 2015).
Today, despite having an advanced postoperative symptom management,
fatigue is still a common symptom after operation. The result of an investigation on
the prevalence of fatigue in postoperative hysterectomy patients, showed that overall
74 % of patients experienced moderate-to-severe fatigue within the first few weeks
after surgery (DeCherney et al., 2002). Rubin et al. (2004 b) reviewed 91 cohort
studies and confirmed that the prevalence of postoperative fatigue had increased up to
92 %. Long (2010) indicated that tiredness appeared as one of the most problematic
symptoms for three whole days after abdominal surgery among Vietnamese
population. Measuring fatigue by using 0 - 10 Visual Analogue Scale and Numeric
Scale, it was reported that in the first day after laparoscopic cholecystectomy surgery,
the average fatigue score presented at 1 hour was 6; 3 hours was 5 and 24 hours was 4
(Graversen & Sommer, 2013). Comparing fatigue between preoperative and
postoperative period, Yu et al. (2015) showed that the increase of fatigue from mean
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1.65 (SD = .73) before surgery to mean 7.14 (SD = 0.72) on the first day, mean 4.23
(SD = 1.00) on the 10th
day, and to mean 2.34 (SD = .90) on the 30th
day after surgery.
Postoperative fatigue has a huge impact on physical, psychological, and
social life of patients after undergoing surgery. Physically, postoperative patients’
immobility due to fatigue leads to many complications. Zalon (2004) investigated the
recovery among 60 major abdominal surgery patients and reported that pain,
depression, and fatigue explained 13.4 % of the variation in functional status for three
to five days after surgery; 30.8 % for one month and 29.1 % for three months after
discharge. Moreover, earlier the initiation of rehabilitation treatment after total knee
arthroplasty, the better the outcome (Labraca et al., 2011). However, suffering fatigue
makes patient with leg surgery lose effort to adhere to physical therapy designed for
early rehabilitation phase. Thus, patients with lower limb fracture after operation
showed significantly less joint range of motion, and higher scores for gait and balance
(Ersözlü, Sahin, Ozgür, & Tuncay, 2009; Labraca et al., 2011). Furthermore, it is
extremely challenging for lower limb injury patients to mobilize by using assistive
equipment after surgery because of fatigue (Susilahti, Suominen, & Leino-Kilpi,
2004). Staying in bed or immobility caused by fatigue is considered as a high risk for
the development of incision complication, deep vein thrombosis of the lower
extremity, respiratory decompensation/ pneumonias, pulmonary embolism, urinary
tract infections, sepsis or infection, malunion, muscle atrophy, and delay bone healing
process (Epstein, 2014; Ignatavicius, 2013; Zhang et al., 2012).
In addition to the impact on physical health, fatigue can also be a source
affecting psychological and social aspects of patient’s life. Postoperative fatigue
contributes substantially to feelings of frustration, depression, or hopelessness and to
difficulty in concentrating or being attentive; some patients describe fatigue as a
‘‘change in emotional state’’ (DeCherney et al., 2002). Rubin, Cleare, and Hotopf
(2004 a) also reported that patient’s psychological health has a close relationship with
postoperative fatigue. Moreover, because of physical impairment due to fatigue,
postoperative patients may have longer hospital stay, preventing them from returning
to work. A large numbers of patients report loss of salary as a result of this prolonged
surgical recovery time. Patients miss an average of 6 weeks of work after
uncomplicated abdominal operations (Bisgaard, Klarskov, Rosenberg, & Kehlet,
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2001; DeCherney et al., 2002). Compare to patients with less fatigue, tired patients
placed significantly greater demands on their primary health care teams (Bisgaard et
al., 2001; DeCherney et al., 2002; Rubin et al., 2004 b). Researchers asserted that
recovery time lasts longer than normal because of fatigue and it also has a similar
impact on caregivers (Bisgaard et al., 2001). With a huge impact on both physical and
emotional health, fatigue after surgery can have a negative effect on patient’s quality
of life (Wijesuriya, Tran, Middleton, & Craig, 2012). If fatigue persists for a long
time, it may delay getting back to recreational activities and prolong the time to return
to normal work (Rubin et al., 2004 b; Wijesuriya et al., 2012).
One of the most important tasks of a surgical nurse is help patient to manage
their fatigue after surgery. In order to do that, understanding the factors influencing
postoperative fatigue is extremely crucial. As mentioned above, fatigue is an
unpleasant symptom and according to Lenz, Pugh, Milligan, Gift, and Suppe (1997), it
can be announced that postoperative fatigue is affected by various factors classified
into three categories, that is physiologic, psychological, and situational antecedents.
However, findings from previous studies in investigating factors influencing
postoperative symptoms have inconsistently supported variables derived from
situational factors (Ai, Wink, & Shearer, 2012; Long, 2010). For physiologic and
psychologic antecedents, researchers have been investigating factors that can affect
postoperative fatigue such as pain, anxiety and uncertainty (Lasker, Sogolow, Olenik,
Sass, & Weinrieb, 2010; Montgomery, Schnur, Erblich, Diefenbach, & Bovbjerg,
2010; Rubin et al., 2004 a).
Derived from physiologic antecedent, pain is considered as an important
factor influencing postoperative fatigue. Pain is defined by International Association
for the Study of Pain as an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage (Lubkin
& Larsen, 2006). An investigation on 101 breast cancer surgical patients, the result
indicated a positive correlation (r = .36, p < .001) between pain severity and fatigue
(Montgomery et al., 2010). With regard to abdominal surgery population, in the first
and second day after surgery, pain showed correlation with fatigue (r = .39, p < .001
and r = .19, p < .05) (Long, 2010). In another study, it was shown that pain explained
for 20 % of variation in fatigue (Beck, Dudley, & Barsevick, 2005). Saowaluck (2009)
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asserted that pain was significant predictors of postoperative fatigue (β = .28, p < .01).
It was also indicated that although several variables were found to contribute to the
severity of fatigue, the presence of pain explained up to 7.6 % of variance of fatigue
(Lee, Miller, Townson, Anton, & F2N2 Research Group, 2010). By using multiple
logistic regression models, Garabeli Cavalli Kluthcovsky et al. (2012) showed that the
presence of pain was one of predictive factors for postoperative fatigue (OR = 3.87,
95 % CI = 1.88 - 7.98, p = .000).
In addition to pain, anxiety is a significant psychological predictor for
subjective feeling of fatigue after surgery. Mental disorders such as anxiety and
depression are common in hospital inpatients, with an estimated prevalence of
20 - 40 % in worldwide studies (Grau Martin, Suner Soler, Abuli Picart, & Comas
Casanovas, 2003; Hansen et al., 2001) and especially high in orthopedic trauma
(Becher, Smith, & Ziran, 2014; de Moraes, Jorge, Faloppa, & Belloti, 2010). An
assessment of the relationship between postoperative fatigue and anxiety in 183
surgical patients showed that psychological processes including anxiety may well be
relevant in the etiology of postoperative fatigue (Rubin et al., 2004 a). An examination
in abdominal surgery population, the result indicated that on the second day after
surgery, anxiety had association with tiredness (r = .33, p < .01) (Long, 2010). The
increase in psychological distress is a factor related to worsening fatigue after surgery
(Rotonda, Guillemin, Bonnetain, Velten, & Conroy, 2013). In 180 postoperative
patients with breast cancer, the finding showed that moderate/ severe fatigue was
positively associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05)
(Tan & Xia, 2014). After controlling for all other variables, depression variable was a
significant predictor of postoperative fatigue (β = .40, p < .01) in hysterectomy
population (Saowaluck, 2009).
Another important psychological antecedent of patients’ postoperative
fatigue has been considered is uncertainty. Fracture of leg is often an acute injury,
surgery for treatment of these surgical patients come up unexpectedly. Hence, these
patients do not have any preparation for getting operation, staying in hospital for a
long time up to 7 to 10 days, coping with many postoperative symptoms, leaving
family and work. In addition, being unsatisfied with information getting from
healthcare provider is a common complaint of Vietnamese patients, it makes surgical
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patients suffer uncertainty (Loi, 2014). Previous research findings proved the
relationship between fatigue and uncertainty. Providing adequate medical information
will reduce illness uncertainty for patients and this in turn is an important strategy in
reducing fatigue (Stiegelis et al., 2004). In heart failure population, the finding also
confirmed a positive association between uncertainty and tiredness (Falk, Swedberg,
Gaston-Johansson, & Ekman, 2007). Conducting a study in 100 female patients
undergoing liver transplantation operation, Lasker et al. (2010) indicated that there
was a significant relationship between uncertainty and fatigue.
Khanh Hoa General Hospital is the biggest general hospital in Khanh Hoa
province. In Traumatology – Orthopedic department, there are many patients
undergoing open reduction and internal fixation (ORIF) surgery. In the postoperative
phase, the problem of caring for this group of patient is that they always stay in bed,
immobilize, delay getting back to activities of daily livings (ADLS) and refuse to take
part in rehabilitation sessions. These are risk factors for the development of many
severe complications. As previously mentioned, fatigue plays an important part in
these performances. Understanding the factors affecting fatigue among fracture
patients following internal fixation surgery is the first crucial step to improve the
quality of postoperative nursing care in Khanh Hoa General Hospital, Vietnam.
In conclusion, the experience of postoperative fatigue varies among
individuals, reflecting their physiological, psychological, and social differences. There
are many factors leading to fatigue after surgery. Among them, pain, anxiety, and
uncertainty have been highlighted as reliable factors and they are supported by
previous research findings. Understanding the characteristics of fatigue and predicting
factors is crucial for nurses to improve the quality of care for postoperative patients.
Nurses will also be able to differentiate the patients who are at higher risk of
experiencing severe fatigue after surgery. However, most of studies reviewed almost
exclusively from abdominal surgery and cancer population; there has been few
researches focusing on postoperative fatigue in orthopedic population (Long, 2010;
Saowaluck, 2009; Tan & Xia, 2014). In addition, with the increasing rate of trauma
and injury by traffic accident in Vietnam and overload of patient admission and longer
hospital stay (7 - 10 days) in the Traumatology – Orthopedic department, Khanh Hoa
General Hospital, a homogeneous model such as lower limb fracture sample needs to
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be employed. Thus, a study of factors predicting postoperative fatigue among patients
with closed fracture of leg after undergoing internal fixation surgery in Vietnamese
population is necessary.
Research objectives
1. To describe the characteristics of pain, anxiety, uncertainty, and
postoperative fatigue among patients with closed fracture of leg undergoing internal
fixation surgery in Khanh Hoa General Hospital, Vietnam.
2. To examine the influence of pain, anxiety, and uncertainty on
postoperative fatigue among patients with closed fracture of leg undergoing internal
fixation surgery in Khanh Hoa General Hospital, Vietnam.
Research hypothesis
Pain, anxiety, and uncertainty predict postoperative fatigue among patients
with closed fracture of leg undergoing internal fixation surgery in Khanh Hoa General
Hospital, Vietnam.
Scope of the study
This study examined the influence of pain, anxiety, and uncertainty on
postoperative fatigue among patients with closed fracture of leg undergoing internal
fixation surgery. The population of the current study was patients with closed fracture
of femur, tibia and fibula bone undergoing internal fixation surgery. Data collection
was performed at the Traumatology – Orthopedic department of Khanh Hoa General
Hospital in Khanh Hoa province, Vietnam from March to April, 2015.
Conceptual framework
The theory of unpleasant symptoms [TOUS] (Lenz et al., 1997) was used as
a framework for this study. The TOUS has three major components: the symptoms
that the individual is experiencing, the influencing factors that give rise to or affect the
nature of the symptom experience, and the consequences of the symptom experience”.
Symptoms have the dimensions of intensity (severity), timing (frequency, duration,
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and relationship to events), distress (the person’s reaction to the sensation), and
quality (descriptors used to characterize the symptom, location of the symptom, or
response to intervention). These symptom dimensions are influenced by three
categories of variables: physiologic factors, psychologic factors, and situational
factors. Physiological factors are often reflected in unpleasant symptoms associated
with alterations in the normal functioning of bodily systems or the existence of any
pathology. The psychological factors that are antecedents include the individual’s
mental state or mood (depression), affective reaction to illness (mood status),
psychological response to stress (the degree of perceived stress or the level of anxiety)
and degree of uncertainty and knowledge about the symptoms and their possible
meaning (perception of illness experience or symptom experience). Situational/
environmental antecedents include aspects of the social and physical environment that
may affect the individual’s experience and reporting of symptoms (Lenz et al., 1997).
The outcome or consequence of the symptom experience is the final component of the
Theory of Unpleasant Symptoms. Performance is conceptualized to include the
functional status or performance, cognitive functioning, and physical performance.
In the present study, postoperative fatigue is considered as a symptom that
the individual is experiencing. Based on the meaning of antecedent factors, pain
belongs to the physiologic factor; anxiety and uncertainty are the psychologic factor.
According to the theory of unpleasant symptoms (Lenz et al., 1997), those above
factors could relate to the symptom of fatigue among patients following internal
fixation surgery for closed fracture of leg. Moreover, to date, a large body of research
has consistently confirmed the relationship among pain, anxiety, uncertainty and
postoperative fatigue. In abdominal surgery population, in the first and second day
after surgery, pain showed correlation with fatigue (r = .39, p < .001 and r = .19,
p < .05) (Long, 2010). After a hysterectomy operation, pain was a significant predictor
of postoperative fatigue (β = .28, p < .01) (Saowaluck, 2009). In 180 postoperative
patients with breast cancer, the finding showed that moderate/ severe fatigue was
positively associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05)
(Tan & Xia, 2014). After controlling for all other variables, depression variable was a
significant predictor of postoperative fatigue (β = .40, p < .01) in hysterectomy
population (Saowaluck, 2009). Furthermore, the positive association between
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uncertainty and tiredness was confirmed in heart failure population (Falk et al., 2007).
In patients after liver transplant operation, Lasker et al. (2010) indicated that there was
a significant relationship between uncertainty and fatigue. Therefore, the influence of
pain, anxiety, and uncertainty factors on postoperative fatigue among patients with
closed fracture undergoing internal fixation surgery will be examined in this study as
demonstrated in figure 1.
Independent variables Dependent variable
Figure 1 Research framework of the study
Definition of terms
Postoperative fatigue refers to an unpleasant and distressing symptom with
feeling of tiredness, strain, exhaustion and lack of vigor in the first three days after
internal fixation surgery for patients with closed fracture of leg; being associated with
impacts on concentration, energy and daily activities. In the current study,
postoperative fatigue was measured by using The identity - consequence fatigue scale
developed by Paddison, Booth, Hill, and Cameron (2006).
Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage among
patients with closed fracture of leg undergoing internal fixation surgery. In this study,
pain was measured by using numeric pain rating scale (NPRS) (McCaffery & Beebe,
1989).
Physiologic factor
- Pain
Psychologic factors
- Anxiety
- Uncertainty
Postoperative fatigue
among patients with closed
fracture of leg undergoing
internal fixation surgery
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Anxiety refers to an emotional state involving subjective feelings of tension,
apprehension, nervousness, and worry experienced by patients with closed fracture of
leg undergoing internal fixation surgery. Anxiety in the present study was measured
with the hospital anxiety and depressed scale (HADS) (Zigmond & Snaith, 1983).
Uncertainty is a cognitive state indicating inability to determine the
meaning of illness-related events, occurring when patients with closed fracture of leg
undergoing internal fixation surgery are unable to assign definite value to objects or
events, or are unable to predict outcomes accurately. In this study, uncertainty variable
was measured with the Mishel uncertainty in illness scale (MUIS) (Mishel, 1981).
CHAPTER 2
LITERATURE REVIEWS
This study examines postoperative fatigue and its predicting factors among
patients with closed fracture of leg undergoing internal fixation surgery. The literature
review presents an overview about issues related to the study, including:
1. Overview of closed fracture of leg
1.1 Background of closed fracture of leg
1.2 Pathophysiology of closed fracture of leg
1.3 Principles of treatment for closed fracture of leg
1.4 Symptoms after surgery for closed fracture of leg
2. Concepts of postoperative fatigue
2.1 Definition of postoperative fatigue
2.2 Pathophysiology of postoperative fatigue
2.3 Causes of postoperative fatigue
2.4 Classification of postoperative fatigue
2.5 Impacts of postoperative fatigue
2.6 Management for postoperative fatigue
3. The Theory of Unpleasant Symptoms
4. Factors predicting postoperative fatigue among patients with closed
fracture of leg
4.1 Pain
4.2 Anxiety
4.3 Uncertainty
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Overview of closed fracture of leg
Background of closed fracture of leg
Closed fracture of leg is a medical condition in which there is a break in the
continuity of the leg bone with overlying skin being intact. It has happened more than
open fracture and caused commonly by trauma such as a fall, road traffic accident,
fight, etc. (Stannard, Duke, & Alonso, 2008).
Lower extremity trauma is increasingly common and leading cause of
physical trauma to patients admitted to hospitals in the United States (Vyrostek,
Annest, & Ryan, 2004). Each year, trauma accounts for 41 million emergency
department visits and 2.3 million hospital admissions across the United States
(National Trauma Institute, 2014). An exploration on incidence of orthopedic surgery
intervention in a level I urban trauma center with motorcycle trauma, Amin et al.
