الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 289 |  |  |
| | | from | 289 | | |
Abstract
Literature review cited that a breast cancer patient is often accompanied by pain and sleep disturbance that have a negative impact on their quality of life, sleep quality, anxiety and function ability. The current study is aiming to identify the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality among breast cancer patients.
Research Design:
The quasi-experimental design was utilized in this study to identify the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality among breast cancer patients.
Research Setting:
The study was conducted in Clinical Oncology Department of Menoufiya University Hospital., Menoufia Governorate, Egypt. The setting is considered representative for patients with breast cancer.
Subjects:
A convenient sample of 60 patients were randomly and alternatively divided into two equal groups; 30 for each group:
o Study group (I) were received progressive relaxation and acupressure for pain management and sleep disorders.
o Control group (II) were exposed to routine hospital care for pain management and sleep disorder.
The patients had been selected according to the following criteria:
Consciously, adult cancer patients ranged from 21 to 60 years of old
Metastatic breast cancer with stage IV whether synchronous or metachronous presentation
Summary
137
Complained from moderate to severe pain
Free from any disorders that contradict with the therapy such as fracture, deep vein thrombosis, severe respiratory problems
The two groups were matched as much as possible as regards age, stage and pain severity
Variables: The independent variable is progressive relaxation technique and acupressure, while the dependent variable is the pain management and sleep quality among breast cancer patients.
The following research hypotheses have been formulated in an attempt to achieve the aim of the study:
Subject who receive progressive relaxation technique and acupressure (study group I) show improvement in pain management compared to subjects who do not receive it (control group II).
Subject who receive progressive relaxation technique and acupressure (study group I) show improvement in sleep quality compared to subjects who do not receive it (control group II).
Tools:
Five tools were utilized for data collection, based on review of related literature to assess the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality among breast cancer patients. These tools are:
Tool 1: Structured interview schedule (knowledge assessment sheet)( Appendix II):
It was developed by the researcher to assess patients’ knowledge. It was included three parts as the following:
Summary
138
* Part one: Sociodemographic Data:
It was compromised of eight questions about patient’s sociodemographic data related to age, sex, residence area, level of education, employment, monthly income, marital status.
* Part two: Medical History:
It was comprised of ten questions related to patient’s past and present medical history such as date of admission, length of hospital stay, chief complaint, previous treatment modalities, current treatment; family medical history
*Part three: Patient’s Knowledge:
It was included fifteen questions related to patient’s knowledge regarding to disease, pain and its management, pharmacological or non pharmacological therapy, in addition to, patient’s knowledge about sleep disorders and its management.
It was comprised of twenty-two questions and three parts about the following:
A- Disease:
It was comprised of five questions about definition, risk factors, signs and symptoms, diagnostic test, stages of the disease, and different treatment modalities. Questions were given a score out of twenty. Each question was given 4 marks if the patient reported correct and complete answer; 2 mark if the patient reported correct and incomplete answer; and zero if the patient reported an incorrect answer questions.
B- Pain:
Five questions assessed patient’s knowledge about pain: definition, causes, signs and symptoms, pharmacological interventions and its side effects, and non pharmacological management. These
Summary
139
questions were given a score ranged from 0 as a minimum to 20 as a maximum. Each question was given 4 marks if the patient reported correct and complete answer; 2 mark if the patient reported correct and incomplete answer; and zero if the patient reported incorrect answer.
C- Sleep:
Five questions concerning sleep: definition, causes, signs and symptoms of insomnia, causes of insomnia, treatment modalities of insomnia.
The questions were given a score ranged from zero as a minimum to 20 as a maximum. Each question was given 4 marks if the patient reported correct and complete answer; 2 mark if the patient reported correct and incomplete answer; and zero if he/she reported an incorrect answer.
Finally, the patient’s scores were added and collected for each part separately out of twenty and these scores of each part were classified into:
A score below 10 denoted poor or unsatisfactory results
A score of 10 < 15 indicated fair results
A score between 15 and 20 illustrated good or satisfactory results
Tool 11: Pain assessment sheet (Appendix III):
It was developed by the researcher for pain assessment and compromised of four parts for overall assessment of pain:
*Part one: characteristics of pain:
It was comprised of eight questions related to location, radiated area, quality, factors aggravating and alleviating, duration, pain affections, and analgesics Part two: Physiological signs:
It was included of five questions concerning physiological manifestations of pain related to respiratory rate, pulse, body temperature, blood pressure, status of skin whether color or temperature.
*Part three: Behavioral signs:
It was included of three questions related to behavioral manifestations of pain concerning to facial expressions, vocalization, and non verbal behaviors,
*Part four: Numeric rating Scale:
It was an adopted scale that provides a simple way to record subjective estimates of pain intensity. The measurments is from zero to ten to rate the patient’s intensity level of pain (National institutes of health, 2003) .
