الفهرس 
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Abstract
Breast cancer is an important global public health problem due to its high incidence and mortality. The statistics indicate that breast cancer affects about 2.1 million women annually around the worldwide. It is also the most common cause of death among women, and the World Health Organization (2018) indicates that deaths due to breast cancer claimed the lives of 627,000 women in 2018, or about 15% of all cancer deaths among women. The incidence of breast cancer was higher among women in developed countries. Breast cancer in Egypt is the most common type of cancer among women, accounting for approximately 35.0% of malignant tumors among women in Egypt.
Discharge plan for breast cancer elders patients improves their self-care behaviors, diminishes anxiety, creates a positive effect on their emotions and attitudes, helps them prepare for the future, strengthens their ability to cope with treatment and adverse effects, increases their quality of life, decreases symptoms, postoperative complications and the need of postoperative analgesia as well as the duration of hospital stay while maintaining patient satisfaction.
The aim of this study was to identify the effect of implementing a nursing discharge plan on the occurrence of the early post-operative mastectomy complications among geriatric patients.
Materials and Method
Research design:
A quasi-experimental research design was used to carry out this study.
Setting:
The study was carried out at Damanhur Oncology Center in Behaira Governorate.
Subjects:
The study subjects comprised eighty (80) geriatric female patients with breast cancer undergoing modified radical mastectomy and attending the previous setting. The subjects were divided into two equal groups by randomly (study and control) where each group consists of 40 geriatric female patients.
Tools:
Five tools were used for data collection.
Tool (I) Socio-Demographic and Clinical Data of Geriatric Cancer Patients Undergoing Modified Radical Mastectomy Structured Interview Schedule.
This tool was developed by the researcher to collect the required data from the female geriatric patient’s and from their medical records it included two parts, the collected data was related to socio demographic data as age, marital status, educational level and the clinical data of the female geriatric patient’s such as the date of admission, family history of breast cancer, past and present medical history and medication received.
Tool (II): Early Post Modified Radical Mastectomy Complications Checklist:
This tool was developed by the researcher based on relevant literature to monitor presence or absence of early post-operative modified radical mastectomy complications such as (seroma formation, lymphedema, wound infection, parasthesia, hematoma, hemorrhage, flap necrosis and deep vein thrombosis) was obtained from patient’s record during follow up period. Each statement was score 0 or 1; while, zero (0) for no presence and (1) for yes presence.
Tool (III): Colored Analogue Pain Assessment Scale (CAS).
The colored version of the visual analogue pain assessment scale was used to assess geriatric patients’ pain severity. It rated from 1 to 10 cm where zero (0) indicates no pain and ten (10) indicates the worst pain.
Tool (ΙV): Visual Analog Scale (VAS) for Anxiety.
The visual analog scale (VAS) for anxiety was used to measure the patient’s state of anxiety. It consists of a 100- mm horizontal line. The maximum score on the scale is 10. A score from zero (0) to less than 2 indicates ”not at all anxious”, a score from 2 to less than 4 indicates ”mild anxiety”, a score from 4 to less than 6 indicates ”moderate anxiety”, a score from 6 to less than 8 indicates ”severe anxiety” and a score from 8 to less than 10 indicates ”extreme anxiety or panic”.
Tool (V): Knowledge and Self-Care Practices of Post-operative Modified Radical Mastectomy Geriatric Patients Structured Interview Schedule:
This tool was developed by the researcher after reviewing of relevant literature to evaluate the geriatric cancer patient’s pre and post mastectomy knowledge and self-care practice and it was used for both groups. It consisted of two parts: first part knowledge of Post-operative Modified Radical Mastectomy Geriatric patients, items were scored from 0 to 1. The total score was adjusted from 0 to 100.Second part was Self-Care Practices of Post-operative Modified Radical Mastectomy Geriatric patients. Items were scored using a 5-point Likert scale in terms of frequency as the following: 5 for frequently and 1 for it never occurred to me. The total score was adjusted from 0 to 100.
Method
1. The necessary approvals were obtained from responsible authorities.
2. Tool I (Socio-Demographic and Clinical Data of Geriatric Cancer Patients Undergoing Modified Radical Mastectomy Structured Interview Schedule, tool II (Early Post Modified Radical Mastectomy Complications Checklist), and tool V (Knowledge and Self-Care Practices of Post-operative Modified Radical Mastectomy Geriatric Patients Structured Interview Schedule) were developed by the researcher based on relevant literature.