(2011) showed that the most common site of fracture involved the lower extremities
with average age was 35 years, with men compare to women at a ratio of 8:1. In
Vietnam, according to statistics from the National Road Safety Commission (2013),
traffic accidents caused up to 30,000 injured people including orthopedic trauma
victims. A survey on trauma by traffic accident in Can Tho, showed that half of the
victims suffered lower limb trauma, needing surgical treatment (Giang et al., 2013).
Results from this study also reported that 71.4 % patients were men and 66.7 %
victims were the main labor resource in the family and most economically active
group.
Lower limb injuries, even when expertly treated, are known to induce a
considerable effect on the patient’s physiology, they have the potential to create long-
term and permanent disabilities (McCarthy & Mackenzie, 2001; McKoy & Hartsock,
2000; Mock et al., 2000; Ponsford et al., 2008). Many patients with lower limb
injuries require a variety of treatments and rehabilitation, which affects their social
psychology and impedes their full/ complete recovery even one year after trauma.
(Dischinger et al., 2004). In a prospective study of 215 fractured patients after
orthopedic trauma, 1 in 5 met the threshold for psychological distress (Bhandari et al.,
2008). A literature review from two authors, Remizov and Lungu (2008) concluded
that there was reduction in quality of life among patient with lower limb fracture.
A common source of patient complaints and clinical outcome is not only focused on
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unpleasant symptoms such as pain, fatigue, disturbances of sleep, limitation of
mobility but also functional recovery, complications, mortality, costs and
psychological status following orthopedic trauma (Remizov & Lungu, 2008).
Today, in the modern society closed fracture of lower limb is the most
common health issue, affecting great aspect of the quality of life in trauma population.
It is important to understand the systemic impact of lower extremity injuries in order
to decrease their morbidity and increase the potential function following rehabilitation.
Pathophysiology of closed fracture of leg
A fracture is a break or disruption in the continuity of a bone that often
affects mobility and sensation (Ignatavicius, 2013). It can occur anywhere in the body
and at any age. All fracture has the same basic pathophysiologic mechanism
regardless of fracture type or location. A fracture is described by the extent of
associated soft-tissue damage as open (or compound) or closed (or simple). When a
bone is fractured, vascular disruption with blood dispersing through soft tissue causes
ecchymosis. Over an area of injury, continuous muscle contraction occurs and
considered a protective mechanism of the muscle to splint the injured part (LeMone &
Burke, 2008). In addition, bone fracture fragments cause injury to the soft tissue and
interruption of the venous and lymphatic return system lead to swelling condition at
trauma place. Pain is usually caused by injury to the periosteum, muscle spasm, soft
tissue disruption, and swelling with fascial compartments. Deviation from normal rage
or limitation of motion or muscle strength is noted (Smith, Stahel, Morgan, & Trafton,
2008; Walsh, 2009).
Fractures of the lower two thirds of the femur usually result from trauma
often from a motor vehicle crash (Stannard et al., 2008). Extensive hemorrhage can
occur with femur fracture. Untreated fractures of the lower limbs can lead to
significant blood loss, which may be external and obvious, or covert. The estimated
blood loss for a closed fracture of the femur is 1,000 - 1,500 ml and for a closed
fracture of the tibia is 500 - 1,000 ml. Fractures of the lower limb, particularly the
femur, should be considered a potential cause of hypovolemic shock, especially if
compound (Lee & Porter, 2005). In a few cases in which extensive bone
fragmentation or severe tissue trauma is found. Healing time for a femur fracture may
be 6 months or longer (Ignatavicius, 2013).
14
When a bone is fractured, the body immediately begins the healing process
to repair the injury and restore the body’s equilibrium. Fractures heal in five stages
that are a continuous process not a single stage (Smith et al., 2008). Stage one begins
within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture
because bone is extremely vascular. Stage two occurs in 3 days to 2 weeks when
granulation tissue begins to invade the hematoma. This then prompts the formation of
fibrocartilage, providing the foundation for bone healing. Stage three a bone healing
occurs as a result of vascular and cellular proliferation. The fracture site is surrounded
by new vascular tissue known as a callus within 3 to 6 weeks. Callus formation is the
beginning of a non-bony union. That healing continues is stage four, the callus is
gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks.
During the fifth and final stage of healing, consolidation and remodeling of bone
continue to meet mechanical demands. This process may start as early as 4 to 6 weeks
after fracture and can continue for up to 1 year, depending on the severity of the injury
and the age and health of the patient (Ignatavicius, 2013)
Even pathophysiologic mechanism is quite similar for various types of
fractures; the identified treatment is more complicated.
Principles of treatment for closed fracture of leg
deWit and Kumagai (2013) reported that the three principles are used when
treating fractures are reduction, retention, and rehabilitation
1. Reduction
Due to the force of impact or surrounding muscle groups, the normal
alignment of the affected bone may be compromised. If this is the case and the
alignment of the bone is not satisfactory, the position of the fragments will need to be
altered in order to maximize bone healing in the correct position. Not all fractures
result in misalignment, and in these circumstances reduction will not be indicated.
Soft tissue swelling post injury can cause difficulty in reduction and for this reason
there should be no unnecessary delay. There are two types of reduction: closed
reduction and open reduction (deWit & Kumagai, 2013).
1.1 Closed reduction: If the degree of displacement is minimal, or in most
pediatric fractures, the option of closed reduction is preferred. This can be with
repositioning in a regular clinical setting with analgesia or manipulation under
15
anesthetic, where the patient is taken to theatre and the fracture is reduced by the
surgeon with the assistance of X-ray (deWit & Kumagai, 2013).
1.2 Open reduction: Surgical intervention is required if closed reduction
fails, or if initially the degree of displacement is significant. Open reduction is usually
the first stage to internal fixation.
2. Retention
The theory behind retention the fracture is to hold the bone fragments in a
good position for healing, prevent excessive movement that could hamper fracture
union (this may require joint immobilization proximal and/ or distally) and reduce
pain. There is no hard and fast rule for which fracture should be stabilized by which
method. Each fracture is individual and should be managed as such, also taking into
account patient factors. Stabilization falls into two broad categories, conservative and
operative. Methods of fracture retention are discussed respectively (LeMone & Burke,
2008).
2.1 Conservation
2.1.1 Casting, usually with Plaster of Paris is a splint to maintain the
either original or post reduction position.
2.1.2 Traction, a calculated force is applied to the long axis of the
bone, causing opposing fragments to separate and align in the correct position. This is
enabled with specialized equipment using weights to generate the traction force.
Traction can be applied in either of these two methods: skin traction and skeletal
traction. Skin traction where the device is applied superficially, around the skin.
Secondly, skeletal traction where per cutaneous pins are directly attached to the distal
bone fragment.
2.2 Operation
Open reduction and internal fixation (ORIF) is one of the most common
methods of reducing and immobilizing a fracture. Using ORIF surgery may decrease
pain and help broken leg heal correctly, restore the bone to its normal function and
prevent further injury. Furthermore, ORIF is often the preferred surgical method due
to permit early mobilization. Open reduction allows the surgeon to directly view the
fracture site. Internal fixation uses metal pins, crews, rods, plates, or prostheses to
immobilize the fracture during healing. Krishner wires, also known as K-wires is per
16
cutaneous insertion, across the fracture site to maintain alignment. Plates and screws
usually used in conjunction to provide mechanical stability as well as ensuring
maintenance of alignment. Screws can also be used independently, across a fracture
site. Intramedullary nailing, most commonly used in long bones; a nail is passed along
the long axis of the bone, within the cortex, acting as an internal splint. External
fixation provides stability away from the fracture site, without interruption of soft
tissue structures with screws are applied to the proximal and distal fragments of the
bone, and attached to an external frame. The surgeon makes one or more incisions
gain access to the broken bones and implants one or more devices into bone tissue
after each fracture is reduced. After the bone achieves union, the metal hardware may
be removed, depending on the location and type of fracture. If the metal implants are
not bothersome, they may remain in place (deWit & Kumagai, 2013; Stannard et al.,
2008).
3. Rehabilitation
Once the fracture has been stabilized and the healing process is underway,
attention is diverted to functional improvement and a return to normality. Early
mobilization is often encouraged, providing stability is not compromised. This aids in
avoiding joint stiffness, loss of muscle power and edema. Rehabilitation is tailored
according to both the injury and patient circumstance. Multidisciplinary input is used
in varying degree, including the expertise of physiotherapists and occupational
therapists if necessary (deWit & Kumagai, 2013).
The patient’s rehabilitation program was divided into 3 phases: the first
phase is from the first day after surgery to postoperative week 4; phase two is
postoperative time from week 4 to week 8, and the last phase is post surgery week 16
to month 8. The purpose of rehabilitation program for lower limb fracture patients
focuses on immediate weight bearing and progression of gait training, range of
motion, strength, balance, and return to function. In range of this study, it is really
important to understand about the designed rehabilitation sessions for the first phase,
particularly during hospitalization time (Paterno, Archdeacon, Ford, Galvin, &
Hewett, 2006).
Exercises in phase I focus on hip and knee joint mobility, non–weight-
bearing strengthening, and progression of weight bearing during gait. Inpatient
17
physical therapy is ordered twice daily and consisted of gentle range of- motion
activities, initiation of a weight-bearing-as tolerated ambulation program with either a
walker or bilateral axillary crutches, and lower-extremity isometric exercises. Usually,
the patient uses bilateral axillary crutches immediately following surgery. Active-
range-of-motion and passive-range-of-motion exercises of the hip, knee, and ankle are
initiated immediately following surgery in all 3 cardinal planes. The main initial focus
is knee extension. Full knee extension is pursued aggressively immediately following
surgery to decrease the risk of knee flexion contracture. Passive and active assisted
knee flexion exercises are initiated while the patient is in the seated position on a chair
or table. The patient performs posterior lower-extremity stretching, including seated
hamstring muscle stretching and seated gastrocnemius muscle stretching with the
assistance of a towel. In addition, the patient’s involved lower extremity is elevated
with the heel propped up for 10 minutes 3 or 4 times per day. This static heel propping
stretch is intended to provide a low-load, long-duration stretch of the posterior knee
(Paterno et al., 2006).
Orthopedic nurses play an important role in early rehabilitation phase,
especially during the first 3 days after surgery in providing care for lower fracture
patients. In early rehabilitation, effective assessment and management of unpleasant
symptoms bring good quality of care, improve patient satisfaction, and limit post-
surgery complications. Furthermore, the patient with a fracture after surgery is
expected to have no compromise in neurovascular status as evidenced by adequate
circulation, movement, and sensation. Perform neurovascular assessment before and
after fracture treatment is recommended for all health care provider in surgical ward
(Burden, 2007). Additionally, nursing care for postoperative fracture patients in early
rehabilitation phase should increase physical mobility to prevent associated
complications with impaired mobility. The patient is recommended to move
purposefully in his or her own environment independently with or without and
ambulatory device unless restricted by traction or other modality. The use of crutches
or a walker increase mobility and assists in ambulation. In most agencies, the physical
therapist or emergency department/ambulatory care nurse fits the patient for crutches
and teaches him or her how to ambulate with them. Reinforce those instructions, and
evaluate whether the patient is using the crutches correctly (Mamaril, Childs, &
18
Sortman, 2007).
Helping patients reduce the unpleasant symptoms will make them physically,
psychologically and socially able to stay adhered to designed therapeutic program; this
in turn will give them faster and better recovery. In order to do that, the nurses need to
have a sound scientific knowledge of the signs and symptoms troubling their patients
and impeding the healing.
Symptoms after surgery for closed fracture of leg
Despite significant interest in improving postoperative symptoms
management, the rate of symptom clusters is still high. Concerning the first 3 days
after surgery, these symptoms are more severe and make a huge impact on patient
health satisfaction. Literature reviews revealed a wide variance in prevalence of
symptoms following operation including pain, sleep disturbance, fatigue, nausea and
vomiting, dizziness, drowsiness, headache and voiding difficulty (Adlin Dasima &
Karis, 2013; Long, 2010; Mattila et al., 2005; Pavlin et al., 2004).
1. Pain: Orthopedic surgery is often cited as among the most painful of
surgeries (Adlin Dasima & Karis, 2013). It has since been repeatedly confirmed that
30 - 80 % of patients undergoing surgery suffer from inadequately treated pain
(Mwaka, Thikra, & Mung’ayi, 2013; Pavlin et al., 2004; Pitimana-Aree et al., 2005;
Zaslansky et al., 2006). At 4, 24, 48 and 72 hours postoperatively, the incidence of
moderate to severe pain (VAS ≥ 40) at rest is 39 %, 43 %, 27 % and 16 %,
respectively. During the first 24 hours after operation, 88 % of patients experienced
moderate or severe pain at some time and 7 % of them reported unbearable pain
(Svensson, Sjostrom, & Haljamae, 2000). The mean score measured by visual analog
scale in the first two days was 40 (SD = 29) and on the third day was 20 (SD = 26).
In a large Dutch cohort of 1,490 surgical patients who received postoperative pain
treatment, patients still experienced moderate to severe pain on the day of the surgery,
which continued in 15 % at four days after surgery (Sommer et al., 2008; Sommer
et al., 2010). Despite significant advances in the understanding of pain mechanisms
and innovative developments of analgesic and anesthetic agents, acute postoperative
pain control remains a challenge in about one-third of surgical patients (Wu & Raja,
2011).
19
Postoperative pain management in orthopedic surgery
Provision of sufficient post-operative pain therapy is an obligation in the
clinical management of patients. Assessment and evaluation of pain are as important
as the correct use of analgesics and application techniques (Giesa et al., 2007).
Opioids, administered intramuscularly, as epidurals, or IV as patient-controlled
analgesia, are effective for severe pain. Oral opioids are effective for moderate to
severe pain, and tramadol is selected for moderate to moderately severe pain. Opioid-
sparing NSAIDs, such as ketorolac, and COX-2-specific NSAIDS have use in pain
management of hip, knee, and ACL procedures. An individualized regimen of
appropriate analgesics, combined with nonpharmacologic treatments such as physical
therapy or cryotherapy and patient education, can aid orthopedic surgery patients'
recovery (Bourne, 2004).
2. Fatigue: Fatigue is one of the most common symptoms after undergoing
operation and can negatively affect functioning. Upon measuring 63 patients
undergoing major joint arthroplasty 1 week after surgery, the result showed physical
and mental fatigue is less than preoperation but the mean scores of physical fatigue
indicate more than usual (Aarons, Forester, Hall, & Salmon, 1996). To assess the
prevalence and impact of postoperative fatigue from the postoperative hysterectomy
patient's perspective, the result showed that overall, 74 % of patients experienced
moderate-to-severe fatigue within the first few weeks after surgery and fatigue
occurred more frequently and persisted twice as long as pain, the next most frequent
symptom, which was experienced by 63 % of patients overall (DeCherney et al.,
2002). Rubin et al. (2004 b) reviewed 91 cohort studies and reported that the
prevalence of postoperative fatigue was increased up to 92 %. Long (2010) indicated
that tiredness appeared as one of the most problematic symptoms for three whole days
after surgery. Another study on this population, Kahokehr, Broadbent, Wheeler,
Sammour, and Hill (2012) confirmed that fatigue persisted until post-operation for 1
month in both fatigue and fatigue subscale score. Measuring fatigue by 0 - 10 visual
analogue scale and numeric scale, it was reported that in the first day after
laparoscopic cholecystectomy surgery, fatigue presented at 1 hour was 6 (4.5 - 8),
3 hours was 5 (3 - 7) and 24 hours was 4 (2 - 6) (Graversen & Sommer, 2013).
Comparing fatigue between preoperation and postoperation for gastrointestinal
20
surgery, Yu et al. (2015) showed the increase before surgery from mean 1.65 (SD =
.73) to mean 7.14 (SD = .72) (p < .001) on postoperative first day, to mean 4.23 (SD =
1.00) (p < .001), on the 10th
day, and to mean 2.34 (SD = .90) (p < .001) on the 30th
day, respectively.
3. Sleep disturbance: Additionally, lack of sleep is also an important
postoperative symptom. Closs, Briggs, and Everitt (1997) reported that the duration of
sleep after surgery was significantly shorter than before hospitalization. There are
about 42 % of patients complained of unsatisfactory sleep after orthopedic, vascular,
and general surgery versus 28 % the night before surgery, and their sleep remained
unsatisfactory after four days in 23 % of cases (Kain & Caldwell-Andrews, 2003).
Sleep disruptions can persist up to three or four nights postsurgery (Cronin, Keifer,
Davies, King, & Bixler, 2001; Krenk, Jennum, & Kehlet, 2012). In one of the recent
reviews, Chouchou, Khoury, Chauny, Denis, and Lavigne (2014) confirmed sleep
disruptions can persist up to three or four nights postsurgery and longer up to several
weeks for cardiac surgery. There is at least 41 % and 19 % of patients presented total
slow wave sleep and rapid eye movement sleep suppression, respectively, during at
least one night after surgery (Chouchou et al., 2014).
