nfralick
Fri, 10/28/2022 - 00:27
Edited Text
Post-operat i ve
educa t ionaI pamphIe t
for hysterectomy
patients / by Stacy
L. Kowalczyk.
Thesis Nurs. 1999 K88p
A POST-OPERATIVE EDUCATIONAL PAMPHLET
FOR HYSTERECTOMY PATIENTS
by
Stacy L. Kowalczyk, BSN, RN
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Edinboro University of Pennsylvania
Approved by:
Alice Conway, PhD, Rl^y
Committee Chairperson
Mary L6u Keller, PhD; CRNP
Committee Member
Date/7
4)ate
u
■'
ii
Table of Contents
Content
Page
Chapter 1. Introduction..
1
Background of the Problem,
1
Statement of the Problem
2
Statement of the Purpose
3
Assumptions
3
Limitations
3
Definitions of Terms
3
Theoretical Framework,
4
Summary,
5
Chapter 2. Review of Literature
6
Introduction
6
Female Reproductive Anatomy.
6
Factors Influencing Need for Hysterectomy.
7
Types of Hysterectomy.
8
Post-operative Aspects and Expectations
Written Patient Educational Materials.
12
Printed Educational Materials Development,
12
Summary,
13
Chapter 3. Methodology....
Introduction...
Project Design and Procedures,
14
iii
Summary....
Chapter 4. Results
15
16
Demographics
16
Pilot Study Results.
16
Description of the Pamphlet.
17
Summary.
18
Pamphlet
19
References
22
1
Chapter 1
Introduction
This chapter provides an overview of the need for improved educational material
for women undergoing hysterectomy. Dorothea Orem’s (1991) self-care deficit theory of
nursing is utilized as the theoretical framework for this project and is described.
Assumptions, limitations, and definition of terms are also provided.
Background of the Problem
Hystei ectomy, the removal of the uterus, is one of the most common surgical
piocedures perfoimed; after cesarean delivery, it is the second most frequently performed
major surgical procedure in the U. S. Approximately 75% of all hysterectomies are
performed in women between the ages of 20 and 49 years. The highest overall rate is in
the southern states with the lowest rates consistently in the northeastern portion of the
U. S. Hysterectomy is more often performed in African-Americans than in Caucausians
and is more frequently performed by male gynecologists than female gynecologists. One
in five women in the United Kingdom will have a hysterectomy by the time they reach the
age of sixty-five (Chapple, 1995). Hysterectomy is often the last resort for women
suffering from problems affecting the uterus. The most common problems include:
uterine fibroids, cancer, abnormal uterine bleeding, pain and endometriosis. A lot of
effort is made by the patient and her health care provider to avoid unnecessary surgery.
Once the decision for hysterectomy is made it is important for the woman to understand
the surgery and its risks as well as what is to be expected after surgery (Berek, Adashi, &
Hillard, 1996).
Women undergoing hysterectomy require special education and emotional support
(Dulaney, Crawford, & Turner, 1990). A study of social support for women undergoing
hysterectomy revealed women’s need for basic information and their desire to obtain it
from their caregivers (Webb, 1986). This study involved two groups of women. One
group received information prior to surgery the other group did not. The group receiving
2
information was less hostile but more critical of their treatment, but overall had higher
levels of satisfaction (Webb, 1986). Patients are often best informed about risks of
surgery and least about the post-operative treatment and healing (Ebert-Hampel, &
Holzle, 1983). Information about post-operative treatments and expectations from the
patient are often not mentioned to the patient at all. Many women go into surgery without
realizing their need to take an active part in the recovery process (Dulanley et al., 1990).
With insurance companies dictating shorter length of stay for surgical patients, women
who have had hysterectomies are often rudely awakened to the fact that they cannot stay
in the hospital as long as expected (Dulaney et al, 1990). Because they are not informed
before the operation about information such as length of stay, they often become resentful
of the health care providers for making them leave when they believe they are not ready.
Many women feel that they are being pushed out of the hospital (Dulaney et al., 1990).
Nurses have concluded that lack of information and erroneous information play a
major role in post-operative problems (Dulaney et al., 1990). A study showed that
women, who have received adequate information prior to surgery, reported generally high
levels of satisfaction, health and resumption of activities after hysterectomy (Webb,
1986). Findings have also shown that patients, who are given pre-operative instructions,
performed at a significantly higher level (Williams et al., 1988). They required neither
prompting, nor assistance in the initiation and completion of tasks compared to those
patients who did not receive pre-operative instructions (Williams et al., 1988). Providing
patients having a hysterectomy with adequate information may help to decrease patient
anxiety, improve patient outcomes, increase satisfaction of stay, decrease length of stay
and provide motivation for the patient to actively participate in her recovery.
Statement of the Problem
Although more and more women are undergoing hysterectomies and studies have
shown improvement of activities after receiving information poor to surgery, written
information for these patients is given a relatively low priority (Scriven & Tucker, 1997).
3
Statement of the Purpose
purpose of this study was to design a pamphlet to educate women undergoing
hysterectomy about their post-operative course; in order to improve recoveiy and
facilitate satisfaction of stay.
