الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
SUMMARY
Recently in 2023, American Cancer Society estimates about 43, 720 new cases of thyroid cancer (12, 540 in men and 31,180 in women), about 2,120 deaths from thyroid cancer (970 in men and 1,150 in women), Thyroid cancer is often diagnosed at a younger age than most other adult cancers. The average age when a person is diagnosed with thyroid cancer is 51. This cancer is about 3 times more common in women than in men, and it is about 70% more common in White people than in Black people, who have the lowest rate (American Cancer Society, 2023).
In this regard, post-thyroidectomy neck hematoma is a matter of concern for surgeons since it can lead to severe and life-threatening complications. In fact, bleeding during thyroidectomy causes serious damages to the laryngeal nerve and parathyroid glands. Finally, accurate homeostasis is of most importance in the prevention of postoperative hematoma; moreover, it is highly important in all surgical procedures. Nevertheless, the head and neck are particularly sensitive to bleeding due to high vascularity in these areas and are prone to hematoma formation which leads to severe consequences, such as airway obstruction, respiratory distress, or even death from suffocation (Patel et al., 2020).
Early airway obstruction with acute respiratory distress is a rare but life-threatening complication after total thyroidectomy. It could be a potential result of some well-known postoperative complications: recurrent laryngeal nerve injury, especially bilateral, with vocal cord paralysis and tracheomalacia. usually, they are seen after the operation and tracheal extubation. The immediate patient’s management consists of reintubation with or without tracheostomy, followed by definitive treatment. In comparison, delayed airway obstruction, presenting even days after is due to unexpected events, like tracheal compression because of postoperative neck oedema, inflammation or hemorrhage. These delayed postoperative patient falls, though infrequent, are possible and unexpected, which represent a critical emergency (Belitova et al., 2023).
Nurses play an important role in immediate post-anesthesia, nursing care focuses on maintaining ventilation and circulation, monitoring oxygenation and level of consciousness, preventing shock, and managing pain. Following thyroidectomy, the nurse should give the patient the appropriate position, as the body’s position affects oxygenation and hemodynamics such as (heart rate, systolic and diastolic blood pressure). The effect of the position given to patients following thyroidectomy is important, as early detection and rapid response are key to ensure safe nursing practice and positive outcomes (Moyer & Naglier 2020).
The aim of this study was to:
Evaluate the effect of different degrees of head-of-bed elevation on the patients’ respiratory pattern and drainage following thyroidectomy.
Research hypothesis:
The current study hypothesized that:
The different degrees of head-of-bed elevation may have positive effects on patients’ respiratory pattern and drainage following thyroidectomy.
Research design:
A quasi- experimental design; It was used to achieve the aim of the present study. quasi- experimental design is an empirical study used to estimate the causal impact of an intervention on its target population. (Neves & Daniel 2020).
Setting:
The study was conducted in endocrine surgical department at Eldemerdash general surgical hospital, affiliated to Ain Shams University Hospitals.
Subjects:
A purposive sample of 90 patients was selected from the previously mentioned setting.
Tools of data collection:
Two tools for data collection were used to conduct this study as following:
Tool I: Patients’ demographic and medical data form (Appendix I);
This tool was developed by the investigator based on extensive review of relevant and recent literature (Yüksel et al., 2020 & Khazaei et al., 2021) and consisted of two parts as follow: -
Part (1): Demographic characteristics of patients: This part composed of (5) items used to assess the patient’s demographic data such as; gender, age, marital status, level of education, and occupation.
Part (2): Medical data: This part was used to obtain general appearance including 3items (weight, height & BMI) present medical history including 7 items (medical diagnosis, signs and symptoms, date of surgery, medication received for thyroidectomy, type of surgery source of information about proper position post thyroidectomy and the proper position postthyroidectomy), past medical history including 3 items (previous hospitalization,previous chronic illness and past surgery) and family history including 1item.
Tool II: Patients’ outcome parameters assessment form (Appendix II).
It was developed by the investigator based on extensive recent literature review (Amir et al., 2010, Promberger et al., 2012, Terris et al., 2013 & Flenady et al., 2017). It was included the following outcome parameters;
Part (I): respiratory pattern related parameter including the following components; 1-measuring Vital signs (Temp, Bp, Rr, Hr). 2- Monitoring oxygen saturation by pulse oximeter (Spo2). 3- Auscultateing breath sound. 4- Monitoring signs and symptoms of respiratory distress. 5- Assessing level of consciousness by glasgow coma scale scoring its components (Eye Opening, Verbal Response & Motor Response).