4. Nausea and vomiting: Post-operative nausea and vomiting (PONV) is one
of the most common and distressing side effects of surgery (Mace, 2003). The
prevalence of nausea and vomiting in the first 24 hours after surgery was reported by
9.7 % of 1,017 patients (Chung, Un, & Su, 1996). The general incidence of vomiting
is about 30 %, the incidence of nausea is about 50 %, and in a subset of high-risk
patients, the PONV rate can be as high as 80 % (Apfel, Läärä, Koivuranta, Greim, &
Roewer, 1999; Koivuranta, Läärä, Snåre, & Alahuhta, 1997; Sinclair, Chung, &
Mezei, 1999). It was demonstrated that the incidence of PONV increased by
approximately ten times when the length of operation increased from less than 30
minutes to between 151 to 180 minutes (Ku & Ong, 2003). In the research of Mace
(2003), the overall prevalence of nausea among postoperative patients is 66.5%, but
only 34 % actually vomited. Both incidences of nausea and vomiting reach their peaks
at the first two days and might persist for more than six days after surgery (Mace,
2003; Rosén, Clabo, & Matensson, 2009). The incidence and intensity of PONV
largely relies on operative procedure (Rosén et al., 2009). With regard to gender,
21
Mace (2003) reported more females (80 %) suffering from PONV than males (60 %),
and the risk of PONV in females is three times greater than in females.
Besides the majority of symptoms mentioned above, because of effects of
anaesthethic agents as patients were interviewed after surgery, headache (7 - 11 %),
dizziness (49.7 %) and drowsiness/ sleepy (8 - 70 %), difficulty voiding (9 % - 18 %)
occur 24 hours post-surgery. During the first week after surgery, from 1 % to 73 % of
patients complained about dizziness; it appeared to be related to postural hypotension
and is exaggerated on mobilizing (Rosén et al., 2009; Stephenson, 1990). A study with
the sample of 1,017 patients reported that in 24 hours after operation, three most
common symptoms are pain, headache, and drowsiness, respectively. Other small
proportions of patients reported dizziness (9.7 %) and fever (5 %) (Adlin et al., 2013;
Mwaka et al., 2013).
In conclusion, there are many postoperative symptoms that are interfering
surgical patients to reach their health outcome in rehabilitative phase. It is a challenge
for nurses taking care of such patients. Understanding and having advanced strategies
to manage these unpleasant symptoms is essential in caring for patients in order to not
only reduce cost of treatment and increase satisfaction with health care services but
also improve recovery for patients. However, most of patients stay in bed all the time
until discharge day. It is leading to severe complications after surgery for closed
fracture of leg. According to literature review, fatigue is one of the factors playing an
important role, forcing lower limb fracture patient stay bedridden during the day
(Susilahti et al., 2004). Hence, it is extremely necessary to have in depth
understanding of the concept of postoperative fatigue.
Concepts of postoperative fatigue
Definition of postoperative fatigue
Fatigue is an unpleasant and distressing symptom in convalescence that is
often expressed as a feeling of tiredness, strain or exhaustion (Kennedy, 1988).
It describes reduced capacity to sustain force or power output, reduced capacity to
perform multiple tasks over time and simply a subjective experience of feeling
exhausted, tired, weak or having lack of energy (Kaasa, Loge, Knobel, Jordhøy, &
Brenne, 1999). Rubin et al. (2004 b) defined postoperative fatigue as ‘‘unpleasant and
22
distressing symptoms associated with a major impact on the patient’s quality of life’’.
It is a collection of physical and psychological symptoms that delay return to normal
activity after surgery (Zargar-Shoshtari & Hill, 2009). Yu et al. (2015) considered
fatigue as a kind of subjective feeling of discomfort leading to loss of ability to engage
in normal work or daily life activities. Therefore, definition for postoperative fatigue
in this study is considered as an unpleasant and distressing symptom with feeling of
tiredness, strain or exhaustion in the first three days after internal fixation surgery for
closed fracture of leg; being associated with impacts on concentration, energy and
daily life activities.
Pathophysiology of postoperative fatigue
According to the theory of postoperative fatigue from Salmon and Hall
(1997), major surgery is a trauma that provokes a constellation of hormonal,
metabolic, hematological, and immunological responses. There is a marked increase in
secretion of catabolic hormones, which are catecholamines and corticosol together
with suppression of the key anabolic hormone, insulin. This results in mobilization of
substrates, including glucose and amino acids, to maintain key synthetic processes in
the postoperative period. Surgical trauma also rapidly increases circulating white
blood cells and reflecting tissue damage, cytokine secretion, particularly interleukin
(IL)-6. Cytokines produced at the site of surgery enter the blood stream and proceed
through a variety of mechanisms to act directly on the brain. The second method is a
neural route represented by paracrine actions of cytokines on primary afferent neurons,
which innervate the body site where the injury has taken place. Proinflammatory
cytokines such as IL-1b and IL-6 levels in plasma lead to decline in mood, absence of
any other physical symptoms and induce human “sickness behavior,” such as fever,
malaise, pain, fatigue, low mood, and poor concentration. Furthermore, changes in
lymphocyte function are associated with immune suppression. These changes have
been regarded as deleterious: in particular, the marked loss of muscle protein that
inevitably follows major surgery has been largely attributed to catabolic hormone
secretion and regarded as a hindrance to the mobilization and recovery of the patient.
Moreover, tryptophan is the precursor of the neurotransmitter 5-
hydroxytryptamine (5-HT), known to be involved in sleep and fatigue. Free
tryptophan levels in blood are increased after surgery, which is associated with an
23
increased amount of tryptophan entering the brain. This may lead to higher 5-HT
concentrations in some parts of the brain, may contribute to a need for increase in
sleep, and possibly an increase in central fatigue. Subsequently, significant
correlations have been shown between fatigue scores and plasma-free tryptophan
(Yamamoto et al., 1997).
Enhancing nursing care for fatigue among lower limb patients,
understanding about etiology of fatigue is also an essential step.
Causes of postoperative fatigue
In context of lower limb fracture patients, there is a combined etiology for
development of postoperative fatigue. It is the result that is caused by injury, surgical
intervention and prolonged bed rest after operation.
Firstly, injuries to the soft tissue, including muscle, nerves, vessels,
subcutaneous fat and skin, occur to some degree in conjunction with all fractures.
Suffering from high-energy incident leads patients experiencing severe pain caused by
injury to the periosteum, muscle spasm, soft tissue disruption, and swelling within
fascial compartments. Furthermore, any musculoskeletal injury results in blood loss.
Fracture of the closed fracture of the femur is 1,000 - 1,500 ml and for a closed
fracture of the tibia is 500 - 1,000 ml (Lee & Porter, 2005). Suffering injury, facing
with pain and blood loss are the first causes for fatigue among lower limb fracture
patients.
Secondly, after exhausted by injury, lower limb fracture patient have to face
with ORIF surgery. In the surgical setting, surgical trauma is also an important factor
contributes postoperative fatigue. As mentioned, fatigue increases significantly after
major surgery. After undergoing operation, the combination of anesthesia, surgical
intervention and hormonal response lead to changes in whole body protein breakdown
and systematic plasma endocrine-metabolic response that may be involved in the
pathogenesis of postoperative fatigue (Zargar-Shoshtari & Hill, 2009).
Thirdly, there are a number of other physiological changes observed within
muscle fibers, although these have not been shown to correlate with the development
of fatigue, postoperatively. Surgery is followed by a prolonged period of reduced
activity, which can lead to significant impairment of muscle functioning, particularly
endurance, similar to changes seen in volunteers undergoing bed rest. Additionally,
24
cardiovascular fitness also deteriorates after surgery. Objective measures of
cardiovascular fitness and musculoskeletal deterioration both correlate with the
development of fatigue. Therefore, as muscular endurance and cardiac fitness both
decline, patients may need to use more energy to perform a given physical task, which
may lead to sensations of fatigue. These factors are thought to lead to reduced
mobility and contribute to fatigue (Christensen & Kehlet, 1993; Zargar-Shoshtari &
Hill, 2009).
Different from other operations, patients with closed fracture of leg
undergoing internal fixation surgery feel fatigued because of the combination of
multiple causes. It is a consequence of effect lasting from preoperation to
postoperation period. Screening potential factors for fatigue occurrence in these
patients should be considered from resuscitation through rehabilitation.
Based on etiology and mechanism of fatigue, it is recognized that
postoperative fatigue concept not only focused on physical meaning but also related to
mental aspect.
Classification of fatigue
According to Chalder et al. (1993), fatigue is considered as physical and
mental fatigue. In the process of analyzing the concept of fatigue, it is common to
classify fatigue into two types: physical fatigue and mental fatigue.
1. Physical fatigue: Physical fatigue, or muscle fatigue, is the temporary
physical inability of a muscle to perform optimally. The onset of muscle fatigue
during physical activity is gradual, and depends upon an individual's level of physical
fitness, and also upon other factors, such as sleep deprivation and overall health.
Physical fatigue can be caused by a lack of energy in the muscle, by a decrease of the
efficiency of the neuromuscular junction or by a reduction of the drive originating
from the central nervous system (Gandevia, 2001). The central component of fatigue
is triggered by an increase of the level of serotonin in the central nervous system
(Davis, Alderson, & Welsh, 2000). During motor activity, serotonin released in
synapses that contact motoneurons promotes muscle contraction (Perrier & Delgado-
Lezama, 2005). During high level of motor activity, the amount of released serotonin
increases and a spillover occurs. Serotonin binds to extrasynaptic receptors located on
the axon initial segment of motoneurons with the result that nerve impulse initiation
25
and thereby muscle contraction is inhibited (Cotel, Exley, Cragg, & Perrier, 2013).
2. Mental fatigue: Mental fatigue is a temporary inability to maintain optimal
cognitive performance. The onset of mental fatigue during any cognitive activity is
gradual, and depends upon an individual's cognitive ability, and also upon other
factors, such as sleep deprivation and overall health. Mental fatigue has also been
shown to decrease physical performance (Marcora, Staiano, & Manning, 2009). It can
manifest as somnolence, lethargy, or directed attention fatigue. Decreased attention is
known as ego depletion and occurs when the limited 'self-regulatory capacity' is
depleted (Baumeister, 2002). It may also be described as a more or less decreased
level of consciousness. In any case, this can be dangerous when performing tasks that
require constant concentration, such as operating large vehicles. For instance, a person
who is sufficiently somnolent may experience microsleep. However, objective
cognitive testing can be used to differentiate the neurocognitive deficits of brain
disease from those attributable to tiredness. The perception of mental fatigue is
believed to be modulated by the brain's reticular activating system.
It is quite complicated to analyze the etiology and mechanism for
development of fatigue after surgery. However, the presence of fatigue in surgical
population is obvious. It leads to a massive impact on physical, psychological and
social life of postoperative patients.
Impacts of postoperative fatigue
This definition recognizes the fact that postoperative fatigue has a
multimodal etiology and disrupts normal function after surgery and hence is clinically
significant (Rubin et al., 2004 b; Zargar-Shoshtari & Hill, 2009). The impact of
postoperative fatigue can be classified as physiological, psychological and social
impact.
1. Physiological impacts
Following major surgery, patients are fatigued and it might be one of the
main complaints after surgery and may last much longer than pain and wound healing,
even as long as 3 months (DeCherney et al., 2002). According to Susilahti et al.
(2004), because of fatigue after many kinds of surgeries, in the first week after surgery
54 % of patients had to rest during the day, 6.5 % of patients could not cope with their
daily activities and 9,6 % could not feel that resting helps to reduce their fatigue.
26
Zalon (2004) investigated the recovery among 60 patients after abdominal surgery and
reported that pain, depression, and fatigue explained 13.4 % of the variation in
functional status from three to five days after surgery, 30.8 % for one month, and
29.1 % for three months after discharge. Post-surgery fatigue adversely affects
physical functional capacity and role function and significantly declines from
preoperative (baseline) levels during 1 month following major abdominal surgery and
returns to baseline only after 3 months (Tsunoda, Nakao, Hiratsuka, Tsunoda, &
Kusano, 2007) and has impaired physical performance, including reduced work
capacity (Christensen & Kehlet, 1993) and muscular function (Jensen, Houborg,
Nørager, Henriksen, & Laurberg, 2011; Edwards, Rose, & King, 1982).
Furthermore, Labraca et al. (2011) asserted that the earlier initiating
rehabilitation treatment after total knee arthroplasty, the more advantage. However,
because disturbance from fatigue so orthopedic patients are difficult to follow
recommendations for training. Thus, postoperative fatigue patient must be showed
significantly more rehabilitation sessions until medical discharge, more pain, lesser
joint range of motion in flexion and extension reduced strength in quadriceps and
hamstring muscles, and higher scores for gait and balance because of lost afford to
adherence with physical therapy designed for early rehabilitation phase (Ersözlü et al.,
2009; Labraca et al., 2011). In addition, prolonged bed rest or immobility and
immobilization devices are considered as predisposing factors in contributing deep
vein thrombosis, pulmonary thromboembolism and stiffness and contractures (Ohura,
Sanada, & Mino, 2004; Walsh, 2009). Therefore, if fatigue persists in postoperative
patients, the risk for developing these complications is high.
2. Psychological impacts
Not surprisingly, postoperative fatigue may be one of the main complaints
after surgery. A higher degree of postoperative fatigue is followed by worse
emotional, physical, and functional outcomes proved in major joint arthroplasty
(Aarons et al., 1996). Fatigue contributes substantially to feelings of frustration,
depression, or hopelessness and to difficulty in concentrating or being attentive. Some
patients describe fatigue as a ‘‘change in emotional state’’ (DeCherney et al., 2002).
Among patients with lower limb fracture, they can not help themselves to mobilize
because of fatigue. Depending on other people due to immobility remain one of the
27
most frightening and psychological significant components of musculoskeletal
trauma. Fear and powerlessness related to immobility, along with social isolation and
alteration in role performance, and result in an individual’s decreased coping skills
(Walsh, 2009).
3. Social impacts
Postoperative fatigue may prevent otherwise fit patients from returning to
work. Large numbers of patients report loss of salary as a result of this prolonged
surgical recovery time. Patients miss an average of 6 weeks of work after
uncomplicated abdominal operations. It also has a similar impact on caregivers
(Bisgaard et al., 2001, DeCherney et al., 2002). Because of preventing return to
normality, activities of daily living, that can negatively impact on patient’s quality of
life (Rubin et al., 2004 b; Wijesuriya et al., 2012). Fatigue has been negatively
associated with social integration, productive activity and quality of life (McColl et
al., 2003). Postoperative fatigue can also be a source of increased costs to the health
service. It may be a source of increased costs to the health service, with patients who
suffer from fatigue placing significantly greater demands on their primary health care
teams compared with those who feel less tired (Bisgaard et al., 2001; DeCherney et
al., 2002; Rubin et al., 2004 b)
It is no argument that postoperative fatigue is causing burden for patient,
health care system and society. The symptom negatively influences both physical and
mental health of patients thus delaying the recovery. They also increase the cost of
treatment and reduce patient satisfaction with health care services as well. Therefore,
understanding about management for postoperative fatigue symptoms is essential in
caring of patients after surgery.
Management of postoperative fatigue
Postoperative fatigue has a multimodal etiology, and therefore, single
modality interventions seem to have little influence on the progression of
postoperative fatigue. A meta-analysis has assessed various interventions used to
modify postoperative fatigue, and there may be no single intervention to effectively
eliminate postoperative fatigue (Rubin & Hotopf, 2002). However, with the
implementation of multimodal enhanced care pathways, combining strategies, such as
effective management for pain, nausea and vomiting management, early oral intake
28
and psychological intervention achieved significantly and clinically measurable
improvements in postoperative fatigue (Zargar-Shoshtari & Hill, 2009, Fishbain et al.,
2005).
Balanced analgesia reduces the surgical stress response, effective treatment
of pain to facilitate mobilization, and exercise to increase postoperative nutritional
intake (Christensen & Kehlet, 1993). Eleven studies comparing between increased
analgesia and routine care or placebo in reducing postoperative fatigue, the result
confirmed that using increased analgesia reduced post-operative fatigue significantly
(Rubin & Hotopf, 2002). Moreover, opioids are commonly thought to be a very
effective form of analgesia in surgical patients (Shoshtari, 2009).
Additionally, postoperative nausea and vomiting (PONV) are among the
most common adverse events related to surgery and anaesthesia and lead to patient
discomfort, dehydration and electrolyte disturbances as well as delayed oral feeding.
This is the extreme reason for developing postoperative fatigue. A systematic,
multimodal approach may be the most effective method of controlling PONV. This
should consist of decreasing the baseline risk factors for all patients, identifying
patients with high risk of PONV for administration of appropriate prophylactic
therapy and suitable rescue antiemetics if these measures fail (Shoshtari, 2009).
Furthermore, nutrition intake and psychological intervention also
demonstrate the evidence in reducing postoperative fatigue. Early oral feeding and
post-operative dietary supplementation is the most successful strategy has been a fast-
track care program that includes sufficient oral nutrition for reduce fatigue (Kehlet &
Wilmore, 2008). Individual studies have shown that early feeding may decrease
postoperative infections, length of hospital stay, muscle loss and fatigue. Experimental
and clinical studies have demonstrated that early oral feeding, dietary supplementation
can provide added benefits in terms of reduction in fatigue, weight loss and overall
morbidity in normal as well as malnourished patients (Shoshtari, 2009).