Assumptions
The assumptions of this study were as follows:
1. There is a need for post-operative education for women undergoing
hysterectomy.
2. Current information provided by women’s health care providers is not
adequate.
3. Information provided to patients prior to hysterectomy will lead to improved
patient outcomes in recovery, both in the hospital and at home, and will increase
satisfaction of stay.
Limitations
The usefullness of the pamphlet is limited to patients who are able to read and
understand the pamphlet and patients who are interested in the pamphlet. It is also
limited by lack of participation from women’s health care providers in providing
information to their patients.
Definition of Terms
The terms utilized in this study are defined as follows:
1. Hysterectomy is the surgical removal of the uterus (Berek et al., 1996).
2. Fibroids are noncancerous growths that form on the inside of the uterus, on its
outer surface, or within the uterine wall itself (American College of Obstetricians and
Gynecologists [ACOG], 1995).
3. Uterus is the muscular organ that is located in the female pelvis and contains
and nourishes the developing embtyo and fetus during pregnancy (ACOG, 1995).
4
4. Endometriosis is a condition in which tissue similar to that normally lining the
uterus is found outside of the uterus, usually in the ovaries, fallopian tubes, and other
pelvic structures (ACOG, 1995).
5. Abnormal uterine bleeding is any bleeding pattern that differs in frequency,
duration, or amount from the pattern observed during a normal menstrual cycle
(Braunwald et al., 1987).
6. Salpingo-oophrectomy is the removal of one or both of the ovaries and
fallopian tubes (ACOG, 1995).
7.
Wertheims or radical hysterectomy is the removal of the uterus, cervix, part
of the vagina, fallopian tubes, peritoneum, the lymph glands and fatty tissue of the pelvis
and possibly one or both ovaries (Newall, 1998).
8. Peritoneum is the broad band of ligament below the uterus (Newall, 1998).
Theoretical Framework
The theoretical framework for this study was based on Dorothea Orem’s (1991)
self-care deficit theory. Orem (1991) states that the individual’s ability to initiate and
perform activities to meet their health needs is self-care. Self-care agency is described by
Orem (1991) as the ability to engage in self-care. Self-care agency is necessary for
self-care (Orem, 1991).
Orem (1991) also believes that nursing’s role is to help people meet their own
therapeutic self-care demands. There are three types of nursing systems according to
Orem (1991): wholly compensatory, partially compensatory, and supportive-educative.
This study focuses on the supportive-educative system. The nurse or health care provider
functioning in this system assists the patient in acquiring skills and knowledge. The
hysterectomy patient has a self-care deficit due to lack of knowledge about the surgery.
The nurse practioner functions in the supportive-educative role by providing the patient
with oral as well as written information, via the pamphlet, to the patient. The pamphlet is
used to help the patient reach her self-care demand and resolve her self-care deficit.
5
Summary
Many women in today’s society will undergo hysterectomy (Berek et al., 1996).
The information given to these women prior to surgery is an important factor in positive
outcomes after surgery (Webb, 1986). These women are often provided with information
about the female body, uterine abnormalities, reasons for surgery and the surgery itself,
but are rarely supplied with information about expectations following surgery
(Ebert-Hampel, & Holzle, 1983). This study was intended to provide a pamphlet for
women prior to hysterectomy to inform them of these post-operative expectations.
Dorothea Orem’s (1991) theory provided support to this study. It emphasized the
importance of the supportive-educative role of health care providers in helping to
promote and support self-care. Providing these women with information they can use to
perform self-care and meet their own therapeutic self-care demands was an important
aspect in a positive hysterectomy experience.
The terms used in this study were defined. The limitations and assumptions were
provided.
6
Chapter 2
Review of Literature
Introduction
The purpose of this project was to design and construct a post-operative
educational pamphlet for hysterectomy patients. The material in the pamphlet pertained
to both vaginal and abdominal hysterectomies.
This literature review addressed female reproductive anatomy and factors
influencing the need for a hysterectomy. It included types of hysterectomies and
post-operative aspects and expectations. Finally, this review examined the literature on
constructing written patient education materials.
Female Reproductive Anatomy
The female reproductive anatomy consists of the vagina, the cervix, the uterus, the
fallopian tubes and the ovaries (Seidel, Ball, Dains, & Benedict, 1995). The vagina is a
muscular tube that carries menstrual flow from the uterus, serves as the terminal portion
of the birth canal, and is the receptive organ for the penis during sexual intercourse
(Seidel et al., 1995). The vagina typically remains unchanged after hysterectomy (Berek
et al., 1996). The uterus opens into the vagina by way of the cervix (Seidel et al., 1995).
The cervix may or may not be removed during hysterectomy depending on the type
performed (Berek et al., 1996). The uterus, a muscular organ in the pelvis, is always
removed during hysterectomy (Berek et al., 1996).
The fallopian tubes are responsible for the transportation of the ovum (egg) to the
uterus (Seidel et al., 1995). The fallopian tubes may or may not be removed during
surgery depending on the type performed (Berek et al., 1996).