3. Tools I, tool II and tool V was tested for content validity by five experts in the related fields of the study namely Gerontological Nursing, Community nursing, and Medical Surgical Nursing and the required modifications were carried out accordingly.
4. The Arabic version of tool III (Colored Visual Analogue Scale for pain) and tool IV (Visual Analog Scale (VAS) for Anxiety) were used in the study to assess the geriatric patient’s pain and anxiety level post radical mastectomy surgery.
5. A pilot study was carried out on eight female geriatric patients diagnosed with breast cancer undergoing mastectomy surgery.
6. The proposed formal nursing discharge plan was developed as a manual guideline by the researcher after review of the relevant literature. It included the general and specific objectives of the discharge plan related to the scientific contents provided to patients, pre-operative instruction and exercises, post-operative instructions, and follow up instructions and danger signs. This booklet is written in Arabic language, and entails includes detailed pictures for more clarity and to overcome prevalence of illiteracy among elderly population
7. Informed written consent was obtained from each study participant fulfilling the study criteria after they were informed about the purpose and methods of the study and they were free to withdraw from study any time without penalties.
8. Baseline assessment: In the preoperative period, female geriatric patient’s participants from both (study and control groups) were interviewed individually in order to assess their pre-baseline data such as (socio-demographic data, pain level, anxiety level and knowledge) using tool I, III, IV and part one of V.
Implementation phase:
9. The nursing formal discharge plan was implemented through individual sessions with female patient’s participants for 16 days. 3days inpatient at female surgical ward in the oncology center. In addition to, 13 days in outpatient clinic after discharge from oncology center until patients remove surgical sutures and before start receiving chemotherapy or radiotherapy”.
10. The female geriatric patient’s assigned to the control group received the routine oncology center care provided for all patients with modified radical mastectomy regardless of their age.
11. The nursing formal discharge plan was implemented through three; one session preoperatively and two sessions were held postoperatively and extended till patient discharge from the oncology center as follow:
First session: It last about 45 minutes and included items related to introduction about breast cancer, post mastectomy exercises, and post-operative complaints: such as pain, anxiety and deep vein thrombosis and measures of preventing them.
Second session: It started at zero day of operation at the end of evening shift of the same day of the surgery (7-9 pm), and took about 30 minutes to allow chance for patient to tolerate the pain, regain her ability to communicate and follow up the given instructions. This session covered items related to position, post mastectomy exercises, and instructions about warning signs that require seeking medical advices, such as high temperature, bleeding, discharge from the wound, and edema.
Third session: This session was started in the morning of the first day after surgery and continued as: (three interviews with each patient/week for a period of two weeks) each interview took about 30-45 minutes after the first day of the operation and the discharge of the patient from the hospital. This session covered items related to care of wound, diet, breast self-examination and follow up.
At the end of each session, a brief summary was given by the researcher, emphasizing the most important points in the session. A booklet illustrate activities of discharge planning was given to the female geriatric patients to support their understanding and compliance.
12. Schedule meetings at second day of operation before discharge from hospital were planned for 13 days, 3times/week for first two weeks after discharge from hospital until patients remove surgical sutures and before start receiving chemotherapy or radiotherapy with study group and control group at the outpatient follow up clinic for both groups.
13. The data collection covered a period of 5 months from the beginning of February until July 2019.
Evaluation Phase: After 14 days from the operation date, the researcher interviewed geriatric patients in the study group and control group evaluate the occurrence of early post-operative mastectomy complications by using the study tools; II, III and IV. In addition, geriatric patients from the both groups were evaluated regarding their knowledge and adherence to self-care activities after mastectomy by using tool V.
Statistical analysis:
Data was analyzed using PC with statistical package for social science (SPSS) version 20. The 0.05 level was used as the cutoff value for statistical significance and the following statistical measures were used: Descriptive statistics such as Count and percentage and Arithmetic mean (X) and standard deviation (SD). Analytical statistics which include, Chi test (χ2) and Student t-test of significance.
Results
The main results obtained were as follows:
Part (I): Socio-demographic and health profile of the studied elders undergoing modified radical mastectomy.