In addition, reducing stress and anxiety may reduce post surgery fatigue as
relaxation therapies have been shown to be beneficial in patients undergoing
procedures in many surgical settings (Wilmore, 2002). One found a significant effect:
reduced fatigue was reported during the first post-operative week for cardiac patients
engaged in guided imagery (Rubin & Hotopf, 2002). Soft music may reduce later
29
post-operative pain and fatigue by decreasing the surgical stress response (Graversen
& Sommer, 2013). Forty five minutes relaxation session with a health psychologist
and were given relaxation exercise CDs to take home was proved as effective method
in manage fatigue after laparoscopic cholecystectomy (Kahokehr et al., 2012).
Preoperative counseling is necessary to care for surgical patient (Kehlet & Wilmore,
2008). It is also confirmed that provide enough medical information to let patient take
self-management intervention and reduce illness uncertainty is an important factor in
decreasing fatigue (Stiegelis et al., 2004).
Notably, postoperative fatigue is considered as an unpleasant symptom. So,
to understand this symptom better, it is recommendable to explore the Unpleasant
Symptoms theory by Lenz et al. (1997). This theory had been used and found effective
in explaining the influencing factors, impact, and in finding effective approach to
manage postoperative fatigue.
The theory of unpleasant symptoms
The theory of unpleasant symptoms (TOUS), developed by Lenz et al.
(1997) was first introduced in 1995. The updated version of this middle-range theory
was then presented two years later in 1997. In the original model of the TOUS, one
symptom is depicted and it is a purely linear model. The updated model of the TOUS
(Figure2) proposes that symptoms can occur alone or in isolation from one another but
that, more often, multiple symptoms are experienced simultaneously. Each symptom
is conceptualized to be a multidimensional experience, which can be conceptualized
and measured separately or in combination with other symptoms. In addition,
compared to the original TOUS model, the revised TOUS model more accurately
depicts the relationships among central concepts (influential/ antecedent factors,
symptom experience, and outcomes/ consequences). Therefore, updated version of
TOUS theory was used for this study.
According to Lenz et al. (1997), the TOUS has “three major components: the
symptoms that the individual is experiencing, the influencing factors that give rise to
or affect the nature of the symptom experience, and the consequences of the symptom
experience”. Symptoms are the central focus of the TOUS. Symptoms are defined as
perceived indicators of change in normal functioning as experienced by patients.
30
Symptoms can be considered alone or combination. They are seen as multiplicative,
rather than additive. Symptoms have the dimensions of intensity, timing, distress and
quality. Intensity refers to the severity, strength, or amount of the symptom being
experienced. The time dimension includes the frequency with which an intermittent
symptom occurs, the duration of a persistent symptom, or a combination of frequency
and duration of symptoms. The symptoms can be intermittent but persist over long
periods of time or chronic but varying in intensity. The distress dimension of the
symptom experience refers to the degree to which the person is bothered by the
symptom(s). Symptoms can vary in their quality or the way they are manifested. The
quality of a symptom can include description of the location of a given sensation, as
well as the degree to which a patient responds to a particular intervention (Lenz et al.,
1997).
These symptom dimensions are influenced by three categories of variables:
physiologic factors, psychologic factors, and situational factors (Lenz et al., 1997).
Physiological factors are often reflected in unpleasant symptoms associated with
alterations in the normal functioning of bodily systems or the existence of any
pathology. Physiological antecedents commonly characterize the severity of the
disease, such as comorbidities, abnormal laboratory findings or other pathological
findings (Lenz et al., 1997). Examples of physiological factors include the
mechanisms of head injury, the individual’s immunity and defense functioning, or
physiological response to stress (i.e. the level of stress hormone). The psychological
factors that are antecedents include the individual’s mental state or mood (depression),
affective reaction to illness (mood status), psychological response to stress (the degree
of perceived stress or the level of anxiety) and degree of uncertainty and knowledge
about the symptoms and their possible meaning (perception of illness experience or
symptom experience). Situational/ environmental antecedents include aspects of the
social and physical environment that may affect the individual’s experience and
reporting of symptoms (Lenz et al., 1997). Examples of situational/ environmental
factors include social support, marital status, and resources or any situational events
that may influence symptom experience. All of these factors may impact an
individual’s experience with individual and multiple symptoms. The TOUS asserts
31
that these three factors relate to one another and interact with one another to impact
symptoms.
Performance is the last component of the TOUS. Performance is the result of
symptom experience which includes functional and cognitive activities. It refers to a
broad content which can be considered as the consequence of experiencing symptoms.
Performance could be physical activities, social activities, working role, concentrating,
or problem solving. It is assumed that more numerous or more severe symptom, the
poorer the performance manifested.
Lenz et al. (1997) asserted that the three components of the model are related
and the correlation might be reciprocal. Antecedents/ influential factors can have an
interaction effect in their relation to the symptom experience. The experience of
unpleasant symptoms can change one’s performance which includes the change in
individual physical, psychological, and social status. Furthermore, the symptom
experience can have a moderating or mediating influence on the relationship between
influential factors and outcomes/ performance (Lenz et al., 1997). Additionally, the
performance can also conversely impact on symptoms and the influencing factors. The
revised TOUS model proposes that outcomes (performance) have a reciprocal relation
with the symptom experience. The decreased levels of performance can have a
negative feedback loop to the influential factors (physiological, psychological, and
situational factors).
In present study, postoperative fatigue is considered as unpleasant symptom.
It happens with frequent rate and severity after surgery. Symptom of fatigue occurs
immediately right after surgery but remains persistent for a long time and distress
patients on physiological, psychological and social aspects. It is a subjective
perception caused by many reasons. Even though, in TOUS symptom dimensions are
influenced by three categories of variables: physiologic factors, psychologic factors,
and situational factors. However, previous studies inconsistently supported variables
from situational antecedent in predicting postoperative fatigue. Thus, factors affect
postoperative fatigue derived from physiologic and psychologic antecedents. Among
them, pain belongs to physiologic factor, anxiety and uncertainty are the psychologic
factors. Patients, who experienc fatigue after ORIF surgery, will affect physical,
psychological and social aspects. Studies proved consequences on physiological
32
health including impaired physical performance, reduced work capacity (Christensen
& Kehlet, 1993) and muscular function, psychological health composes feelings of
frustration, depression, or hopelessness and difficulty concentrating or being attentive
(DeCherney et al., 2002). From physical and psychological impact, it leads to an
influence on social life of postoperative fatigue patients such as reduce quality of life,
increase cost for medical care fee, become a burden on family caregivers (Bisgaard et
al., 2001).
Figure 2 The unpleasant symptom model (Lenz et al., 1997, p.17)
Factors predicting postoperative fatigue among patients with closed
fracture of leg
There are multiple factors that affect postoperative fatigue such as age, type
of surgery, gender, preoperative fatigue, nutrition status, nausea, fatigue expectation,
pain, anxiety and uncertainty (Long, 2010; Tolver, Strandfelt, Rosenberg, & Bisgaard,
2013; Yu et al., 2015). Among these factors, pain, anxiety and uncertainty are three
variables which have been studied and have a consistent association with
33
postoperative fatigue.
Pain
Pain and fatigue are the most unpleasant symptoms after surgery and happen
together. Pain is defined as an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage (Lubkin
& Larsen, 2006). The severe pain seen so frequently after orthopedic operation is
largely a result of the nature of the surgical procedure, which often involves
significant muscle and skeletal tissue repair or reconstruction (Pasero & McCaffery,
2007). It has since been repeatedly confirmed that 30 - 80 % of patients undergoing
surgery suffer from inadequately treated pain (Mwaka et al., 2013; Pavlin et al., 2004;
Pitimana-Aree et al., 2005; Zaslansky et al., 2006). Ineffective control of pain after
surgery also causes patient distress, sleep disturbance, mood disorders, and has
adverse effects on the endocrine and immune functions, which can affect wound
healing and fatigue (Chiu et al., 2005; Chouchou et al., 2014; Peters et al., 2007).
There is a close relationship which existing between muscle pain and fatigue.
The links between pain and fatigue included development of fatigue after the
development of pain, and improvement in fatigue with lessening of pain, the longer
pain was present the greater the likelihood of fatigue; the greater the pain experienced
the more certain it was that fatigue occurred (McCarberg & Cole, 2009). A group
using a structured evidence-based review of 17 studies related to the coexistence of
fatigue and pain found that 94 % indicated that there was an association between
fatigue and pain; a subgroup of 13 reports indicated there may be a cause and effect
relationship between pain and fatigue (Fishbain et al., 2003). Concerning about
abdominal surgery population, in the first and second day after surgery, pain proved
correlation with fatigue (r = .39, p < .001 and r = .19, p < .05) respectively (Long,
2010). Investigation on 101 breast cancer surgical patients, the result indicated pain
severity and fatigue have a positive correlation (r = .36, p < .001) (Montgomery et al.,
2010). In another research, it was shown that pain explained for 20 % of variation of
fatigue (Beck et al., 2005). In Saowaluck’s study (2009), the result asserted pain was
significant predictors of postoperative fatigue (β = .28, p < .01). It is reported that
although several variables were found to contribute to the severity of fatigue but the
presence of pain which contributes to explain up to 7.6 % of variance of fatigue
34
(Lee et al., 2010). By using multiple logistic regression models, Garabeli Cavalli
Kluthcovsky et al. (2012) reported that presence pain is one of predictive factors for
postoperative fatigue (OR = 3.87, 95 % CI = 1.88 - 7.98, p = .000).
Anxiety
Mental disorders such as anxiety and depression are common in hospital
inpatients, with an estimated prevalence of 20 - 40 % in worldwide studies (Grau
Martin et al., 2003; Hansen et al., 2001) and especially high in orthopedic trauma
setting (Becher et al., 2014; de Moraes et al., 2010). It is a consequence of changes
and unpredictability in daily life, face many unpleasant symptoms and indefinite
rehabilitation period (Becher et al., 2014). Furthermore, prolonged treatment time, use
of the supportive aids can lead to a breakdown in the routine of family and prevent the
individual from working during the treatment process, which are also important causes
leading to anxiety (de Moraes et al., 2010). Evidence suggests that the more anxious a
patient, the poorer the outcome in terms of hospital length of stay and complications
(Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser, 1988).
Anxiety is a significant factor affecting feeling of fatigue after surgery.
Assessment about the relationship between postoperative fatigue and anxiety on 183
surgical patients, the results indicate that psychological processes including anxiety
may well be relevant in the etiology of postoperative fatigue (Rubin et al., 2004). In
abdominal surgery population, the result was indicated that on the second day after
surgery, anxiety had associated with tiredness (r = .33, p < .01) (Long, 2010). A cross-
sectional study in muscular dystrophy persons 20-89 years old, symptoms of fatigue
are significantly and independently related to depression (Alschuler et al., 2012).
Increase in psychological distress is a factor related to worsening fatigue after surgery
(Rotonda et al., 2013). To describe the relationship of fatigue with psychological
functioning in adults with spinal cord injury, fatigue was an independent factor
associated with depression (Alschuler et al., 2013). In 180 postoperative patients with
breast cancer, the finding showed that moderate/ severe fatigue was positively
associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05) (Tan & Xia,
2014). After controlling all other variables, depression variable was significant
predictors of postoperative fatigue (β = .40, p < .01) in hysterectomy population
(Saowaluck, 2009).
35
Uncertainty
Uncertainty is a result of experiencing the acute phase of illness or is in a
downward illness trajectory (Mishel, 1988). In circumstance of orthopedic patients, it
was reported that all patients responded similarly in terms of having moderate levels
of uncertainty (Calvin & Lane, 1999). That is considered as a consequence of urgent
operation. Furthermore, hospitalization in long time, up to 7 to 10 days and struggling
with postoperative symptoms are reasons that make patient with lower fracture
suffering uncertainty. Fracture of leg is usually accompanied with a long time
recovery and high risk for long-term disability. That patients feel inability to
determine the meaning of illness-related events, unable to predict outcomes accurately
is easy to happen. In addition, being unsatisfied with information getting from
healthcare provider is a common complaint of Vietnamese patients, making surgical
patient suffering uncertainty (Loi, 2014). According to Mishel (1988), patients with
uncertainty will have negative thoughts and beliefs regarding the disease. It leads to
altered coping, severe cognitive impairment and search for opportunities to get
relevant answers. With both psychological distress and depressive symptoms caused
by uncertainty, it is the reason for the occurrence of postoperative fatigue.
Previous research findings proved the relationship between fatigue and
uncertainty. Providing enough medical information to let patient take self-
management intervention and reduce illness uncertainty before radiotherapy is an
important factor in decreasing fatigue (Stiegelis et al., 2004). To examine the
prevalence and severity of fatigue, conceptualized as a multiple dimensional
symptom, and to determine the influence of sense of coherence and uncertainty on the
fatigue experience in 93 consecutive patients with chronic heart failure, Falk et al.
(2007) asserted that fatigue was a prevalent and distressing experience in patients and
uncertainty was associated positively with tiredness and reduced functional status.
Lasker et al. (2010) conducted a study in 100 female patients undergoing liver
transplantation operation and indicated that even undergoing a life-saving procedure,
uncertainty was still persistent and associated with a reduced quality of life and there
was a significant relationship between uncertainty and fatigue.
36
Conclusion
Lower limb fracture is a common health issue in modern society. ORIF
surgery for management fracture is an advanced management system. However, with
high incidence and longer duration than other after surgery, fatigue is limiting
treatment outcome for fracture of leg. Postoperative fatigue has a huge impact on
physical, psychological and social health. The need for an in-depth understanding of
this concept and predicting factors is necessary. Moreover, evidences from previous
studies have emphasized the consistent relationship between pain, anxiety, uncertainty
and postoperative fatigue. Therefore, in order to enhance the quality of care and
treatment, shorten postoperative period for patients, a study on factors predicting
postoperative fatigue needs to be conducted on patients with closed fracture of leg
undergoing internal fixation in Vietnamese population.
CHAPTER 3
RESEARCH METHODOLOGY
A descriptive predictive design was used in the present study to examine the
influence of pain, anxiety, and uncertainty on postoperative fatigue among patients
with closed fracture of leg undergoing internal fixation surgery. This chapter explains
design and methods used in this study, including description of population and
sample, the research setting, instruments, protection of human subjects, data collection
procedure, and data analysis.
Research design
A descriptive predictive design was used in this study to investigate the
influence of pain, anxiety, uncertainty on postoperative fatigue among patients with
closed fracture of leg undergoing internal fixation surgery in Khanh Hoa General
Hospital, Vietnam.
Population and sample
Population
The target population of this study was the patients who got orthopedic
injury and hospitalized at the Traumatology – Orthopedic department, after
undergoing internal fixation surgery for closed fracture of femur, tibia and fibula in
Khanh Hoa General Hospital, Vietnam in 2015.
Sample
The sample was adult surgical patients who were emergency hospitalization
at the Traumatology - Orthopedic department after undergoing internal fixation
surgery for closed fracture of femur, tibia and fibula in March to April, 2015. They
were selected according to the following inclusion criteria:
1. Age from 18 to 60 years old
2. Be able to communicate and read in Vietnamese
3. Do not have history of mental illness and others serious illness such as
cancer, heart or kidney disease
38
4. Do not have any peri or post operative complications (shock, hemorrhage,
infections, etc.)
5. Do not have any simultaneous operation on other parts of the body.
Sample size
The sample size in this study was calculated based on the formula
recommend by Tabachnick and Fidell (2007) as follows:
N ≥ 50 + 8M
N = sample size
M = independent variables
50 = constant of formula
This study had 3 independent variables
N ≥ 50 + 8 x 3
N ≥ 74
Therefore, the sample size in this study was a minimum of 74 patients.
However, to ensure an adequate sample size at the completion of the study,
it is encouraged to determine to possible attrition rate about 10% for the study (Grove,
Burns, & Gray, 2013). Thus, the sample size of the study was identified as 80 patients.
Sampling technique
Patients with fracture of leg are hospitalized because of accidental events.
Open reduction and internal fixation surgery for fracture was beyond patient’s
expectation and prediction. Therefore, admission of these patients at the Traumatology
– Orthopedic department at Khanh Hoa General Hospital was totally random. The
sample in this study was recruited when they met inclusion criteria over 2 months,
March to April in 2015. The researcher collected data every day from Monday to
Sunday. Each day, at 8AM the researcher asked the head nurse or nurses on shift for
the list of patients with closed fracture of leg on the first day after undergoing internal
fixation surgery who met the inclusion criteria. Then, the research contacted patients
and distributed questionnaire. The desired sample size was reached when a total of at
least 80 cases were completed.
39
Setting of the study
This study was conducted at Khanh Hoa General Hospital, located in Khanh
Hoa province, in the South Central Coast of Vietnam. Khanh Hoa province has a
population of 1,066,300 and spans an area of 5,197 km². It is the economically most
developed province of South Central Vietnam. There are 2 cities and 7 districts in this
province. Khanh Hoa General Hospital is the biggest general hospital, located in the
largest and the capital city of Khanh Hoa province. It has 1000 beds with 20 units. The
Traumatology – Orthopedic department has 70 beds for orthopedic surgery patients.