The ovaries are a pair of oval organs that secrete estrogen and progesterone and
are responsible for controlling the menstrual cycle and supporting pregnancy (Seidel et
al., 1995). The ovaries may be left untouched or may be removed during surgery
depending on the type being performed (Berek et al., 1996)
7
Factors Influencing Need for Hysterectomy
Hysterectomy may be performed to treat conditions that can affect the uterus
(Berek et al, 1996). These conditions may be treated with medical or surgical
intervention. Hysterectomy is often considered as a last resort treatment for many of
these conditions (Berek et al., 1996).
Uterine fibroids are the most common type of benign uterine tumors and are the
leading indication for hysterectomy (Berek et al., 1996). They are estimated to be present
in at least 20% of all women of reproductive age. They are more common in
African-American women than in Caucasians (Berek et al., 1996). Fibroids that don’t
cause symptoms may be present in 40-50% of women older than 40 years of age. One or
many may be present (Berek et al., 1996). They can cause symptoms from pelvic
pressure to irregular or heavy bleeding from the lining of the uterus with fewer than
one-half producing symptoms at all (Berek et al., 1996). The most common presenting
symptom associated with fibroids and the one that most frequently leads to surgical
intervention is heavy bleeding (Berek et al., 1996). If nonsurgical treatment such as
hormone therapy or removal of the fibroids is not effective, a hysterectomy may need to
be performed (Berek et al., 1996).
Another reason for hysterectomy is cervical cancer. It may also be performed due
to cancer of the lining of the uterus and the ovaries (Berek et al, 1996). Patients who do
not respond to treatment with chemotherapy or radiation are advised to have a
hysterectomy (Berek et al., 1996).
Abnormal uterine bleeding is bleeding for which no specific cause has been found
(Berek et al.. 1996). Abnormal uterine bleeding may be caused by fibroids or hormonal
changes, infection of the uterus or by cancer (Berek et al.. 1996). There are many ways to
treat abnormal uterine bleeding. Hysterectomy may be an option if nonsurgrcal
treatments don’t work (Berek et al., 1996).
8
Pelvic pain encompasses a large proportion of gynecologic complaints and is
among the most challenging to treat (Berek et al., 1996). There are many possible causes
for pelvic pain and treatment is dependent on the cause (Berek et al., 1996). Treatments
vary from observation, to antibiotics, to surgical intervention such as hysterectomy (Berek
et al., 1996).
Endometriosis may cause scarring, adhesions, and pain (Berek et al., 1996). It is
often treated by the least invasive method first, such as hormones, but in severe cases
hysterectomy is advised (Berek et al., 1996).
Types of Hysterectomies
There are four types of hysterectomies: a subtotal or partial hysterectomy, a total
or complete hysterectomy, a total hysterectomy with bilateral or unilateral
salpingoophrectomy, and a radical or “Wertheim’s” hysterectomy (Newall, 1998). The
type of hysterectomy depends upon the condition it is being used to treat (Newall, 1998).
A subtotal or partial hysterectomy removes the uterus, but the cervix is left in
place (Newall, 1998). A total or complete hysterectomy removes the entire uterus
including the cervix. This is the operation most commonly performed (Newall, 1998). A
total hysterectomy with bilateral or unilateral salpingoophrectomy removes the uterus,
cervix, fallopian tubes and one or both of the ovaries (Newall, 1998). Finally, a radical or
“Wertheim’s” hysterectomy removes the uterus, cervix, part of the vagina, fallopian
tubes, peritoneum, the lymph glands and fatty tissue of the pelvis, and possibly one or
both ovaries (Newall, 1998).
There are two main ways to perform a hysterectomy. The most common way is to
remove the uterus through a cut in the lower abdomen or an abdominal hysterectomy
(Newall, 1998). The second, less common, way is to remove the uterus only through a
cut in the top of the vagina or a vaginal hysterectomy (Newall, 1998).
9
Postoperative Aspects and Expectations
The usual post-operative course should be discussed in enough detail
pre-operatively to allow the patient to understand what to expect in the days following
surgery (Berek et al., 1996). The successful outcome of gynecologic surgeiy is based on
thorough evaluation, pre-operative preparation and careful post-operative management of
the patient (Berek et al., 1996). Written information for patients is given a relatively low
priority (Seriven & Tucker, 1997).