1- Ascore of 0 means : No pain
2- Ascore of 1-3 means : Mild pain
3- Ascore of 4-6 means : Moderate pain
4- Ascore of 7-10 means : Severe pain
Tool III: Sleep Scale (Appendix IV):
It was developed by Snyder-Halpern and Verran (1987), and was modified by Call-Schmidt (2003). It was used to assess quality of the previous night’s sleep. The scale is composed from a16-items; a 15-item out of them in visual analog scale paper-and-pencil measure; each item of them was scored from 0 to 10. These 15-items categorized into three parts for measuring: (1) Effectiveness of sleep part, it was comprised of five items to measure quality i.e. restfulness and depth of sleep in addition length i.e. hours of sleep while in bed, the total scores of this part ranged from 0 to 50 where zero indicate poor in the effectiveness of the sleep and 50 indicate higher better effectiveness of the sleep. (2) Sleep disturbance part, it includes seven items for measuring
Summary
141
the interruption of sleep and delay in getting to sleep; the total scores of this part ranged from 0 to 70 where zero indicate higher presence in a sleep disturbance and 70 indicate absence in a sleep disturbance. While (3) Supplementation for sleep part, it was contained three items about naps and falling back asleep after morning awakenings; the total scores of this part ranged from 0 to 30 where zero indicate high supplementation of the sleep and 30 indicate absence of the supplementation of the sleep.
Concerning to, the disturbance and supplementation part of the scale, the 16th item is created by summing the previous two items scores and the lower scores represent more evidence of sleep disturbance and higher scores represent less sleep disturbance. Because the subscales measure distinct components of sleep and sleep disturbance, there was no total score that was a valid indicator of sleep. Theta reliability of the scale was estimated to be .69 to .93 for a hospitalized sample
Tool IV: Symptom Distress Scale (Appendix V):
It was developed by McCorkle and Young (1978) and was modified by McCorkle and Benoliel (1983) and was translated and modified to Arabic format by the researcher. This scale had been used primarily with cancer patients to assess distress symptoms. Distress symptom was defined as ”the degree of discomfort from the specific symptom being experienced as perceived by the patient”. It measured patients’ self-reports on 10 items: frequency of nausea, intensity of nausea, appetite, fatigue, bowel patterns, concentration, appearance, breathing, outlook, and cough. The Likert-type responses (ranging from 0-4) for each symptom were summed to give a total score (ranging from 0-40), the higher score was 40 that reflecting more symptoms distress and the lower score was 0 that reflected no symptom distress. Cronbach’s alpha coefficient of this scale was .82.
Summary
142
Tool V: The state anxiety inventory scale (Appendix VI):
It was developed by the Speilberger (1983) and was translated to Arabic format by the researcher. It was used to assess the anxiety status for the patient. It consisted of 20 items that were rated on a 4-point likert scale as follows: 1 = not at all; 2 = somewhat; 3 = moderately so; 4 = very much so. The total score was ranged from 20 to 80 where 80 indicate the high score that means the more state anxiety and 20 indicate low scores that mean less anxiety. This 20-item Likert scale with well-established validity and reliability estimates was used to measure anxiety and the Cronbach’s alpha reliability coefficient was .90. II- Method of the study
1- Written Approval:
Permission to carryout the study was taken from responsible authorities after explanation of the purpose of the study.
2- Tools development:
Tools I and II were developed by the researcher after reviewing of the relevant literature and content validity was tested by five experts in the field included nurse educator and medical specialist, then modifications were done accordingly to ascertain relevance and completeness. The other three adapted tools III, IV, and V was tested for content validity and reliability using test-retest method that also used to test the other previous tools I and II.
3- Protection of Patient’s Rights and consent:
At the initial interview each patient was informed about the purpose and benefits of the study, and informed that their participation is voluntary,
Summary
143
also confidentiality and anonymity of the patients were assured. Finally, patients’ formal consent for participants has been obtained.
4- Pilot study:
A pilot study was conducted on 10% of study sample (5 patients) to evaluate the developed tools and a designed booklet for clarity and applicability then necessary modification was carried out. The data that was obtained from the pilot study was not included in the actual study.
5- Data collection:
Data collection was extended from November 2010 to the last of December 2012.
Each patient who agreed to participate in the study and fulfilling the inclusion criteria has been interviewed individually by the researcher in Clinical Oncology Department.