This department has 16 nurses, 13 surgical doctors. Because it is a tertiary hospital,
most of severe cases in middle south provinces of Vietnam and other areas in Khanh
Hoa province are referred here for advanced care. Moreover, with high prevalence of
traffic accidents in Khanh Hoa province, the number of patient with closed fracture of
leg hospitalized in this hospital is higher compared to other hospitals in Vietnam.
Therefore, the overload condition usually happens in the Traumatology – Orthopedic
department. According to statistics from Khanh Hoa General Hospital, it is estimated
that there are about 70 operations for femur, tibia and fibula fracture per month.
In the Traumatology – Orthopedic department, there are 4 bachelor and 12
diploma nurses. In one day, there are 14 nurses who work for 8 hours per day (from
7AM to 11 AM and 1 PM to 5 PM). Among 14 nurses, there are 2 nurses in charge
who will work continuously for 24 hours, from 7AM today to 7AM the following day
and take a day off on that day. At the weekend (Saturday and Sunday), there are only
2 nurses in charge will work by themselves in 24 hours without other nurses’ support.
Nurses in the Traumatology – Orthopedic department take responsibility in providing
information about regulations of the department for both patients and their caregivers.
Each day, nurses assess patient health, provide health education about nutrition and
rehabilitative regime, giving medication, dressing change, implement other nursing
techniques according to doctor’s treatment and then write in nursing record. Two
nurses in charge will take care of severe patients and admit new patients on that day.
There is no physical therapist to provide rehabilitation for post-operative patients. All
of the instructions for practice to maintain range of motion, walking with supportive
aid come from orthopedic doctors and nurses.
40
To control postoperative pain, according to the protocol of this setting , it is
recommended to use Nonsteroidal anti-inflammatory drug (NSAID) via oral or
intramuscular injection administration (Alphachymotrypsin, Tenoxicam, Meloxicam)
combined with Paracetamol 500 mg for oral administration at 4 hours after surgery
and twice per day at 8AM and 4 PM in following days. If patients report unbearable
pain, nurses may provide analgesic drugs more frequently. As for orthopedic trauma
patients, after being transferred from post-surgery intensive care department, they are
admitted to this ward. After the average length of stay from 7 to 10 days, patients are
discharged.
Research instruments
Instruments used in this study include the patient’s profile record form,
numeric pain rating scale (NPRS) to measure pain, hospital anxiety and depression
scale (HADS) to measure anxiety, the Mishel uncertainty in illness scale (MUIS) to
measure uncertainty and the identity – consequence fatigue scale (ICFS) to measure
fatigue.
1. The patient’s profile record form
This form was developed by the researcher, encompassing two parts: the
Sociodemographic data and the Disease and Treatment data. The Sociodemographic
data included age, gender, marital status, educational level, occupation, income. The
Disease and Treatment data carried the information about patient diseases and
treatment, such as diagnosis, part of bone fracture, type of surgery, co-morbidity and
medication for the 1st, 2
nd and 3
rd day after surgery.
2. Numeric pain rating scale (NPRS)
The NPRS was an unidimensional measure of pain intensity in adults
(McCaffery & Beebe, 1989). Patients verbally select a value that was most in line with
the intensity of pain that they had experienced. The NPRS was an 11-point scale from
0-10: “0” = no pain, “10” = the most intense pain imaginable. A written form was also
frequently used with the numeric values of 0 - 10 written out. Scores range from 0 - 10.
Higher scores indicate greater pain intensity. Pain severity could be categorized into
3 distinct groups as related to pain interference:
41
Score Level
1 - 3 Mild pain
4 - 6 Moderate pain
7 - 10 Severe pain
Herr, Spratt, Mobily, and Richardson (2004) reported its internal consistency
was 0.88. High test - retest reliability had been observed .79 to .92 (Jensen &
McFarland, 1993). For construct validity, the NPRS was shown to be highly
correlated to the Visual Analogue Scale for pain in patients correlations equal to .94
(Bijur, Latimer, & Gallagher, 2003).
3. The hospital anxiety and depression scale (HADS)
The hospital anxiety and depression scale (HADS) was used to determine the
levels of anxiety and depression that a patient was experiencing. It was developed by
Zigmond and Snaith (1983); and back translated to Vietnamese by Long (2010). The
HADS was a patient-reported instrument with 14 items. The fourteen items were
classified into two parts: seven items measure anxiety (HADS-A) and 7 items evaluate
depression (HADS-D). Since this study focused on patient anxiety level, only the
HADS-A was used. Patients were asked to answer seven statements in the
questionnaire by rating in the four points Likert scale. The anxiety score was the total
score for all seven items, ranged from 0 to 21; higher scores represent more anxiety.
Bambauer, Locke, Aupont, Mullan, and McLaughlin (2005) recommended the cutoff
point of 7 for the HADS. Based on that, the anxiety score was interpreted as follows:
Score Level
0 no anxiety
1 - 7 mild anxiety
8 - 14 moderate anxiety
15 - 21 severe anxiety
The Cronbach‘s alpha of the HADS - A was reported to range from .80 to
.93; and the concurrent validity coefficient between HADS – A and state – trait
anxiety inventory was .81 (McDowell, 2006). Long (2010) reported its internal
consistency was .89.
42
4. The Mishel uncertainty in illness scale (MUIS)
The Mishel uncertainty in illness scale (MUIS) was developed by Mishel
(1980) and the result of initial testing was first published in 1981, back translated to
Vietnamese by Loi (2014). The scale had been used to examine uncertainty in
symptomatology, diagnosis, treatment, relationship with caregivers and planning for
the future in multiple patient populations include post myocardial infarction patients,
brain trauma injury. This instrument had 28- item self-administered tool. Each item
was graded on five point Likert scales; ranging from strongly disagree to strongly
agree. Items could be scored on a scale of 1 - 5, giving a global score range of 28 -
140. Higher scores indicated higher levels of uncertainty. The reliability of original
version of MUIS showed good internal consistency with Cronbach’s alpha from .74 to
.92 (Mishel, 1981). Cronbach’s alpha of this instrument in Vietnamese population was
.89 (Loi, 2014).
5. The identity – consequence fatigue scale (ICFS)
The identity – consequence fatigue scale was an instrument used to assess
fatigue and its impact in post-surgical patient. It was developed by Paddison et al.
(2006). It had 25 items and 5 subscales divided into 2 dimensions. Of five subscales,
two feelings namely feeling of fatigue and feeling of vigor belong to a fatigue-identity
dimension of the ICFS, while other three, impacts on concentration, impacts on
energy and impacts on daily activities form the fatigue-consequences dimension. Each
item of the ICFS was rated on 6-point adjectival scales. For all items the anchors
were: not at all (score = 1), almost never (score = 2), some of the time (score = 3),
fairly often (score = 4), very often (score = 5), and all of the time (score = 6). With
possible score for fatigue-identity dimension range of 9 - 54 (items 1 - 9) and fatigue-
consequences dimension range of 16 - 96 (items 10 - 25). Global score range of 25 -
150. Higher score represented more fatigue. The identity - consequence fatigue scale
had been found to be reliable. All subscales showed high internal reliability with
Cronbach’s alpha ranged from .88 to .92 (Paddison et al., 2006).
43
Translation of the instruments
In order to have appropriate instrument in Vietnamese, the Identity –
Consequence Fatigue Scale (ICFS) was translated from English to Vietnamese with
Back – Translation technique (Cha, Kim, & Erlen, 2007).
Step 1 A person who was influent in both English and Vietnamese translated
the English original version into Vietnamese version.
Step 2 The Vietnamese version was back translated to English by another
translator.
Step 3 The original English version and the back translated version were
compared in order to validate the accuracy of the translation process. The necessary
changes in the Vietnamese questionnaires were made after the discussion between
researcher and major advisor in order to get most common and precise instrument.
Validity and reliability of the instruments
Validity
The identity – consequence fatigue scale (ICFS) was original in English. It
needed to be translated into Vietnamese language in order to properly use with the
Vietnamese sample. The process of back translation by Cha et al. (2007) was used to
ensure the validity of the questionnaire of The identity – consequence fatigue scale.
After getting the final Vietnamese version of ICFS questionnaire, to ensure the content
validity, it was tested by 3 Vietnamese experts in nursing science. The item-content
validity index score (CVI) for ICFS was 1.0.
Reliability
The translated measurements include The hospital anxiety and depression
scale (HADS), The Mishel uncertainty in illness scale (MUIS) and The identity –
consequence fatigue scale (ICFS) in Vietnamese language were tested for internal
consistency reliability on 30 patients after undergoing lower limb surgery who had
similar characteristics of the actual samples and met the inclusion criteria of this
study. According to Grove et al. (2013), the acceptable level of Cronbach’s alpha for a
newly developed psychosocial instrument is .07 and .08 for a well-developed
instrument. In this study HADS, MUIS and ICFS were well-developed instrument.
44
The Cronbach’s alpha coefficents of HADS, MUIS and ICFS were .86, .90 and .87,
respectively.
Protection of human subjects
Human subject’s approval was obtained from the institutional review board
(IRB), Faculty of Nursing, Burapha University. Before conducting data collection, this
study was also got permission from the Director of Khanh Hoa General Hospital. In
the process of collecting data, all patients was informed clearly about the aims of the
study, the data collecting procedure, risks that may occur as well as their rights.
Participants volunteered to participate in the study, the consent form was completed
before data collection and they were entitled to withdraw whenever they wanted. The
participant’s anonymity and confidentiality were respected. All the forms were
anonymous. No physical examination or interference was implemented to further
investigate patient’s situation.
Data collection procedure
The data collection procedure in this study was performed by the researcher
as follows:
1. After the proposal was approved by the institutional review board (IRB),
Faculty of Nursing Burapha University to collect data. The researcher approached the
Director of Khanh Hoa General Hospital, Vietnam to get permission for collecting
data.
2. Based on the patient list of the traumatology – orthopedic department, the
researcher visited patients who met the eligibility criteria on the first day after the
surgery day. The researcher introduced herself to build the relationship with the
patients. The researcher then informed patients about the study, ethical issues, and
data collection procedures and invited them to participate in the research. If patients
consented to participate, the pain intensity level was assessed by using The Numeric
Pain Rating Scale (NPRS) questionnaire.
3. On the second day after surgery, the researcher revisited patients to assess
their pain intensity by the instrument of The numeric pain rating scale (NPRS).
45
4. On the third day after surgery, the questionnaire of The numeric pain
rating scale (NPRS), The hospital anxiety and depression scale (HADS), The Mishel
uncertainty in illness scale (MUIS) and The identity - consequence fatigue scale
(ICFS) were distributed for patients self-report.
5. Other necessary information such as diagnosis, co-morbidity, medication
for the 1st, 2
nd and 3
rd day after surgery was obtained from patients' medical record.
6. During data collection, if patients were in the middle of some procedures,
the questionnaire would not be administered until they feel calm and comfortable to
answer.
7. After having all necessary information, data collecting forms were
checked for completeness and prepared for analysis.
Data analysis
The data was analyzed by using statistical package software. The level of
significance was set at an alpha of .05.
1. Descriptive analysis including frequency, percentage, mean, standard
deviation (SD) and mean percentage was used to describe demographic data, pain,
anxiety, uncertainty and fatigue.
2. Multiple regression analysis was used to explore the prediction of pain
(average pain from 3 days assessment), anxiety, uncertainty on postoperative fatigue.
CHAPTER 4
RESULTS
This chapter presents the results of the study from data analysis that describe
factors predicting postoperative fatigue among patients with closed fracture of leg
undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam. This
finding related to objectives and hypotheses are presented with the details in the tables
as follows:
1. Description of sample characteristics including demographic
characteristics and medical information of the sample
2. Description of the studied variable including pain, anxiety, uncertainty
and postoperative fatigue
3. Influence of pain, anxiety and uncertainty on postoperative fatigue among
patients with closed fracture of leg
Description of sample characteristics including demographic
characteristics and medical information of the sample
1. Demographic characteristics of the sample
This section presents the demographics data of participants in this study.
A total of 80 patients who underwent internal fixation surgery for closed fracture of
leg and met the inclusion criteria were recruited from Khanh Hoa General Hospital,
Vietnam. Table 1 illustrates characteristics of the sample including gender, age,
marital status, educational level, occupation and incomes.
47
Table 1 Frequency and percentage of samples’ demographic characteristics (n = 80)
Characteristics n %
Gender
Male 63 78.8
Female 17 21.2
Age (years)
18 - 35 38 47.5
36 - 60 42 52.5
Range: 18 - 60, M = 38.25, SD = 11.92
Marital status
Single 24 30.0
Married 56 70.0
Educational level
No Schooling 1 1.3
Elementary school 8 10.0
Secondary school 35 43.8
High school 23 28.8
Diploma 9 11.2
Bachelor or higher 4 4.9
Occupation
Farmer 28 35.0
Industrial worker 21 26.3
Business person 17 21.3
Government officer 9 11.3
Retired/ Unemployment 3 3.8
Student 2 2.3
48
Table 1 (cont.)
Characteristics n %
Income/ month (USD)
< 150 39 48.8
150 - < 199.9 25 31.2
200 - < 249.9 8 10.0
≥ 250 8 10.0
Table 1 shows that the majority of patients were male (78.8 %). Age of
sample ranged from 18 - 60 with a mean of 38.25 years (SD = 11.92). In marital
status, the married group was the biggest one (70.0 %). Regarding the educational
level, 43.8 % of sample had completed secondary school and 28.8% had finished their
high school. For occupation, farmer was the most common occupation (35 %)
followed by industrial worker (26.3 %). It was also revealed that the majority of
sample (48.8 %) earned less than 150 USD per month, followed by 150 to 199.9 USD
per month (31.2 %).
2. Medical information of the sample
Table 2 Frequency and percentage of samples’ medical information (n = 80)
Characteristics n %
Cause of surgery
Traffic accident 80 100%
Part of bone fracture
Femur 28 35.0
Tibia 30 37.5
Tibia and fibula 22 27.5
Type of surgery
ORIF with plating 31 38.8
ORIF with nailing 49 61.2
49
Table 2 (cont.)
Characteristics n %
Co-morbidity
No 75 93.8
Yes 5 6.2
Hypertension 4 80
Diabetes 1 20
According to the table 2, the most common part of bone fracture was tibia
(37.5 %), followed by femur (35 %). In addition, ORIF with nailing was the major
surgical method used in fixing fractured bone (61.2 %). Notably, 93.8 % of the sample
reported having no co-morbidity. Among patients who demonstrated co-morbidity
(6.2 % of the sample), there were 80 % of them reporting hypertension and 20 % with
diabetes.
Description of the studied variables including pain, anxiety,
uncertainty and postoperative fatigue
Table 3 Frequency and percentage of samples’ the level of pain in the first three days
after surgery (n = 80)
Level of pain Pain in day 1 Pain in day 2 Pain in day 3
n % n % n %
No pain (0) 0 0 0 0 3 3.8
Mild pain (1-3) 1 1.3 19 23.8 45 56.3
Moderate pain (4-6) 31 38.8 46 57.5 26 32.5
Severe pain (7-10) 48 59.9 15 18.7 6 7.4
Table 3 indicates that in the first day after surgery, 59.9 % of the sample got
severe pain, 38.8 % got moderate pain and 1.3 % got mild pain. For the postoperative
50
day two, moderate pain was the most common level of pain accounting for 57.7 %,
followed by mild pain with 23.8 % and severe pain with 18.7 %. In the third day
postoperation, 56.3 % of the sample got mild pain, 32.5 % got moderate pain and
7.4 % got severe pain.
Table 4 Frequency and percentage of samples’ level of anxiety in the third day after
surgery (n = 80)
Level of anxiety n %
Mild anxiety (1 - 7) 11 13.8
Moderate anxiety (8 - 14) 47 58.8
Severe anxiety (15 - 21) 22 27.4
Table 4 showed that 58.8 % of samples reported moderate level of anxiety.
Notably, there were up to 27.4 % had anxiety in severe level.
Table 5 Range, mean and standard deviation of samples’ studied variables including
pain, anxiety, uncertainty (n = 80)
Variables Possible score Actual score M SD
Pain 0 - 10 2 - 8.67 5.09 1.71
Pain in day 1 0 - 10 3 - 10 6.90 1.95
Pain in day 2 0 - 10 2 - 9 4.95 1.74
Pain in day 3 0 - 10 0 - 8 3.43 1.83
Anxiety 0 - 21 3 - 20 12.29 3.78
Uncertainty 28 - 140 60 - 108 82.06 10.57
From table 5, the mean of samples’ pain in the first three days after surgery
was 5.09 (SD = 1.71) which mean pain in the first, second and third day was 6.90
(SD = 1.95), 4.95 (SD = 1.74) and 3.43 (SD = 1.83), respectively. In addition, mean
score of anxiety was in moderate level (M = 12.29, SD = 3.78) and mean score of
uncertainty was quite high (M = 82.06, SD = 10.57).