A research study was conducted focusing on whether a program of pre-operative
teaching and post-operative rehabilitation/discharge planning would promote optimum
post-operative self-care among women who had undergone mastectomy and hysterectomy
at two points in time: immediately after surgery, and at one month after surgery
(Williams et al., 1998). Sixty adult female surgical patients, 30 mastectomy and 30
hysterectomy, were equally divided into an experimental and control group. The
independent variable, structured teaching, was administered by a nurse clinician before
and after surgery. There were two sets of structured teaching programs. One for each
group, hysterectomy and mastectomy. The hysterectomy patients on their first contact
with the nurse were given a checklist of their knowledge about the surgery, given a
simple explanation of the anatomy and physiology of the uterus and a simple explanation
of surgery including physical preparation, incision, dressing, foley catheter, IVs, diet and
ambulation exercise. On their second visit with the nurse they discussed clinic visits and
home activities (do’s and dont's). The control group did not receive these instructions
(Williams et al., 199S). The dependent variable, self-care, during the immediate
post-operative period, was defined as the performance of three ambulation tasks on day
one. Task performance was rated on three criteria: time interval, amount of prompting
and amount of assistance required for the first complete performance (as demonstrated
and practiced pre-operatively) of each exercise (Williams, et al. 1998). Effects of the
nursing intervention were measured immediately after surgery in terms of performance of
10
.mbuhtion and rehabilitation exercises; as well as one month after surgery, in terms of
performance of self-care activities at home and the incidence of complications (Williams
et al., 1998).
Dorothea Orem’s (1991) theory of self-care was used as a theoretical framework.
The supportive-educative nursing role was tested in the study. The role consisted of
pre-operative teaching and discharge planning given by a nurse clinician (Williams et al.,
1988).
Findings showed that for the in-hospital phase, patients in the group given
pre-operative instructions performed at a significantly higher level. They required neither
prompting nor assistance in the initiation and completion of ambulation tasks compared
to the uninstructed group (Williams et al., 1998). During the clinic visit one month after
surgery, instructed patients reported performing self-care activities at home significantly
better than and more frequently than the control or uninstructed group (Williams et al.,
1998). The results of the study showed favorable effects of pre-operative teaching and
discharge planning on patients performance of essential post-operative tasks, such as
ambulation and rehabilitation exercises, and on reported self-care at home. The nurse’s
or clinician’s role in patient-teaching cannot be over-emphasized . The results of the
study attest to the fact that patients can be taught to assume self-care with a general sense
of responsibility for their recovery and the maintenance of their health (Williams et al.,
1988).
The length of stay in the hospital after surgery varied by the type of surgery,
usually two to three days for abdominal hysterectomy and two days for vaginal
hysterectomy (Williams et al., 1988). One can expect to have moderately-severe pain
after surgery and for several days afterward, but options for pain control such as
injections or patient controlled analgesia (PCA) will be discussed between the health care
provider and patient prior to surgery (Berek et al., 1996).
11
Early ambulation decreases the incidence of compile,,™ such as blood clots and
pneumonia (Berek et al., 1996). Patients are encouraged to begin ambulation on their
first post-operative day and increase their time out of bed progressively (Berek et ah,
1996). Movement such as sitting on the edge of the bed or walking in the hahs will also
help the patient to expell the build up of painful gas in the intestines that is a common
side effect of hysterectomy (Newall, 1998).
Post-operative care consists of many different aspects. Immediately following
surgery and for the next 18-24 hours the patient will have a catheter in the bladder to
prevent complications and to drain the bladder (Berek et al., 1996). Patients are typically
allowed ice chips only the day of surgery with resumption of diet on the first
post-operative day, assuming bowel sounds are present. Diet begins with clear liquids
and advances to solid food as the patient tolerates (Berek et al., 1996). The patient can
expect to receive IV antibiotics after surgery to prevent infection. Infections are a major
source of sickness in the post-operative period due to decreased patient mobility and lack
of deep breathing (Berek et al., 1996). The patient will be expected to perform deep
breathing exercises to promote adequate lung expansion following surgery (Newall,
1998). The patient will learn about deep breathing exercises prior to surgery and the
teaching will be reinforced by nurses and respiratory therapists after surgery. The patient
will typically experience some light to moderate vaginal bleeding after surgery, but can
expect it to gradually decrease over a few days (Newall, 1998). After the bleeding
experienced following surgery subsides, the patient can expect her periods to stop (
et al., 1996).
The patient can expect to be discharged from the hospital when specific criteria
are met (Newall, 1998). These criteria include: adequate urination, presence of bowel
sounds and expelling flatus from the body, absence of fever for 24 hours and the ability to
tolerate a regular diet (Newall, 1998).
12
Once at home the patient is advised to limit activities for four to six weeks (Berek
et ah, 1996). The patient win be restricted to less than 20 pounds of lifting, advised not
to push or pull anything for one to two weeks, avoid sexual intercourse, tampons, and
douches for four to six weeks, and will not be allowed to drive for one to two weeks
(Berek et al., 1996). The patient will be tired, but is encouraged to return to normal
activities as soon as she feels comfortable doing so (Berek et al., 1996). The patient may
experience some emotional ups and downs after surgery. This is often due to lack of
estrogen (if the ovaries are removed), the trauma of the surgery, and feelings of loss and
the awareness of no longer being able to bear children (Newall, 1998).
Sexual activity can be resumed after four to six weeks (Berek et al., 1996). Some
women may notice a change in their sexual response after hysterectomy (Berek et al.,
1996). Factors such as less intense orgasms and vaginal dryness can affect a woman’s
sexuality after hysterectomy (Newall, 1998).
Written Patient Education Materials
An essential component of comprehensive health care is education about
preventive health practices (Whitman, Graham, Gleit, and Boyd, 1992). Health care
providers have a major role in this educational process (Whitman et al., 1992).