1) The age of the patients ranged from 60- 75 years with a mean of 71.15±3.457 years. The material status 42.5% of the study groups were married compared to 52.5% of the controls group.
2) The level of education was as follow, 22.5% of the study group 17.5% of the control group where illiterate, on the other hand, those with University education constituted 10.0%, 5.0 % among the study group and is a control group respectively.
3) The main health problems were: Diabetes mellitus is the most common reported disease among the total subjects. It was reported by 36.7% of the study and 60.0% of the control groups, followed by heart diseases 50.0% and 28.0% of the study and control groups respectively. None of the subjects in the study group and only 4.0% in the control group reported having gout.
4) It is observed that, positive family history of cancer was found especially among first degree related relatives 50.0%the study group and 55.6% for the control group, and those who reported positive family history of cancer among second degree related relatives constituted 50.0% of the study and 44.4% control group respectively.
Part (II): Effect of the discharge plan on the studied elders undergoing modified radical mastectomy.
1) In relation total knowledge level about breast cancer in the pre-operative phase and post-operative phase. 100% of both the study and the control group had total poor knowledge regarding breast cancer with M ± SD in study group 2.62±1.43 compared to 2.08±1.39 in control group. No statistically significant differences between them (p= 0.084). On the other hand, 90.0% of the study had good total knowledge compared to only 2.5% of the control group with a statistically significant differences between the two group (p= 0.000).
2) Concerning the lymph Odem and tingling pain were experienced by 7.5% of the study group, while hematoma and fluid collection at wound site were experienced by 12.5% of them. On the other hand, lymph Odem and tingling pain were experience by the same percentage of the control group 75.5%, while hematoma and fluid collection were reported by 62.5% and 47.5% of the control group respectively. A statistically significant differences between two groups (p= 0.000).
3) In relation to the severity of pain, the mean score for severity of pain after of the discharge plan with a mean score of 3.130±0.822 for the study group compared to 7.750±1.891for the control group. There is a statistically significant differences between two means P= 0.000
4) The mean anxiety level was found of the study group is 2.780±0.768after the discharge and it is 6.901±1.997for the control group with a statistically significant differences between two means is p= 0.000.
5) In relation to the self-care practices, the study group has higher mean scores than the control group in relation to all the studied dimensions as well as the total score of the self-care practices. The differences are statistically significant in all studied items p= 0.000.
Part (III): Relation between socio-demographic and health profile of the studied elders undergoing modified radical mastectomy and their level of knowledge and self-care practices.
1. No significant relation was found between levels of knowledge after implementation of discharge plan and age, marital status, living arrangement, place of residence, income sufficiency, having health problems, previous hospitalization, Family history of cancer, and duration of the disease (months).
2. Significant relationship was found between levels of knowledge after the implementation of the discharge plan and level of education and Prior knowledge about breast cancer.
3. Significant relationship was found between the levels of self-care practices after implementation of discharge plan and age.
4. No significant relation was found between the levels of self-care practices after implementation of discharge plan and place of residence, level of education, income sufficiency, having health problems, previous hospitalization; family history of cancer, prior knowledge of breast cancer, and duration of the disease.
5. The relation between self-care practices and their anxiety level, pain level, knowledge level, and complications after implementation of the discharge plan. The result reveals that, higher self-care practice mean score was more encountered among those with no complications 355.57±8.406 those women with mild pain 356.79±8.669, those with mild anxiety 356.75±7.402 and for women those with good level of knowledge 360.25±5.737.
Conclusion
Based on the findings of the present study, it can be concluded that nursing discharge plan that was implemented for geriatric patients with mastectomy is necessary to control early pot operative complications and increase women’s awareness about the importance of self-care practices and adherence to follow the schedule of checkup. Support and care during the post-operative period help decrease anxiety and emotional disturbances of geriatric women with mastectomy.
The main recommendations were:
1) In service training program to nurses working with geriatric female patients with breast cancer undergoing modified radical mastectomy about the importance and component of the discharge plan.
2) Hand out of printed booklet should done and given to each geriatric female patients admitted to the hospital for mastectomy, this booklet will illustrate the components of the emphasizing measures to be adopted in the preoperative and postoperative period.
3) A prospective study to determine the effect of discharge plan on recovering postoperative complications after six months may help in clarifying the importance and necessity of such plan.