51
Table 6 Range, mean, standard deviation and mean percentage of samples’
postoperative fatigue classified by subcategories (n = 80)
Postoperative fatigue Possible
range
Actual
range M SD
Mean
%
Fatigue-Identity dimension 9 - 54 19 - 47 34.41 7.22 63.72
Feeling of fatigue 5 - 30 9 - 27 18.13 4.45 60.43
Feeling of lack of vigor 4 - 24 9 - 24 16.29 3.67 67.88
Fatigue-Consequences
dimension 16 - 96 24 - 72 52.16 9.40 54.33
Impacts on concentration 5 - 30 5 - 25 13.98 4.19 46.60
Impacts on energy 6 - 36 10 - 32 21.0 4.48 58.33
Impacts on daily activities 5 - 30 7 - 26 17.19 3.87 57.30
Postoperative fatigue
(overall score) 25 - 150 45 - 117 86.58 15.06
Table 6 shows that mean score of postoperative fatigue was quite high (M =
86.58, SD = 15.06) with mean score of fatigue-identity dimension and fatigue-
consequences dimension as 34.41 (SD = 7.22) and 52.16 (SD = 9.40). Mean
percentage of fatigue-identity dimension (mean % 63.72) was higher than fatigue-
consequences dimension (mean % 54.33). In fatigue – identity dimension, mean score
of feeling of fatigue was 18.13 (SD = 4.45) and feeling of lack of vigor was 16.29
(SD = 3.67) with mean percentage of feeling of lack of vigor (mean % 67.88) higher
than feeling of fatigue (mean % 60.43). In fatigue-consequence dimension, the mean
score of impacts on concentration was 13.98 (SD = 4.19), the impacts on energy was
21.0 (SD = 4.48), and the impacts on daily activities was 17.19 (SD = 3.87) with
highest mean percentage for impacts on energy (mean % 58.33), followed by impacts
on daily activities (mean % 57.30) and impacts on concentration (mean % 46.60)
52
Influence of pain, anxiety and uncertainty on postoperative fatigue
among patients with closed fracture of leg
Because the multiple regression technique was used to test influence of pain,
anxiety, and uncertainty on postoperative fatigue, assumptions of normality, linearity,
homoscedasticity and normality of residuals and multicollinearity were met for all
variables (Tabachnick & Fidell, 2007).
Table 7 Pearson correlation coefficient of samples’ pain, anxiety, uncertainty and
postoperative fatigue (n = 80)
Pain Anxiety Uncertainty Postoperative fatigue
Pain 1.00
Anxiety .50**
1.00
Uncertainty .21 .40**
1.00
Postoperative fatigue .53**
.55**
.38**
1.00
** = p < .01
As demonstrated in the table 7, correlation matrix for predicted variable of
pain, anxiety and uncertainty indicated no correlation to moderate intercorrelations
(r = 0.21 - 0.55). Therefore, multicollinearity was not a problem in this study.
Furthermore, postoperative fatigue were positively associated with pain (r = .53, p <
.01), anxiety (r = .55, p < .01) and uncertainty (r = .38, p < .01). Thus, there was a
linear relationship between variables.
Table 8 Multiple regression analysis for variables predicting postoperative fatigue
(n = 80)
Variables B Beta
Pain 3.05** .35** Intercept = 33.85**
Anxiety 1.18** .30** R2 = .42
Uncertainty .28* .19* F(3,76) = 18.37***
DV = postoperative fatigue, * = p < .05, ** = p < .01, *** = p < .001
53
From table 8, standard multiple regression analysis indicated that pain,
anxiety and uncertainty significantly explained 42 % of the variance in postoperative
fatigue (F(3,76) = 18.37, p < .001). Particularly, pain explained the most variance in
postoperative fatigue (β = .35, p < .01), followed by anxiety (β = .30, p < .01) and
uncertainty (β = .19, p < .05).
The equation was:
postoperative fatigue = 33.85 + 3.05(pain) + 1.18(anxiety) +
0.28(uncertainty)
or
‘Zpostoperative fatigue = .35(Zpain) + .30(Zanxiety) + .19(Zuncertainty)’.
Based on regression model shows that sample who increase 1 score of pain,
could increase 3.05 point in total score of postoperative fatigue. In addition, increase 1
score of anxiety, could increase 1.18 point in total score of postoperative fatigue in the
sample. Finally, the sample who increase 1 score of uncertainty, could increase 0.28
point in total score of postoperative fatigue.
CHAPTER 5
CONCLUSION AND DISCUSSION
This chapter presents a summary and discussion of the study results.
Implication and recommendation of the findings for nursing are also addressed.
Summary of the study
This study aimed to examine the influence of pain, anxiety, and uncertainty
on postoperative fatigue among patients with closed fracture of leg undergoing
internal fixation surgery at Khanh Hoa General Hospital, Vietnam. A sample of 80
patients was recruited from traumatology – orthopedic department of Khanh Hoa
General Hospital, Vietnam. Data were obtained by self-report using 5 instruments.
The patient’s profile record form, The numeric pain rating scale (NPRS), The hospital
anxiety and depression scale (HADS), The Mishel uncertainty in illness scale (MUIS)
and The identity – consequence fatigue scale (ICFS). The ICFS was translated into
Vietnamese by using back translation process. Three experts in nursing science were
consulted about the content validity of Vietnamese version of the instrument and the
CVI was 1. Furthermore, a pilot study was conducted using 30 samples to test the
reliability of measurements. The internal consistency coefficients of HADS, MUIS,
and ICFS were .86, .90 and .87, respectively. Frequency, percentage, mean, standard
deviation, mean percentage, and multiple regression analysis were employed to
analyze the data.
Research findings
1. Characteristics of participants: A majority of samples were male (78.8 %).
The age ranged from 18 to 60 with a mean of 38.25 years (SD = 11.92). There were
70 % of participants who were married, and 43.8 % of participants had completed
secondary school and 28.8 % had finished their high school. Farmer was the major
occupational group accounting for 35 % of the sample, followed by industrial worker
with 26.3 % of the sample. Majority of sample (48.8 %) earned less than 150 USD per
month, followed by the income group of 150 to 199.9 USD per month (31.2 %).
About medical information of the sample, ORIF with intramedullary nailing was the
55
major surgical method used in fixing fractured bone (61.2 %). Operation on tibia was
the most common procedure (37.5 %), followed by femur (35 %). In addition, 93.8 %
of the sample reported co-morbidity. Among patients who demonstrated co-morbidity
(6.2 % of the sample), 80 % of them reported hypertension and 20 % reported
diabetes.
2. Major study variables
On the first day after surgery, most of the sample got severe pain (59.9 %)
and it reduced gradually in the following days with severe pain in the second day and
third day after surgery was 18.7 % and 7.4 %, respectively. Furthermore, the sample
of this study had a moderate level of pain during the first three days after surgery as
presented by the mean of 5.09 (SD = 1.71). Majority of the sample had moderate level
of anxiety in the third day after surgery (58.8 %). Especially, there were up to 27.4 %
with severe level of anxiety. Anxiety score for this sample was also at moderate level
with the mean score of 12.29 (SD = 3.78). Additionally, uncertainty was reported
quite high in this study by the mean of 82.06 (SD = 10.57).
In regard to postoperative fatigue, the participants in this study had a
moderate level of fatigue (M = 86.58, SD = 15.06) with mean score of fatigue-identity
dimension and fatigue-consequences dimension as 34.41 (SD = 7.22) and 52.16
(SD = 9.40). Notably, the mean percentage of fatigue-identity dimension
(mean % 63.72) was higher than fatigue-consequences dimension (mean % 54.33).
In dimension of identifying fatigue, the mean score for feeling of fatigue and feeling
lack of vigor were 18.13 (SD = 4.45) and 16.29 (SD = 3.67), with feeling of lack of
vigor (mean % 67.88) higher than feeling of fatigue (mean % 60.43). Regarding the
consequence of fatigue dimension, impact on energy had the mean score (M = 21,
SD = 4.48), impact on daily activities (M = 17.19, SD = 3.87) and impact on
concentration (M = 13.96, SD = 4.19). The highest mean percentage was for impacts
on energy (mean % 58.33), followed by impacts on daily activities (mean % 57.30)
and impacts on concentration (mean % 46.60).
3. Factors predicting postoperative fatigue
The result from multiple regression analysis suggested that pain, anxiety and
uncertainty were significant predictors of postoperative fatigue (R2 = .42, p < .001).
In addition, pain was the strongest predictor for postoperative fatigue in this sample
56
(β = .35, p < .01), followed by anxiety (β = .30, p < .01) and uncertainty (β = .19, p <
.05).
Discussion
Pain
The study finding indicated that on the first two days after surgery, 100 % of
the sample reported pain. Particularly, on the first day after surgery, 59.9 % of sample
had severe pain and 38.8 % had moderate pain. On the second day, patients with
severe pain accounted for 18.7 % of the sample and moderate pain accounted for
57.7 %. For the third day postoperation, 7.4 % of the respondents got severe pain and
32.5 % got moderate pain. Previous studies also identified the same pattern of pain
occurrence after surgery: pain was most severe on the first day and then gradually
lessened on the following days (Mace, 2003; Rosén et al., 2009). Using visual analog
scale (VAS) to measure pain on patients undergoing elective surgery, Svensson et al.
(2000) reported that 43 %, 27 %, and 16 % patients experience moderate and severe
pain at 24, 48, and 72 hours after surgery, respectively.
The highest percentage of patients suffering severe pain in the first
postoperative day is caused by the combination of stimulation from an injury prior to
surgery and cutting of the skin nerve fibers from operation. These nerve endings send
messages along the nerves into the spinal cord and then up to the brain (Pick,
DeSimone, & Harris, 2010). The daily reduction in the level of pain demonstrates that
postoperative recovery is improving as the body begins to heal. However, all of the
patients in this sample suffered pain in the first two days after surgery, which might
indicate that there is an ineffective pain management. Pain after orthopedic surgery in
the first 3 days is acute pain caused by multiple factors. Many recommendations on
effective acute pain management suggest a continuous opioid drug administration
(Argoff, 2014; Pick et al., 2010). In contrast to these recommendations, it was noted
that the analgesic medications used for those postoperative patients at 4 hours after
surgery and following days were only nonsteroidal anti-inflammatory drug (NSAID)
via oral or intramuscular injection administration (Alphachymotrypsin, Tenoxicam,
Meloxicam) combined with Paracetamol 500 mg for oral administration twice per day
at 8 AM and 4 PM.
57
Moreover, the average pain score of the sample during the first three days
after surgery was in a moderate level as presented by the mean of 5.09 (SD = 1.71)
with the mean score of pain in the first, second and third day as 6.90 (SD = 1.95), 4.95
(SD = 1.74), 3.43 (SD = 1.83), respectively. The current findings showed relatively
higher pain intensity in this sample of postoperative patients. It can be explained by
the combination from damaged muscle and skeletal tissue repair or reconstruction
during pre and post operation (Adlin Dasima & Karis, 2013). Additionally, infective
strategies for pain management must have contributed to the pain severity in this
setting. Measuring pain by 0 - 100 mm VAS, the finding from previous studies had
lower pain score than current study. It was reported that pain score during 48 hours
after general surgery was 26.1 mm (Terry, Niven, Brodie, Jones, & Prowse, 2007).
Wickström, Nordberg, and Johansson (2005) asserted that the mean score after radical
prostatectomy in the first two days was 40 mm (SD = 29) and on the third day was
20mm (SD = 26).
Anxiety
The finding indicated that 100 % patients suffered anxiety on the third day
after surgery. Especially, 58.8 % of samples reported moderate level of anxiety and
27.4 % had anxiety in severe level. The percentage of patients with anxiety was
higher in the current study compared to the anxiety levels reported by previous
studies. Using the same instrument - the hospital anxiety and depression scale on 85
women having major gynecological surgery, Carr, Thomas, and Wilson–Barnet
(2005) reported that the percentage of participants suffering moderate to severe
anxiety in day 2 was 30.6 % and day 4 was 34.1 %. Also with this questionnaire,
de Moraes et al. (2010) indicated that the prevalence of moderate and severe anxiety
was 44 % on 100 orthopedic and trauma inpatients. An explanation for the finding of
higher level of anxiety in sample could be because most of the lower limb fracture
patients were the main labor force in the family as evident from the mean age of the
sample (38.25 years) and male gender majority (78,8 %). Hospitalization makes
patients question about their responsibility of taking care of family members.
Moreover, the sample had high percentage of famers (35 %) with income from mostly
those daily basic jobs; prolonged recovery and rehabilitation related to leg injuries
challenged their source of income and made them anxious.
58
The mean score of anxiety of lower limb fracture patients in the present
study was in moderate level (M = 12.29, SD = 3.78). Notably, score of anxiety in this
study is higher than previous study. The mean score of anxiety in gynecological
surgery for postoperative day 2 was 5.64 (SD = 3.57) and mean score for
postoperative day 4 was 6.08 (SD = 4.44) (Carr et al., 2005). An explanation for the
severity of anxiety in the present study is due to emergency health problem. Patients
got hospital admission from an accidental trauma, which leaves them with no physical
or mental preparedness like in case of medical illness. Struggling with hospitalization
obligation can make fracture patients have no preparation for their own life or for
their families. Separation from family and leaving their work leads to the feeling of
anxiety in those patients. Moreover, in the first three days after surgery, interference
from many unpleasant symptoms cause patients to be more worried (Caumo et al.,
2001; Muglali & Komerik, 2008).
Uncertainty
The respondents in the present study had quite a high score for uncertainty
as reflected by the mean score of 82.06 (SD = 10.57); the possible overall score for
this variable ranged from 28 to 140. A possible explanation for the presence of
uncertainty feeling of leg fracture patients is that operation for this population is a
result of accidental trauma. Timing from admission until operation was very strict,
average time was only 5 hours. Moreover, after surgery in the first three days, as a
consequence of overload condition of patient admission, chances to communicate
between health care providers and fracture patients was less. Hence, insufficiency of
information from health care providers caused patients fall into an unclear situation.
Furthermore, ambiguity about symptomatology, diagnosis, treatment process,
relationship with health care providers and unclear plan for patients’ future can be
considered as important reasons for occurring uncertainty in lower leg fracture
patients (Appendix 7).
The finding of this study was in line with previous study findings mostly
reporting a moderate level of uncertainty in surgical patients. Investigating on 100
patients undergoing abdominal surgery with the same instrument - the Mishel
uncertainty in illness scale - Loi (2014) reported that uncertainty score was 85.70 (SD
= 16.13). On orthopedic population, Calvin and Lane (1999) reported that all of
59
participants responded having moderate levels of uncertainty. Also, moderate level of
uncertainty was indicated in a study on 40 individuals after surgical resection of colon
cancer (Galloway & Graydon, 1996).
Postoperative fatigue
The sample also reported a moderate level of postoperative fatigue. The
mean score was 86.58 (SD = 15.06) with the possible overall score ranging from 25 to
150. In the context of lower limb fracture patients, postoperative fatigue could be
explained by the combination of events lasting from prior to post surgery. Suffering
injury, facing with pain, and blood loss are the first causes for fatigue among lower
limb fracture patients (Ignatavicius, 2013). Moreover, surgical trauma in the surgical
setting with side effect from anesthesia procedure is considered as another important
factor contributing to postoperative fatigue. Finally, insufficient rest caused by
disturbance from inflammatory process and many unpleasant symptoms after surgery
can lead to postoperative fatigue among patients with closed fracture of leg
undergoing ORIF surgery (Zargar-Shoshtari & Hill, 2009).
Similarly, previous studies supported the presence of fatigue in moderate
level in surgical patients. In Vietnamese surgical patients, Long (2010) also indicated
that tiredness appeared as one of the most problematic symptoms in entire three days
after abdominal surgery. Using profile of mood states to measure the intensity of
fatigue feelings among 102 patients after undergoing primary hip arthroplasty in the
first 3 days, the finding showed a mean score of 9.1 (SEM = 0.6) (Hall & Salmon,
2002). Graversen and Sommer (2013) measured fatigue by 0 - 10 numeric scale and
indicated that on the first day after laparoscopic cholecystectomy surgery, fatigue
presented at 24 hours was 4. Yu et al. (2015) showed the mean scores of fatigue on
the first day after surgery was 7.14 (SD = .72) and on the 10th day was 4.23
(SD = 1.00).
Factors predicting postoperative fatigue
The regression model assessed that all the three variables of pain, anxiety
and uncertainty constituted the explanatory 42 % of postoperative fatigue in patients
with lower limb fracture undergoing ORIF surgery. This finding was supported by
both theoretical and empirical basis. Theoretically, according to the theory of
unpleasant symptoms (TOUS), these factors are the antecedent factors for
60
postoperative fatigue. They can directly influence on patients’ symptoms. For
empirical evidence, the results of the current study were the same as previous
researchers’ findings (Falk et al., 2007; Long, 2010; Saowaluck, 2009; Tan & Xia,
2014).
The present study points out that pain had a significant impact on patients’
postoperative fatigue. Findings revealed that pain positively influenced on
postoperative fatigue (β = .35, p < .01). The link between pain and fatigue is that
fatigue develops after the development of pain; and an improvement in fatigue will
lessen pain. Similarly, the more severe the pain, the greater the likelihood of fatigue
and the greater the pain experienced the more certain it was that fatigue occurred.
Theoretically, fatigue plays a role as an unpleasant symptom that is influenced by
physiologic factors including pain (Lenz et al., 1997). For empirical evidence, there
are many studies discussing the impacts of ineffective pain management. Among
them, sleep disturbance, mood disorders such as anxiety, fear and depression occurred
as the most common problems (Chiu et al., 2005; Chouchou et al., 2014). Thus, these
could be considered as reasons for the presence of fatigue. On the other hand, adverse
effects on the endocrine and immune functions resulting from ineffective pain
management can also lead to fatigue (Peters et al., 2007).