Teaching aides such as audio-visual materials, television graphics, games,
demonstrations, and written materials are commonly used to supplement oral
communication (Whitman et al., 1992). Printed educational materials are one of the most
economical and effective instructional mediums available, and provide eff
instructional assistance in the hospital as well as at home (Bernier & Yasko,
)
Printed Educational Materials Development
There is a necessity for needs assessment, an advisee committee, a well defined
goal, and content selection based on what the patient needs to know when developing
printed materials for patient education (Lange, 19S9). Lange (1989) also empt.as.zed the
13
use of figures and diagrams for clarity of content, the repetition of key points, and the use
Of bold letters, underlining and bright colors for patient/reader interest.
Authors creating printed materials for patient education should write simply, use
as few words of more than two syllables as possible, be precise, be accurate, and involve
the reader (Mathis, 1989). The length of the material should be as short as possible, and
the size managable (Mathis, 1989).
While it is estimated that the majority of people in the U.S. read at an eigth grade
level or lower, approximately 68% of the educational materials available are written
above a ninth grade level (Doak, Doak, & Root, 1985). The SMOG Readibility Test
(McLaughlin, 1969) is often used to measure readibility of written materials. It is often
considered one of the easiest and quickest formulas to perform. The EPEM (Evaluating
Patient Education Material) model (Bernier & Yasko, 1991) can be used to evaluate
prepared materials. It serves as a comprehensive checklist. Information written at a level
appropriate to assure patient understanding, increases recall and compliance with
treatment measures (Doak et al., 1985).
Summary
To construct a post-operative educational pamphlet for hysterectomy patients it
was necessary to review the literature on female reproductive anatomy, factors
and post-operative aspects and
influencing need for hysterectomy, types of hysterectomy
was also reviewed.
expectations. The literature on written patient education mate
14
Chapter 3
Methodology
Dorothea Orem's (1991) theory of self-cate provided the theoretical framework
for this project. The EPEM model of preparing printed education materials as well as
literature on developing printed materials for patient education provided the basis for the
development of the pamphlet.
Project Design and Procedures
This project was designed using the ideas of figures and diagrams for clarity of
content, repetition of key points, use of bold letters, underlining and bright colors for
patient/reader interest (Lange, 1989). This pamphlet was written as simply, precisely, and
accurately as possible (Mathis, 1989). The pamphlet was as short as possible with the
readibility at an eighth grade level or lower (Doak et al, 1985).
The five phase EPEM model (Bernier & Yasko, 1991) for the production of
patient education materials was used to design the pamphlet. The pre-design phase
included establishing a purpose, goal, intended audience and objectives. The design
phase contained guidelines for developing content, with emphasis on organization,
motivational features, linguistics, and graphics. The pilot testing phase suggested that
professionals and patients review the materials to provide feedback so that revisions
could be made. Learning potential was maximized during the implementation and
distribution by providing the material at a time when it was needed. The evaluation phase
can be carried out on a formal or an informal basis using either a small, representati
sample of patients or a large, random sample.
The pre-design phase encompassed the design
ing of the pamphlet, the goal of the
pamphlet, the audience or focus group and the objectives,
The design phase involved
verification of content and design by gynecologists, surgical
number of post-hysterectomy patients. The implementatio
nurses, and an undetermined
id distribution phase was
15
mutually decided upon by the gynecologists involved in the design phase and the
pamphlet developer.
A pilot study was conducted on a random group of three post-hysterectomy
patients in an OB/GYN office. Participants were anonymous and comments weren’t
connected to any one participant. Participants were assigned a number to protect their
identity and provide anonymity. The patients verbally explained what they read to the
investigator, thereby acknowledging their understanding of the material. Effectiveness of
the pamphlet was determined by patient opinion of how useful the pamphlet would have
been to them had they received it pre-operatively. Overall the three patients felt that the
pamphlet would have been useful to them in their recovery if they had read it before
surgery. Patient number one felt that the pamphlet should emphasize the tremendous gas
pain one feels after hysterectomy. Patients two and three felt that the pamphlet provided
adequate information. Feedback about the likes and dislikes of the pamphlet was utilized
in the final revision of the pamphlet.
Summary
The five phase EPEM model (Bernier & Yasko, 1991) for designing and
evaluating printed educational materials was used in the construction of the pamphlet.
The literature on developing printed materials for patient education was also used.
16
Chapter 4
Results
This chapter provides the results of the scholarly project relating to the
post-operative educational pamphlet for hysterectomy patients. Demographics and results
of the pilot study are explained. The pamphlet and recommendations for future use are
also described. A post-operative educational pamphlet for hysterectomy patients was
designed to educate women undergoing hysterectomy about their post-operative course;
in order to facilitate satisfaction of stay and improve recovery.
Demographics
The content of the pamphlet was reviewed and verified by three gynecologists in a
local practice, with a total of 35 years of OB/GYN experience between them, and three
medical-surgical nurses in a local hospital. The three nurses have worked on the same
unit for over five years. This hospital unit specializes in care of women undergoing GYN
surgeries. Three post-hysterectomy patients in a local OB/GYN office were involved in
the pilot study.