A convenient sample was divided randomly and alternatively into two equal groups.
o Study group (I) were received progressive relaxation and acupressure for pain management and sleep disturbance.
o Control group (II) were exposed to routine hospital care for pain management and sleep disorder
Data collection was passed by four phases as the following:
1) Preparatory phase:
The researcher received training sessions in conducting progressive relaxation technique and acupressure for four months, one day per week and performed under the previous researcher in faculty of Nursing, Alexandria University, who performed studies in those points of the study concerning progressive relaxation technique and acupressure, and in turn, received the training under the specialist in relaxation therapy and acupressure. Moreover, educational videos derived from an internet, was used also in training the researcher.
2) Assessment phase (for both groups):
Three individually interviews were done for data collection. The first interview were done at the first day of the hospital admission to collect baseline data by using tool 1 for demographic data, medical history and patient’s knowledge, tool 11 for pain characteristics, tool III for sleep quality, tool IV for symptom distress and tool V for anxiety. This interview took about 50 minutes and considered as assessment phase. Moreover, the second interview and the third interview were done at the midst and the latest day of the hospital stay to assess the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality by using tool 1I, III, IV and V. Each interview took about 40 minutes. It is an important to remember that the hospital stay was determined ten days that was considered the common hospital stay for the majority of the patients so equalize the hospital stay for all patients who participate in this study to ten days. So the first day of hospitalization was considered the first day of admission, fifth day was considered the midst day of hospitalization and the tenth day was considered the latest day of hospitalization so the patients who had less than ten days excluded but patients who extend long that the hospital stay cut off in tenth day of hospitalization. So seventh patient were excluded from the study due to sudden death or short hospital stay.
3) Implementation phase (for study group only):
Study group (I) were received progressive relaxation and acupressure for pain management and sleep disturbance.
The session of the intervention started firstly by progressive relaxation then followed by acupressure session. It was performed daily and the
Summary
145
researcher follows the principles of progressive relaxation and acupressure. As well as, a caregiver who was accompanied with the patient and who can read and write to attend the session so, the booklet (Appendix IX) that was designed by the researcher was given to each patient or his/her caregiver in the study group in the first interview.
Regarding progressive relaxation technique (appendix VII), in this study the first session was started immediately after the assessment in the first day of hospitalization. In which each muscle group is tensed for 5 to 10 seconds and then relaxed for 20 to 30 seconds; a systemic approach was followed until the patient tenses and relaxed all muscle groups in the body. It was last 15 to 30 minutes.
The muscles in the body were divided into six groups, the first was the muscle of the head and neck, and the second was the two arms’ muscles, the third was the muscles of the abdomen, the fourth was the muscles of the back, the fifth was the muscles of the right leg, and finally the last group was the muscles of the left leg.
Before progressive relaxation technique the environment and the patient were prepared, the environment was quite, well ventilated, softly lighted, and well cleaned. A comfortable bed with firm mattress and clean without wrinkled linen was used. The patient was asked to evacuate the urinary bladder, and lie in a comfortable position or sitting according the preference of the patient.
After the well preparation the patient asked to lie on bed or sitting on chair, and close her eyes and keep the eyes closed until the end of the technique. Breathing exercises was taught and asked to demonstrate from two to three times before and after the technique as possible as, to induce relaxation before the steps of the technique were started. As well as, gentile massage was applied to forehead, neck, shoulders and arms to decrease tension and induce relaxation response. All the time during the technique, the patient were asked to relax the muscles and calm down. The voice tone of the researcher was loud and rapid while the patient was tensing her muscles group, and low and slow while relaxing.
Regarding acupressure technique (appendix VIII), the acupoints was selected from the chinease map concerning to pain and insomnia. EX.1Yintang acupoint in between eyebrows on the midline of the nose, EX.2Tiayang acupoint in the large depression on the side of the head about 1 inch away from and above the end of the eye brow, TW.15Tianliao found on the external lower third of the scapula, LI4 Hegu found on the dorsum of the hand between first and second metacarpal bones, CV.19Zigong found on the midline level with with the second intercostals space, H7 Located on the inside of the wrist crease, in line with the little finger of the inner arm, P6 Located in the center of the inner side of the forearm, approximately three finger-widths up from the wrist crease. Every point was massaged three minutes for each point until a deep, achy, and numbing feeling is produced (EL-Badrey, etal., 2012 ) and (Sahm and Kofen, 1997).
4) Evaluative phase:
o The second interview and the third interview were done at the midst and the latest day of the hospital stay to assess the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality by using tool 1I, III, IV and V. In addition to, in the third interview, the researcher determined the patient’s knowledge about disease, pain and sleep then the mean value were recorded according to the developed levels of the knowledge
o The comparison was done between two groups to assess the efficacy of progressive relaxation technique and acupressure on pain management and sleep quality among breast cancer patients.