Findings from many other studies also supported the finding of the present
study. There is a close relationship existing between pain and fatigue. In Saowaluck’s
study (2009), the result asserted pain was a significant predictor of postoperative
fatigue (β = .28, p < .01) among hysterectomy patients. It is also reported that
although several variables were found to contribute to the severity of fatigue, the
presence of pain contributed to 7.6 % of variance of fatigue (Lee et al., 2010). By
using multiple logistic regression models, Garabeli Cavalli Kluthcovsky et al. (2012)
reported that the presence of pain is one of the predictive factors for postoperative
fatigue (OR = 3.87, 95 % CI = 1.88 - 7.98, p = .000). Thus, pain constituted one of the
most important factors affecting postoperative fatigue among lower limb fracture
patients. Nurses should be mindful that patients will benefit from nursing
intervention, focusing on effective pain management that can reduce postoperative
fatigue.
61
The results also identified that anxiety constituted another explanatory factor
of postoperative fatigue (β = .30, p < .01). This finding was supported by both
theoretical and research findings. This finding was supported by both theoretical and
studied basis. According Lenz et al. (1997), the psychological factors including the
individual’s mental state or mood (depression), affective reaction to illness (mood
status) and psychological response to stress (the degree of perceived stress or the level
of anxiety) can affect unpleasant symptoms. Moreover, anxiety increases the release
of epinephrine into the circulation which causes blood vessel constriction, increased
heart rate and force of contractility, enhancing blood pressure and temperature,
flushing and sweating (Vaughn, Wichowski, & Bosworth, 2007). Level of anxiety
may alter a patient’s surgical course and cause increased postoperative pain (Caumo
et al., 2002; Katz et al., 2005; Vaughn et al., 2007). Furthermore, negative emotions
such as anxiety can affect immunomodulatory behaviors, causing poor sleep patterns
and poor nutrition. In addition, the patient may have a heightened sense of touch,
smell or hearing and being placed in unfamiliar surroundings can make the individual
feel even more unwell and uncomfortable (Pritchard, 2009). These consequences of
anxiety contribute to the development of fatigue after surgery.
The influence of anxiety on postoperative fatigue is consistent with previous
studies. In abdominal surgery population, the result indicated that on the second day
after surgery, anxiety was associated with tiredness (r = .33, p < .01) (Long, 2010).
Increase in psychological distress is a factor related to worsening fatigue after surgery
(Rotonda et al., 2013). To describe the relationship of fatigue with psychological
functioning in adults with spinal cord injury, anxiety was an independent factor that
was associated with fatigue (Alschuler et al., 2013). On 180 postoperative patients
with breast cancer, the finding showed that moderate/ severe fatigue was positively
associated with anxiety (r = .32, p < .05) (Tan & Xia, 2014).
Uncertainty was identified as another important determinant of postoperative
fatigue for leg fracture patients (β = .19, p < .05). The links between uncertainty and
fatigue included the development of fatigue after the development of uncertainty; the
more severe uncertainty was present, the greater the likelihood of fatigue. This was in
line with both the theoretical basis and previous research results. Based on the Theory
of Unpleasant Symptoms (Lenz et al., 1997), an unpleasant symptom such as
62
postoperative fatigue is influenced by psychological antecedents including the degree
of uncertainty and knowledge about the symptoms and patient’s possible meaning
(perception of illness experience or symptom experience). Additionally, according to
Mishel (1988), patients with uncertainty will have negative thoughts and beliefs
regarding the disease, leading to altered coping, severe cognitive impairment.
Furthermore, if uncertainty keeps developing, it makes patients fall into conditions of
stress and anxiety. Therefore, the psychological distress and depressive symptoms
caused by uncertainty are the reason for occurrence of postoperative fatigue.
The current study result is similar with finding from the previous studies.
Falk et al. (2007) asserted that there was a positive association between uncertainty
and tiredness among heart chronic failure patients. Lasker et al. (2010) conducted a
study on 100 female patients undergoing liver transplantation operation and indicated
that there was a significant relationship between uncertainty and fatigue. Moreover,
for cancer patients undergoing radiotherapy, Stiegelis et al. (2004) indicated that
reduction in illness uncertainty was an important factor in decreasing fatigue.
The results imply that the presence of three variables including pain, anxiety
and uncertainty can explain 42 % variance of postoperative fatigue among patients
with closed fracture of leg undergoing internal fixation surgery in the first three days.
If nurses focus on controlling pain by using effective pain management and reducing
patient’s feeling of anxiety and uncertainty, it will be a good strategy to decrease
fatigue after surgery. These will in turn help patient recover well and get discharged
in the short time.
Implications and recommendations
Results of this study demonstrated that fatigue, pain, anxiety and uncertainty
occurred frequently during first three postoperative days. Moreover, pain, anxiety and
uncertainty constituted as the important determinants of postoperative fatigue for
patients with closed fracture of leg undergoing internal fixation surgery. The findings
of this study can be applied for nursing clinical practice, education and research as
follows:
63
Implications and recommendations for clinical practice
1. Nurses should be aware of the presence of fatigue in patients with lower
limb fracture undergoing ORIF surgery. Additionally, nurses should know that factors
affecting postoperative fatigue are pain, anxiety and uncertainty.
2. Nurses should regularly assess the occurrence of pain, anxiety,
uncertainty and fatigue after surgery and make a good nursing care plan to prevent as
well as manage these symptoms effectively.
3. Nurse administrators can provide an in-service training on postoperative
fatigue assessment and management to their staff, focusing on prevention and
management of pain, anxiety and uncertainty. In addition, provision of the
refreshment courses should be set regularly to all staff nurses who are taking care of
postoperative patients.
Implications and recommendations for education
1. Results of this study can be used to integrate into a nursing curriculum,
focusing on the presence of fatigue after surgery and predicting factors to this
symptom that are pain, anxiety and uncertainty among lower limb fracture patients
undergoing ORIF surgery.
2. Teaching nursing students to understand and realize the presence of
fatigue postoperatively and associated factors is recommended. In addition, nursing
teachers should educate student in assessing postoperative fatigue and provide proper
strategies to prevent and manage this unpleasant symptom by managing pain, anxiety
and uncertainty.
Implications and recommendations for research
It could be said that this study is the confirmation of the Theory of
Unpleasant Symptoms. The associations among symptoms and between symptoms
and antecedents as hypothesized by Lenz et al. (1997) had been proved in the present
study. It is meaningful because the model was tested in a different culture from
Western societies. Adding up to the previous studies, this research affirms that the
Theory of Unpleasant Symptoms is the reliable and applicable theoretical guide for
nursing practice and nursing research. According to the findings, further studies are
recommended:
64
1. A fatigue management program should be developed and tested
empirically. An experimental research on symptom management should focus on
alleviating postoperative fatigue.
2. Clinical guideline for nursing practice in terms of assessing and
managing postoperative fatigue by intervening in pain, anxiety and uncertainty.
3. Since this study is limited only to lower limb fracture surgery patients
who were admitted in Khanh Hoa General hospital, Vietnam; the findings cannot be
generalized to those undergoing other types of surgery and also to those who staying
in other regions in Vietnam. Hence, replication of this study among other types of
surgery and other setting is recommended to validate the results of this study.
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APPENDICES
APPENDIX 1
Instruments (English version)
81
SOCIODEMOGRAPHIC INFORMATION
1. Age: …........years
2. Gender
3. Marital status
4. Educational level
oling
school
Secondary school
High school
5. Occupation:
Farmer
Business person
Government officer
Industrial worker
Retired/ Unemployment
Student
6. Income/ month (USD)
< 150
– < 199.9
200 – < 249.9
250
82
DISEASES AND TREATMENT INFORMATION
This form includes data related to patient disease and treatment. The
information is collected by the investigator from patient record profile.
1. Date of admission: ………/……../……..
2. Date of surgery: ………/……../………..
3. Cause of injury: ………………………………………………………………
4. Diagnosis: ………………………………………………………………………
5. Part of bone fracture
Right femur
Left femur
Right tibia
Left tibia
Right fibula
Left fibula
6. Type of surgery
ORIF with plating
ORIF with nailing
7. Co-morbidity:
(specific)…………………………………………………….........................
8. Medications used during the first three days postoperatively
Day one
Type/ name of drugs Dose Route Time
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
83
Day two
Type/ name of drugs Dose Route Time
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
Day three
Type/ name of drugs Dose Route Time
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
…………………….. ……………………. …………………… ……………….
84
NUMERIC PAIN RATING SCALE
This is the Numeric Pain Rating Scale includes a horizontal 10 lines with
anchor indicating the extremes of pain. The value on the pain scale corresponds to
pain levels as follows:
Please place a mark X on the number that most likely your pain level
occurred to you IN THE LAST 24 HOURS in average.
85
THE ANXIETY MEASUREMENT (HADS-A)
This questionnaire has seven questions. Please read carefully each question
and then mark to the answer that most likely occurs to you during the last three days.
1. I feel tense or ‘wound up’
2. I get a sort of frightened feeling as if something awful is about to happen
t at all
....................................................................................................................................
............................................................
............................................................
............................................................
............................................................
7. I get sudden feelings of panic
Very often indeed
Quite often
Not very often
Not at all
86
THE MISHEL UNCERTAINTY IN ILLNESS (ADULT)
Please read each statement. Take your time and think about what each
statement says. Then circle the appropriate number to the right that most closely
measures how you are feeling today. If you agree with a statement, then you would
mark under either “Strongly Agree” or “Agree.” If you disagree with a statement, then
mark under either “Strongly Disagree” or “Disagree.” If you are undecided about how
you feel, then mark under “Undecided” for that statement. Please respond to every
statement.
□ 1= Strongly Disagree □ 2 = Disagree
□ 3= Undecided □ 4= Agree
□ 5= Strongly Agree
No
The Mishel Uncertainty in Illness
Levels
1 2 3 4 5
1 I do not know what is wrong with me 1 2 3 4 5
2 I have a lot of questions without answers 1 2 3 4 5
… ……………………………………………………………….
… ……………………………………………………………….
… ……………………………………………………………….
… ……………………………………………………………….
13 It is difficult to know if the treatments or medications I am
getting are helping
1 2 3 4 5
… ……………………………………………………………….
… ……………………………………………………………….
… …………………………………………………………….....
… …………………………………………………………….....
… …………………………………………………………….....
28 The doctors and nurses use everyday language so I can
understand what they are saying
1 2 3 4 5
87
THE IDENTITY-CONSEQUENCE FATIGUE SCALE
I would like to know more about any problems you have had with feeling
tired, weak or lacking in energy in the last 3 days. Please answer ALL the questions
by ticking the answer which applies to you most closely.
Please tick only one box per line.
No not
at
all
almost
never
some
of the
time
fairly
often,
very
often
all
of
the
time
1 2 3 4 5 6
1 I have been feeling drained
… ……………………………..
… ……………………………..
… …………………………….
10 I have been able to concentrate
on things
… ………………………………...
… …………………………………
… …………………………………
… ………………………………..
… ………………………………..
… …………………………………
23 I lack the energy to engage in
leisure or recreational activities
such as listening to radio, music,
reading newspaper or book
… …………………………………
… …………………………………
25 I lack the energy to follow
exercise for rehabilitation.
APPENDIX 2
Instruments (Vietnamese versions)
89
CÁC THÔNG TIN CHUNG VỀ NGƯỜI BỆNH
1. Tuổi: …........
2. Giới
ữ
3. Tình trạng hôn nhân
ộc thân
ết hôn
ồng hoặc vợ đã mất
ị/ ly thân
4. Trình độ giáo dục
Cấp 1
Cấp 2
Cấp 3
ấp/ cao đẳng
ại học hoặc sau đại học
5. Nghề nghiệp:
Nông dân
Người làm kinh doanh
Cán bộ viên chức nhà nước
Công nhân
Về hưu/ Thất nghiệp
Sinh viên
6. Thu nhập
D/tháng
– < 3.999.999 VND/ tháng
– < 4.999.999 VND/ tháng
90
CÁC THÔNG TIN VỀ BỆNH VÀ ĐIỀU TRỊ
Phiếu này bao gồm các dữ liệu liên quan đến điều trị và tình hình bệnh tật
của bệnh nhân. Những thông tin trong phiếu này được thu thập từ bệnh án của bệnh
nhân.
1. Ngày giờ vào viện: ………/……../……..
2. Ngày giờ phẫu thuật: ………/……../……..
3. Nguyên nhân chấn thương: ………………………………………………..
4. Chẩn đoán: ………………………………………………………………………
5. Bộ phận gãy xương
Xương đùi phải
ải
ải
6. Loại phẫu thuật
Cố định trong bằng phương pháp nẹp vít
ố định trong bằng phương pháp đóng đinh nội tủy
7. Bệnh kèm theo
(Cụ thể )…………………………………………………….........................
8. Thuốc được sử dụng trong suốt 3 ngày sau mổ
Ngày thứ nhất
Tên/ loại thuốc Liều Đường dùng Thời gian
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
91
Ngày thứ hai
Tên/ loại thuốc Liều Đường dùng Thời gian
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
Ngày thứ ba
Tên/ loại thuốc Liều Đường dùng Thời gian
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
…………………… ……………………. ………………….. ……………..
92
CÔNG CỤ ĐO ĐAU TRÊN BỆNH NHÂN
Đây là thang điểm để đo đau gồm 10 điểm. Gía trị trên thang đâu phản ánh
mức độ đau như hình vẽ. Vui lòng đánh dấu X trên con số mà đau xuất hiện trung
bình trong suốt 24 giờ qua.
Không đau Đau vừa Đau kinh
khủng
93
BỘ CÂU HỎI ĐÁNH GIÁ MỨC ĐỘ LO LẮNG CỦA
NGƯỜI BỆNH
Bộ câu hỏi này gồm 7 câu. Xin anh/ chị vui lòng đọc kỹ và chọn câu trả lời
phù hợp nhất tình trạng của anh chị trong suốt 3 ngày qua bằng cách đánh x vào ô phù
hợp.
1. Tôi cảm thấy căng thẳng
ề
ỉnh thoảng, lúc cảm thấy lúc không
ờng xuyên
ầu như mọi lúc
2. Tôi thấy lo sợ rằng hình như sẽ có chuyện chẳng lành xảy ra
ề
ột chút, nhưng không ảnh hưởng gì
ợ
ều và rất lo sợ
....................................................................................................................................
............................................................
............................................................
............................................................
............................................................
7. Tôi đột nhiên thấy giật mình hoảng hốt
ề
ỉnh thoảng
ờng xuyên
ất thường xuyên
94
BỘ CÂU HỎI ĐÁNH GIÁ VỀ SỰ KHÔNG CHẮC CHẮN VỀ
BỆNH (PHIÊN BẢN NGƯỜI LỚN)
Xin vui lòng đọc từng câu. Hãy dành thời gian để suy nghĩ về nội dung ở mỗi
câu. Sau đó khoanh tròn số thích hợp đo lường gần nhất những gì mà anh/chị đang
cảm thấy ngày hôm nay. Nếu anh/chị đồng ý, anh/chị sẽ đánh dấu vào các ô hoặc là
“rất đồng ý” hoặc đồng ý. Nếu các anh chị không đồng ý, anh/ chị sẽ đánh dấu vào các
ô “rất không đồng ý” và “không đồng ý”. Nếu anh/ chị không xác định được anh chị
cảm thấy như thế nào, anh/ chị đánh dấu vào ô “không xác định” cho câu đó. Xin vui
lòng trả lời cho mỗi câu.
□ 1= Rất không đồng ý □ 2= Không đồng ý
□ 3= Không xác định □ 4= Đồng ý
□ 5= Rất đồng ý
Số Sự không chắc chắn về bệnh Mức độ
1 2 3 4 5
1 Tôi không biết diễn biến bệnh của mình 1 2 3 4 5
2 Tôi có rất nhiều câu hỏi nhưng vẫn chưa có câu trả lời 1 2 3 4 5
… ………………………………………………………………..
… ………………………………………………………………..
… ………………………………………………………………..
13 Rất khó để biết được phương pháp điều trị hoặc thuốc tôi
đang uống.
1 2 3 4 5
… ………………………………………………………………..
… ………………………………………………………………..
… ………………………………………………………………..
… ………………………………………………………………..
… ………………………………………………………………..
28 Bác sĩ và điều dưỡng sử dụng ngôn ngữ hằng ngày nên tôi có
thể hiểu được những gì họ đang nói.
1 2 3 4 5
95
THANG ĐIỂM MỆT MỎI VÀ HẬU QUẢ CỦA MỆT MỎI
Tôi muốn biết về bất cứ vấn để mà anh/ chị đã trải qua về cảm giác mệt mỏi,
yếu, thiếu năng lượng và hậu quả của những cảm giác đó trong 3 ngày qua. Vui lòng
trả lời tất cả các câu hỏi bằng cách đánh dấu X vào câu trả lời mà anh chị cảm thấy
phù hợp nhất
Số Không
hề
Hầu
như
không
Thỉnh
thoảng
Khá
thường
xuyên
Rất
thường
xuyên
Luôn
luôn
1 2 3 4 5 6
1 Tôi cảm thấy không
còn năng lượng
… ………………….