Pilot Study Results
A pilot study of the post-operative educational pamphlet for hysterectomy patients
was conducted in March 1999. Three post-hysterectomy patients in a local OB/GYN
office were asked to review the pamphlet and verbally explain their likes and dislikes to
the investigator. The patients ranged in age from 45 to 65 and all were Caucasian. Two
of the patients had an abdominal hysterectomy, the third a vaginal hysterectomy. All
three patients stayed in the hospital for three days, none had complications. The patients
were seen in the office four weeks after discharge from the hospital for their follow-up
appointments. The patients were assigned a number to provide anonymity.
Feedback about the likes and dislikes of the pamphlet was written down during
the interview and was used in the final revision of the pamphlet. Patient number one had
a vaginal hysterectomy and she felt that the pamphlet should emphasize the tremendous
17
gas pain one feels after hysterectomy. Patients two and three had abdominal
hysterectomies. They felt that the pamphlet provided adequate information. All of the
patients felt that the pamphlet would have been useful to them if they had read it before
surgery.
Description of the Pamphlet
The pamphlet was designed to provide patients with specific information
regaiding post-operative expectations following hysterectomy. It focused on Dorothea
Orem s (1991) concept of self-care. The goal of the pamphlet was to make the patient
feel like she had some control over her recovery in the hospital. Williams et al (1998)
validated that patients can be taught to assume self-care when adequate information is
given prior to surgery.
The pamphlet focuses on elimination, diet, activity, pain and discharge criteria.
Information about elimination, diet and exercise was also provided to patients in
Williams et al (1998) study. The pamphlet informs patients about urinary catheters, when
they are placed and removed. Their diet as well as criteria for advancement of the diet is
explained. Examples of activity and reasons for it are described. The women in the pilot
study had not realized when they had surgery how soon they were expected to get out of
bed. Pain medication is discussed and examples are provided. The women in the pilot
study liked this idea. It gave them a chance to read about the medications before they
took them. Discharge criteria such as adequate urination, presence of bowel sounds,
flatus, absence of fever and tolerating a regular diet are provided. The women in the pilot
study also liked this part of the pamphlet. They all felt this information would have made
them more prepared when the physician discharged them.
Dorothea Orem’s (1991) self-care deficit theory was validated by the research
study conducted by Williams et al (1998). The study found that patients could be taught
to assume self-care. Orem’s (1991) theory was also supported by comments made by the
women in the pilot study.
18
Summary
This chapter provided information about demographics and the results of the pilot study.
A pilot study was necessary to provide input on the usefulness of the post-operative
educational pamphlet for hysterectomy patients. This chapter also provided a detailed
description of the pamphlet as well as recommendations for future use.
19
HYSTERECTOMY:
WHAT TO EXPECT AFTER SURGERY
A post-operative educational pamphlet
20
Hysterecomy: What To Expect After Surgery
Hysterectomy is the second most frequently performed major surgical procedure
in the United States. Hysterectomy is often performed for common problems such as
uterine fibroids, cancer, abnormal uterine bleeding, pain and endometriosis, Because this
surgery is so common it is important for you to be aware of and participate in the care you
receive post-operatively.
By now you should have discussed the surgery and reason for it
with your gynecologist. This pamphlet is designed to inform you of
post-operative procedures, treatments and expectations.
You are an important part of a positive recovery.
Your full participation and
understanding of what is expected
of you after surgery will enhance your hospital stay.
There are several important aspects to your
post-operative hospital recovery period. These
include: elimination, diet, activity and pain
ooooooo;
medications.
Immediately after surgery and for the next 18-24 hours you will have a catheter in
the bladder to prevent complications and to help urinary fluids drain away. After it
removed you will be expected to urinate in the bathroom.
You may be allowed ice chips, only, ihe day of surgery with resumplionofyour
diet on the first post-operative day. Your diet will begin with
clear liquids such as jello, juice, tea, coffee and water
and will advanceto solid food as you can tolerate.
Bowel sounds must be present for your diet to increase.
st
21
You will be encouraged to begin walking on your first post-operative day and
increase your time out of bed progressively. This will help prevent blood clots from
developing in your legs. Movement such as sitting on the edge of the bed or walking in
the halls will also help you to expell the build up of painful gas in the intestines that is a
common side effect of hysterectomy.
You will also be expected to perform deep breathing exercises to promote
adequate lung expansion to prevent pneumonia after surgery. Your
nurse will remind you to take deep breaths and change postitions
frequently.
You can expect to experience moderately-severe pain after surgery. Pain control
may be in the form of injectable narcotics such as
Demerol or pill form such as a Tylenol with
codiene.
You may be in the hospital for 2-3 days. Discharge
will depend on specific criteria. These criteria
include: adequate urination, presence of bowel sounds, and expelling gas from the body,
absence of fever for 24 hours, and the ability to tolerate a regular diet.