Part (II) postoperative hemorrhage and hematoma formation related parameter including: 1- Monitoring signs and symptoms of shock that indicate postoperative hemorrhage. 2- checking the amount of drainage in hemovace or redivace drain suction bottle was recorded to evaluate postoperative hemorrhage (POH). by monitoring the following symptoms including (red drainage, bleeding from incision and the accumulation of more than 150 ml per hour drainage in the suction bottle).
As well as, evaluating hematoma formation was by monitoring warning signs such as progressive neck swelling, hypoxia, tachycardia, dyspnea and stridor. 3- Checking Color of drainage (Exudate type). 4- Checking exudate amount. 5- Monitoring exudate odor. 6- Assessing patency of drainage. 7- Observeing bleeding from incision siet (wound dressing). 8- Observeing Skin color surrounding wound. 9- Assessing (Neck pain/incisional pain) characteristics.10-Assessing nonverbal signs of pain.
Besides,11-monitoring warning signs of hematoma formation. 12- Assessing dyspnea severity level by (5) points likert scale (5PLS) dyspnea, adopted from. Weber et al. (2014) and ranged from (1) absence of dyspnea, (2) Mild shortness of breath, (3) Moderate shortness of breath, (4) Severe shortness of breath and (5) The worst possible shortness of breath. These parameters were evaluated at the 1st, 2nd, 3rd and 4th hrs.
Tools validity and reliability
Tools validity was tested through a jury of (7) experts (2 professors, 3 assistant professors, 2 lecturers) in medical surgical nursing department. The experts reviewed the tools for clarity, relevance, comprehensiveness, understanding and applicability, minor modifications were done.
Reliability was tested statistically for the developed tools using Cronbach’s coefficient alpha statistical tests for measuring internal conitency of the used tools. Reliability value of (Tool I) patients demographic and medical data form was 0.821 and reliability value of (Tool II) part A namely respiratory pattern outcome parameter was 0.707. and reliability value of (Tool II) part B namely postoperative hemorrhage and hematoma formation outcome parameters was 0.824.
Pilot Study:
A pilot study was carried out on 10% of the studied subjects (9 patients) to assess the clarity, feasibility, applicability and the time needed for filling data collection tools. Minor modifications on the tools were done after pilot study so that, the patients were included in the main study group.
Ethical considerations informal and legal consent
The ethical research considerations in the study included the following:
The investigator approval was obtained from the ethical committee in the faculty of nursing before starting the study.
The investigator was clarifying the objective and aim of the study to patients included in the study.
The investigator assured maintaining anonymity and confidentiality of subjects’ data included in the study.
Patients were informed that they were allowed choosing to participate or not in the study and that they had the right to withdraw from the study at any time.
Fieldwork:
It was included three phases:
I – Preparation phase:
The purpose of the study was simply explained to patients who agreed to participate in the study prior to any data collection. Data was collected within 6 months from 19-12-2022 to 19-6-2023. The investigator was visited the selected setting 2 days/week during morning shift (from 8am to 2pm) until the required study subjects needed number in each group was completed.
II – Implementation Phase:
The eligible patients placed in one of 3 assigned groups by the investigator and under the surgeon supervision. The degree of HOBE arranged by investigator as soon as the patients transferred to the surgical ward at the selected setting from operating theatre following thyroiedectomy were randomly assigned to one of 3 groups; control group: base line supine /flat position (group 1) and study groups: semi-fowler 30° HOBE (group 2) & 45°HOBE (group 3) by applying standard positing guidelines and taking into consideration the following proper alignment based on relevant literatures by adjusting bed elevation angles accordingly.
Assessment of demographic & medical data (Tool l) for each patient in different groups was fulfilled by investigator & it took about 5 minutes. After that, each patient post thyroidectomy was observed by the investigator to fulfill respiratory pattern outcome parameter assessment form (tool II) & took about 25-30 minutes. Around 2 patients were followed by investigator in each visit at the 1st , 2nd , 3rd and 4th hrs following thyroidectomy.
III – Evaluation phase:
Evaluating effect of different degree of head of bed elevation on patients’ respiratory pattern following thyroidectomy was done by comparing the results of previous mentioned data collection Tool (II) at the 1st , 2nd 3rd and 4th hrs among the patients in different 3 groups.
Results:
The results of this study revealed the following:
There were statistically significant differences between 3 groups regarding respiratory pattern outcome parameter total mean score in 1st ,2nd & 4th hrs at p–value < 0,001 in 3rd hr at p-value <0.05.
There were statistically significant differences between 3 groups regarding to postoperative hemorrhage and hematoma formation total mean score in 1st ,2nd ,3rd and 4th hrs at p–value < 0,001.