… ………………….
… ………………….
10 Tôi có thể tập trung
để làm mọi việc
… …………………..
… …………………..
… …………………..
… …………………..
… …………………..
… …………………..
23 Tôi không đủ sức để
tham gia vào những
hoạt động giải trí
như nghe đài, nghe
nhạc, đọc sách báo.
… ………………….
… ………………….
96
Số Không
hề
Hầu
như
không
Thỉnh
thoảng
Khá
thường
xuyên
Rất
thường
xuyên
Luôn
luôn
25 Tôi không đủ sức để
theo những bài tập
phục hồi chức năng
sau mổ.
APPENDIX 3
Institutional review board approval
98
APPENDIX 4
Letter of asking permission for data collection
100
101
APPENDIX 5
Patient consent form (English version)
103
INFORMATION SHEET
Dear Sir/Madam,
My name is Nguyen Thi Thuy Trang, a student of Master of Adult Nursing,
Faculty of Nursing, Burapha University, Thailand. I am conducting a study entitled
“Factors predicting postoperative fatigue among patients with closed fracture of
leg undergoing internal fixation surgery in Khanh Hoa General hospital,
Vietnam”. This study will be conducted in order to describe the characteristics of
pain, anxiety, uncertainty, and postoperative fatigue and examine the influence of pain,
anxiety, and uncertainty on postoperative fatigue among patients with closed fracture
of leg undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam.
The findings of the study will provide the basic knowledge for surgical nurses to
assess postoperative fatigue among orthopedic trauma patients and further researches
for developing the interventions in order to prevent and manage postoperative fatigue
and to improve quality of care and quality of life in orthopedic trauma patients.
If you agree to participate in this study, the researcher will distribute for you 1
questionnaire taking 1 minute to finish in the first and second day after surgery. On the
third operation day, five questionnaires will be distributed to complete within about 30
minutes. There are no identified risks with participating in this study. Participation is
voluntary. You have the right to refuse to answer any questions and may withdraw at
any time without any penalty. Anonymity and confidentiality will be assured, and no
personal information will be revealed to any other person. All data will be stored in a
secure place and will be only utilized for the purposes of the study. You will receive a
complete explanation of the nature of the study if you wish to.
If you agree to join this study, please sign your name below to indicate that you
are informed, and you understand all necessary information related to the study, and to
prove your consent to participate in this study as well.
104
The study will be conducted by me. If you have any questions, please contact
me at +84 1696 962 313 or by e-mail: [email protected] or my major adviser
Assist. Prof. Dr. Niphawan Samartkit, e-mail: [email protected]
Thank you very much for your cooperation.
Nguyen Thi Thuy Trang
105
INFORMED CONSENT
Title: “Factors predicting postoperative fatigue among patients with closed
fracture of leg undergoing internal fixation surgery in Khanh Hoa General
hospital, Vietnam”.
IRB approval number:…………………………..
Date of collection data ……………Month ………….Years………………
Before I give signature in below, I already be informed and explained by the
researcher, Ms Nguyen Thi Thuy Trang about purposes, method, procedures, and
benefits of this study, and I understood all of that explanation.
I agree to be as a participant of this study.
I’m Ms Nguyen Thi Thuy Trang, as a researcher has explained all of
explanation about purposes, method, procedures, and benefits of this study to the
participant with honestly; then, all of information of the participants will only be used
for purpose of this research study.
______________________ ________________________
Name and Signature of the Participant Date
______________________ ________________________
Name and Signature of witness Name and Signature of the researcher
Nguyen Thi Thuy Trang
APPENDIX 6
Patient consent form (Vietnamese version)
107
GIẤY ĐỒNG Ý THAM GIA NGHIÊN CỨU
Chào anh/chị
Tôi tên là Nguyễn Thị Thùy Trang, là sinh viên thạc sĩ chuyên ngành điều
dưỡng người lớn tại khoa điều dưỡng, trường đại học Burapha, Thái Lan. Tôi đang
thực hiện một nghiên cứu tên là “Những yếu tố ảnh hưởng đến mệt mỏi sau mổ trên
bệnh nhân gãy kín xương chi dưới trải qua phẫu thuật cố định trong tại bệnh
viện đa khoa tỉnh Khánh Hòa, Việt Nam”. Nghiên cứu này được thực hiện nhằm
mục đích mô tả đặc điểm của đau, lo lắng, sự không chắc chắn, mệt mỏi sau mổ và
kiểm tra sự ảnh hưởng của đau, lo lắng, không chắc chắn lên mệt mỏi sau mổ của
những bệnh nhân gãy kín xương chi dưới tại bệnh viện đa khoa tỉnh Khánh Hòa, Việt
Nam. Kết quả từ nghiên cứu này sẽ cung cấp những kiến thức cơ bản cho điều dưỡng
ngoại khoa để nhận định mệt mỏi sau mổ trên những bệnh nhân chấn thương chỉnh
hình và phát triển những can thiệp để ngăn ngừa và kiểm soát mệt mỏi sau mổ. Ngoài
ra, kết quả nghiên cứu này còn giúp cải thiển chất lượng chăm sóc và chất lượng sống
trên bệnh nhân chấn thương chỉnh hình.
Nếu anh/chị đồng ý tham gia nghiên cứu này, tôi sẽ phát cho anh chị 5 bảng câu
hỏi trong khoảng 30 phút. Khi tham gia nghiên cứu này, anh chị không bị ảnh hưởng
nguy hiểm nào. Sự tham gia là hoàn toàn tự nguyện. Anh/chị có quyền từ chối trả lời
bất kì câu hỏi nào và có thể dừng tham gia trả lời câu hỏi vào bất cứ thời điểm nào mà
không bị ảnh hưởng gì. Khi tham gia nghiên cứu, tôi sẽ đảm bảo sự dấu tên và tuyệt
mật về thông tin cá nhân của anh/chị. Tất cả các dữ liệu sẽ được cất giữ một nơi an toàn
và sẽ chỉ được sử dụng cho mục đích của nghiên cứu này. Nếu muốn, anh/chị sẽ nhận
sự giải thích cặn kẽ về đặc điểm của nghiên cứu.
Nếu anh chị đồng ý tham gia nghiên cứu, xin vui lòng kí tên bên dưới để chỉ ra
rằng anh chị đã được giải thích và hiểu tất cả các thông tin cần thiết liên qua đến nghiên
cứu, và cũng để chứng minh sự đồng thuận tham gia trong nghiên cứu này.
108
Nghiên cứu này sẽ được thực hiện bởi tôi. Nếu anh/chị có bất kì thắc mắc gì,
vui lòng liên hệ tôi với số điện thoại +84 1696 962 313 hoặc qua địa chỉ email
[email protected] hoặc người hướng dẫn của tôi: Phó giáo sư Tiến sĩ Niphawan
Samartkit địa chỉ email: [email protected]
Cảm ơn rất nhiều vì sự hợp tác của anh/chị
Nguyễn Thị Thùy Trang
109
GIẤY ĐỒNG Ý
Tên nghiên cứu “Những yếu tố ảnh hưởng đến mệt mỏi sau mổ trên bệnh
nhân gãy kín xương chi dưới trải qua phẫu thuật cố định trong tại bệnh viện đa
khoa tỉnh Khánh Hòa, Việt Nam”.
Số chứng nhận của IRB:…………………………..
Ngày thu thập số liệu: Ngày ……………tháng ………….năm………………
Trước khi tôi kí bên dưới, tôi đã được thông báo và giải thích bởi nghiên cứu
viên, Nguyễn Thị Thùy Trang về mục đích, phương pháp, quy trình, và lợi ích của
nghiên cứu này và tôi hiểu tất cả những lời giải thích đó.
Tôi đồng ý là một người tham gia của nghiên cứu này.
Tôi là Nguyễn Thị Thùy Trang là nghiên cứu viên đã giải thích thành thật tất cả
những thông tin về mục đích, phương pháp, quy trình, và lợi ích của nghiên cứu cho
người tham gia, sau đó, tất của những thông tin của người tham gia nghiên cứu sẽ chỉ
được sử dụng cho mục đích của nghiên cứu này.
______________________ ________________________
Tên và chữ ký của người tham gia Ngày
______________________ ________________________
Tên và chứ ký của người làm chứng Tên và chữ ký của nghiên cứu viên
Nguyễn Thị Thùy Trang
APPENDIX 7
The scores for each item of the hospital anxiety and depression scale (HADS), the
Mishel uncertainty in illness scale (MUIS) the identity - consequence fatigue scale
(ICFS)
111
Table 9 Range, mean, standard deviation for each item of HADS (n = 80)
No Questions Range Mean SD
1 I feel tense or ‘wound up’ 0 – 3 1.63 .83
2 I get a sort of frightened feeling as if something awful
is about to happen
0 – 3 1.49 .97
3 Worrying thoughts go through my mind 0 – 3 1.84 .86
4 I can sit at ease and feel relaxed 0 – 3 1.75 .86
5 I get a sort of frightened feeling like ‘butterflies’ in
the stomach
0 – 3 1.90 .77
6 I feel restless as if I have to be on the move 0 – 3 1.74 .87
7 I get sudden feelings of panic 0 – 3 1.95 .91
Table 10 Range, mean, standard deviation for each item of MUIS (n = 80)
No Questions Range Mean SD
1 I do not know what is wrong with me 1 – 5 2.73 1.01
2 I have a lot of questions without answers 1 – 5 2.94 1.06
3 I am unsure if my illness is getting better or worse 1 – 5 3.06 .99
4 It is unclear how bad my pain will be 1 – 5 3.09 1.06
5 The explanations they give about my condition seen
hazy to me
1 – 5 2.79 1.00
6 The purpose of each treatment is clear to me 1 – 5 3.00 1.01
7 When I have pain, I know what this means about
my condition
1 – 5 2.95 .99
8 I do not know when to expect things will be done to
me
1 – 5 3.00 .93
9 My symptoms continue to change unpredictably 1 – 5 2.81 1.08
10 I understand everything explained to me 1 – 5 2.94 1.01
11 The doctors say things to me that could have
meanings
1 – 5 2.95 .87
112
Table 10 (cont.)
No Questions Range Mean SD
12 My treatment is too complex to figure out 1 – 5 3.00 .96
13 It is difficult to know if the treatments or
medications I am getting are helping
1 – 5 2.75 .97
14 There are so many different types of staff, it is
unclear who is responsible for what
1 – 5 2.78 .87
15 Because of the unpredictability of my illness, I
cannot plan for the future
1 – 5 2.86 .92
16 The course of my illness keeps changing. I have
good and bad days
1 – 5 2.81 .89
17 It is vague to me how I will manage my care after I
leave the hospital
1 – 5 2.89 .97
18 I have been given many differing opinions about
what is wrong with me
1 – 5 2.84 .99
19 It is not clear what is going to happen to me 1 – 5 2.86 1.05
20 The results of my tests are inconsistent 1 – 5 2.71 .83
21 The effectiveness of the treatment is undetermined 1 – 5 2.83 1.02
22 It is difficult to determine how long it will be before
I can care for myself
1 – 5 3.04 1.04
23 Because of the treatment, what I can do and cannot
do keeps changing
1 – 5 2.94 .97
24 The treatment I am receiving has a known
probability of success
1 – 5 3.03 .95
25 They have not given me a specific diagnosis 1 – 5 2.98 1.07
26 I can depend on the nurses to be there when I need
them
1 – 5 3.15 1.08
27 The seriousness of my illness has been determined 1 – 5 3.16 1.11
28 The doctors and nurses use everyday language so I
can understand what they are saying
1 – 5 3.20 1.07
113
Table 11 Range, mean, standard deviation for each item of ICFS (n = 80)
No Questions Range Mean SD
1 I have been feeling drained 1 – 6 3.44 1.18
2 I have been feeling fatigue 1 – 6 3.59 1.17
3 I have been feeling worn out 1 – 6 3.53 1.29
4 Physically, I have felt tired 1 – 6 3.84 1.21
5 My body has been feeling heavy all over 1 – 6 3.74 1.25
6 I have been feeling refreshed 1 – 6 4.16 1.22
7 I have been feeling lively 1 – 6 4.18 1.19
8 I have been feeling vigorous 1 – 6 4.05 1.09
9 I have been feeling energetic 1 – 6 3.90 1.17
10 I have been able to concentrate on things 1 – 6 2.89 1.11
11 I have made more mistakes than usual 1 – 6 2.79 1.13
12 My thoughts have wandered easily 1 – 6 2.79 1.17
13 I have been forgetful 1 – 6 2.66 1.10
14 I have had trouble paying attention 1 – 6 2.85 1.10
15 It has been hard to get motivated to do my regular
activities
1 – 6 3.35 1.12
16 I do very little in a day 1 – 6 3.43 1.32
17 I have had to restrict how much I try to do in a day 1 – 6 3.65 1.22
18 I have had the energy to do lots of things 1 – 6 3.71 1.20
19 I start things without difficulty and then get tired 1 – 6 3.38 1.12
20 I lack the energy to do things I normally do 1 – 6 3.49 1.18
21 I lack the energy to eating 1 – 6 3.43 1.39
22 I lack the energy to talking or chatting with other
people.
1 – 6 3.23 1.08
23 I lack the energy to engage in leisure or recreational
activities such as listening to radio, music, reading
newspaper or book
1 – 6 3.19 1.16
114
Table 11 (cont.)
No Questions Range Mean SD
24 I lack the energy to walk around or go to bathroom
by using supportive aids
1 – 6 3.46 1.21
25 I lack the energy to follow exercise for
rehabilitation.
1 – 6 3.89 1.30
APPENDIX 8
Letter of permission for using the research instruments
116
PERMISSION FOR USING ENGLISH VERSION OF THE
INDENTITY-CONSEQUENCE FATIGUE SCALE
Date: January 23rd
, 2015
From: [email protected]
Dear Dr Johanna Susan Paddison,
My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,
Burapha university, Thailand. To fulfill the requirements for master degree of nursing
science, I have conducted a thesis with title" Factors predicting postoperative fatigue
among patients with closed fracture of leg undergoing internal fixation surgery". To
measure postoperative fatigue, I am really interested in using the Identity –
Consequence Fatigue Scale. So, it would be grateful if I have your permission for
using this instrument.
Any further information about changes or modifies of this instrument I will let you
know.
I am looking forward to receiving permission from you.
Thank you so much.
Best regards.
Trang
…………………………………………………………………………………………
Date: January 23rd
, 2015
From: [email protected]
Hi Trang,
You are most welcome and have my permission to use the scale.
Kind regards,
Johanna.
117
PERMISSION FOR USING VIETNAMMESE VERSION OF THE
HOSPITAL ANXIETY AND DEPRESSION SCALE
Date: January 23rd
, 2015
From: [email protected]
Dear Mr Nguyen Hoang Long
My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,
Burapha university. Thailand. To fulfill the requirements for master degree of nursing
science,I have conducted a thesis with title" Factors related to postoperative fatigue
among patients with closed fracture of leg undergoing internal fixation surgery". With
one of my thesis variable is anxiety, I would like to ask your permission for using
Vietnamese version of "The Hospital Anxiety and Depression Scale (HADS)"
questionnaire. It would be so great if I had your comments and suggestions about
using this instrument.
I am looking forward to hear response from you soon.
Sincerely,
Trang
…………………………………………………………………………………………
Date: January 19th
, 2015
From: [email protected]
Dear Nguyen Thi Thuy Trang,
Nice to hear from you. I am so happy to learn that more and more Vietnamese nurses
are pursuing their postgraduate studies on clinical problems. Your thesis topic is very
interesting. I do believe that you would see many valuable information while doing
this.
Yes, you can use the Vietnamese version of the Hospital Anxiety and Depression
Scale which was translated in my thesis. Please notify the copyright holder of the
English scale for the use of this instrument if necessary.
Wish you success on your study. Hope to see you someday in Vietnam.
Sincerely,
118
--------------------------
Nguyen Hoang Long RN, M.N.S
Acting Head,
Division of Nursing, Faculty of Health Science
Thang Long University, Ha Noi, Vietnam
Mobile: + 84 904 99 52 53
PhD Candidate, Faculty of Nursing
Chulalongkorn University, Bangkok, Thailand
119
PERMISSION FOR USING VIETNAMESE VERSION OF THE
MISHEL UNCERTAINTY IN ILLNESS
Date: January 18th
, 2015
From: [email protected]
Dear Mr Tran Van Loi,
My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,
Burapha university. To fulfill the requirements for master degree of nursing science,I
have conducted a thesis with title" Factors related to postoperative fatigue among
patients with closed fracture of leg undergoing internal fixation surgery". With one of
my thesis variable is uncertainty, I would like to ask your permission for using
Vietnamese version of "Mishel uncertainty in illness" questionnaire. It would be so
great if I had your comments and suggestions about using this instrument.
I am looking forward to hear response from you soon.
Sincerely,
Trang
…………………………………………………………………………………………
Date: January 21st, 2015
From: [email protected]
Dear Mrs Trang
You have my permission to use the scale. Enjoy using it.
Mr. Loi
--------------------------
Tran Van Loi
Department of surgery
Thai Nguyen Medical college
Telephone number: +84915145268
+66876125383