It is important for you to understand and actively participate in your
post-operative recovery. Your physicians and nurses will provide you with supportive
care and encouragement, but you are ultimately the one who will decide the course of
your recovery
22
References
(1995)'
Berek, J.S., Adashi, E.Y., & Hillard, P.A. (1996). Novak’s gynecology (12th ed)
Baltimore, MD: Williams & Wilkins.
Bernier, M., & Yasko, J. (1991). Designing and evaluating printed education
materials: Model and instrumentation development. Patient Education and CounselinP18.253-262.
Braunwald, E„ Isselbacher, K. J., Peterdorf, R. G., Wilson, J., Martin, J. B„ &
Fauci, A. S. (1987). Harrison’s principles of internal medicine. New York, NY:
McGraw-Hill Book Company.
Chapple, A. (1995). Hysterectomy: British National Health Services and private
patients have very different experiences. Journal of Advanced Nursing, 22, 900-6.
Doak, C., Doak, L., & Root, J. (1985). Teaching patients with low literacy skills
Philadelphia: Lippincott.
Dulaney, P.E., Crawford, V.C., & Turner, G. (1990, July/August). A
comprehensive education and support program for women experiencing hysterectomies.
Journal of Qbstectrical and Gynecological Neonatal Nursing, 12, 319-25.
Ebert-Hampel, B., & Holzle, C. (1983). Knowledge and well-being of patients
before and after preoperative findings disclosed by gynecologic surgery. Geburtshilfe.
Frauenheilkd, 43. 746-54.
Lange, J. (1989). Developing printed materials for patient education.
Dimensions of Critical Care Nursing, 8. (4), 250-259.
Mathis, D. (1989). Writing patient education materials. Orthopaedic Nursing^
(5), 39-42.
McLaughlin, H. (1969). SMOG grading-A new
Reading,J2, 639-645.
readibility formula. Journal of
Newall, L. (1998). What does the operation involve? [On-line]. Available.
http://www.hysterectomy-association.org.uk/info/hyster/operate.titm
St. Louis: Mosby Year
Orem, D. E. (1991). Nursing;
Book.
TS
Scriven, A., & Tucker, C. (1997'j The nnoi t
presented to women undergoing hyste.
,o,.TOl^eS~^y S“ia'
.
P«i«.
Whitman N Graham B, Gleit, C„ & Boyd, M (1992). Teaching in nursing
practice (2nd ed.). Norwalk, CT: Appleton & Lange.
Williams, P. D„ Valderrama, D. M„ Gloria, M. D„ Pascoquin, L. G., Saaverdra,
L. D., De la Rama, D. T., Fetty, T. C., Abaquin, C. M., & Zaldivar, S. B. (1988). Effects
of preparation for mastectomy/hysterectomy on women’s post-operative self-care
behaviors. International Journal of Nursing Studies. 25 (3), 191-206.
educa t ionaI pamphIe t
for hysterectomy
patients / by Stacy
L. Kowalczyk.
Thesis Nurs. 1999 K88p
A POST-OPERATIVE EDUCATIONAL PAMPHLET
FOR HYSTERECTOMY PATIENTS
by
Stacy L. Kowalczyk, BSN, RN
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Edinboro University of Pennsylvania
Approved by:
Alice Conway, PhD, Rl^y
Committee Chairperson
Mary L6u Keller, PhD; CRNP
Committee Member
Date/7
4)ate
u
■'
ii
Table of Contents
Content
Page
Chapter 1. Introduction..
1
Background of the Problem,
1
Statement of the Problem
2
Statement of the Purpose
3
Assumptions
3
Limitations
3
Definitions of Terms
3
Theoretical Framework,
4
Summary,
5
Chapter 2. Review of Literature
6
Introduction
6
Female Reproductive Anatomy.
6
Factors Influencing Need for Hysterectomy.
7
Types of Hysterectomy.
8
Post-operative Aspects and Expectations
Written Patient Educational Materials.
12
Printed Educational Materials Development,
12
Summary,
13
Chapter 3. Methodology....
Introduction...
Project Design and Procedures,
14
iii
Summary....
Chapter 4. Results
15
16
Demographics
16
Pilot Study Results.
16
Description of the Pamphlet.
17
Summary.
18
Pamphlet
19
References
22
1
Chapter 1
Introduction
This chapter provides an overview of the need for improved educational material
for women undergoing hysterectomy. Dorothea Orem’s (1991) self-care deficit theory of
nursing is utilized as the theoretical framework for this project and is described.
Assumptions, limitations, and definition of terms are also provided.
Background of the Problem
Hystei ectomy, the removal of the uterus, is one of the most common surgical
piocedures perfoimed; after cesarean delivery, it is the second most frequently performed
major surgical procedure in the U. S. Approximately 75% of all hysterectomies are
performed in women between the ages of 20 and 49 years. The highest overall rate is in
the southern states with the lowest rates consistently in the northeastern portion of the
U. S. Hysterectomy is more often performed in African-Americans than in Caucausians
and is more frequently performed by male gynecologists than female gynecologists. One
in five women in the United Kingdom will have a hysterectomy by the time they reach the
age of sixty-five (Chapple, 1995). Hysterectomy is often the last resort for women
suffering from problems affecting the uterus. The most common problems include:
uterine fibroids, cancer, abnormal uterine bleeding, pain and endometriosis. A lot of
effort is made by the patient and her health care provider to avoid unnecessary surgery.