There was statistical significant relation between respiratory pattern outcome parameter total score among the studied patients in groups (1) p<0.05 & (2) p<0.01 and their BMI, While ,there were no statistical significant relation with age, gender, educational level, occupation, and marital status among the studied patients in all three groups at p- value >0.05 .
There was highly statistically significant relation between respiratory pattern outcome parameters total score in group 1 in 2nd hr and medication received for thyroid disease & proper position post thyroidectomy at p- value <0.007.
Also, there was highly statistically significant relation between respiratory pattern outcome parameter total score in group 2 in 2nd hr and type of present surgery at p- value <0.008. As well as, there were highly statistically significant relation between respiratory pattern outcome parameter total score in group 3 in 2nd hr and medication received for thyroid disease & type of present surgery at p-value >0.003, and proper position post thyroidectomy at p- value <0.018.
There was statistically significant relation between respiratory pattern outcome parameter total score in group 1 in 2nd hr and the previous chronic illness at p- value <0.026.
There was statistically significant relation between respiratory pattern outcome parameter total score in group 2 in 2nd hr and previous surgery at p- value <0.014. There was no statistically significant relation between respiratory pattern outcome parameter total score in group 3 and past history at p- value >0.05.
Shows that there was statistically significant relation between postoperative hemorrhage and hematoma formation outcome parameter total score in group 1 & gender and BMI at p- value 0.016, &0.023 respectively. Also, here were highly statistically significant relation between the above-mentioned parameter total score in group 2 and marital status & BMI at p- value <0.001. As well as, there was statistically significant relation between the above-mentioned parameter total score in group 3 and education level at p- value <0.031.
There was highly statistically significant relation between postoperative hemorrhage and hematoma formation outcome parameter total score and source of information about proper position post thyroidectomy at p- value <0.001 in groups 1 and 2 in 2nd hr.
Also, there were statistically significant relation between the above-mentioned parameter total score in group 2 and medical diagnosis & signs& symptoms at p- value <0.015, &0.021 respectively in 2nd hr.
Additionally, there was highly statistical significant relation between the above mentioned parameter total score in group 3 and proper position post thyroidectomy in 2nd hr at p- value <0.003, while, there were no statistical significant relation in group 3 with medical diagnosis and signs& symptoms, medication recorded for thyroid disease, type of present surgery, and source of information at p-value >0.05.
Shows that there was statistically significant relation between postoperative hemorrhage and hematoma formation outcome parameter total score and previous chronic illness among the studied patients’ in group 1 at p- value 0.013 in 2nd hr. Besides, there were statistically significant relation between the above-mentioned parameter total score & previous hospitalization & previous surgery at p- value <0.001and 0.002 respectively in 2nd hr. Additionally, there were statistically significant relation between above mentioned parameter total score in group 3 and previous chronic illness & previous surgery at p- value 0.020 and 0.018 respectively in 2nd hr.
Finally, there were highly statistically significant correlation between total score of respiratory pattern outcome parameter and post operative hemorrhage and hematoma formation outcome parameter among the studied patients in different groups in 2nd ,3rd ,4th hrs p<0.001.
Conclusion::
Based on the finding of the current study, it can be concluded that:
Different degrees of HOB Elevation had highly statistical significant positive effect on patients’ outcome parameters, including respiratory pattern and postoperative hemorrhage and hematoma formation outcome parameters during the first 4 hrs following thyroidectomy namely semi-fowler position 45 degree,Whereas highest percentage of the patients on semi-fowler 45 degree in groups 3 had good outcome regarding the above stated parameters versus other groups which supported the stated study hypothesis.
As well as, there was highly statistically significant correlation between total scores of respiratory pattern outcome parameter and post operative hemorrhage and hematoma formation outcome parameters among the studied patients in different groups in 2nd ,3rd ,4th hrs following thyroidectomy p<0.001.
Recommendations:
The results of this study projected the following recommendations:
1- Applying the appropriate position taking into consideration patients’ tolerance and health condition as well as integrating it into the standarized care to provide suggestion for evidence-based clinical practice for nurses for ensuring safety, and positive outcome on patients’ respiratory patterns and drainage following thyroidectomy.
2- Health education program is essential for patints under- going thyroidectomy regarding the standarized care to achieve positive outcome parameter under study.
3- Simple Arabic patients information leaflet / brochures or booklet should be available to encourage participation in their health care for improving the studied outcome parameter following thyroidectomy.
4- Further study is needed to evaluate the efficacy of different degree of HOBE on patients’ outcomes parameters following thyroidectomy using objective measures, as well as, morbidity and mortality rate.
5- Replication of study with a large number of patients in different settings as well as along period of study time should be conducted to support the study results.
6- Further research is recommended to investigate other factors affecting the studied patients’outcomes parameters following thyroidectomy.