Once the decision for hysterectomy is made it is important for the woman to understand
the surgery and its risks as well as what is to be expected after surgery (Berek, Adashi, &
Hillard, 1996).
Women undergoing hysterectomy require special education and emotional support
(Dulaney, Crawford, & Turner, 1990). A study of social support for women undergoing
hysterectomy revealed women’s need for basic information and their desire to obtain it
from their caregivers (Webb, 1986). This study involved two groups of women. One
group received information prior to surgery the other group did not. The group receiving
2
information was less hostile but more critical of their treatment, but overall had higher
levels of satisfaction (Webb, 1986). Patients are often best informed about risks of
surgery and least about the post-operative treatment and healing (Ebert-Hampel, &
Holzle, 1983). Information about post-operative treatments and expectations from the
patient are often not mentioned to the patient at all. Many women go into surgery without
realizing their need to take an active part in the recovery process (Dulanley et al., 1990).
With insurance companies dictating shorter length of stay for surgical patients, women
who have had hysterectomies are often rudely awakened to the fact that they cannot stay
in the hospital as long as expected (Dulaney et al, 1990). Because they are not informed
before the operation about information such as length of stay, they often become resentful
of the health care providers for making them leave when they believe they are not ready.
Many women feel that they are being pushed out of the hospital (Dulaney et al., 1990).
Nurses have concluded that lack of information and erroneous information play a
major role in post-operative problems (Dulaney et al., 1990). A study showed that
women, who have received adequate information prior to surgery, reported generally high
levels of satisfaction, health and resumption of activities after hysterectomy (Webb,
1986). Findings have also shown that patients, who are given pre-operative instructions,
performed at a significantly higher level (Williams et al., 1988). They required neither
prompting, nor assistance in the initiation and completion of tasks compared to those
patients who did not receive pre-operative instructions (Williams et al., 1988). Providing
patients having a hysterectomy with adequate information may help to decrease patient
anxiety, improve patient outcomes, increase satisfaction of stay, decrease length of stay
and provide motivation for the patient to actively participate in her recovery.
Statement of the Problem
Although more and more women are undergoing hysterectomies and studies have
shown improvement of activities after receiving information poor to surgery, written
information for these patients is given a relatively low priority (Scriven & Tucker, 1997).
3
Statement of the Purpose
purpose of this study was to design a pamphlet to educate women undergoing
hysterectomy about their post-operative course; in order to improve recoveiy and
facilitate satisfaction of stay.
Assumptions
The assumptions of this study were as follows:
1. There is a need for post-operative education for women undergoing
hysterectomy.
2. Current information provided by women’s health care providers is not
adequate.
3. Information provided to patients prior to hysterectomy will lead to improved
patient outcomes in recovery, both in the hospital and at home, and will increase
satisfaction of stay.
Limitations
The usefullness of the pamphlet is limited to patients who are able to read and
understand the pamphlet and patients who are interested in the pamphlet. It is also
limited by lack of participation from women’s health care providers in providing
information to their patients.
Definition of Terms
The terms utilized in this study are defined as follows:
1. Hysterectomy is the surgical removal of the uterus (Berek et al., 1996).
2. Fibroids are noncancerous growths that form on the inside of the uterus, on its
outer surface, or within the uterine wall itself (American College of Obstetricians and
Gynecologists [ACOG], 1995).
3. Uterus is the muscular organ that is located in the female pelvis and contains
and nourishes the developing embtyo and fetus during pregnancy (ACOG, 1995).
4
4. Endometriosis is a condition in which tissue similar to that normally lining the
uterus is found outside of the uterus, usually in the ovaries, fallopian tubes, and other
pelvic structures (ACOG, 1995).
5. Abnormal uterine bleeding is any bleeding pattern that differs in frequency,
duration, or amount from the pattern observed during a normal menstrual cycle
(Braunwald et al., 1987).
6. Salpingo-oophrectomy is the removal of one or both of the ovaries and
fallopian tubes (ACOG, 1995).
7.
Wertheims or radical hysterectomy is the removal of the uterus, cervix, part
of the vagina, fallopian tubes, peritoneum, the lymph glands and fatty tissue of the pelvis
and possibly one or both ovaries (Newall, 1998).
8. Peritoneum is the broad band of ligament below the uterus (Newall, 1998).
Theoretical Framework
The theoretical framework for this study was based on Dorothea Orem’s (1991)
self-care deficit theory. Orem (1991) states that the individual’s ability to initiate and
perform activities to meet their health needs is self-care. Self-care agency is described by
Orem (1991) as the ability to engage in self-care. Self-care agency is necessary for
self-care (Orem, 1991).
Orem (1991) also believes that nursing’s role is to help people meet their own
therapeutic self-care demands. There are three types of nursing systems according to
Orem (1991): wholly compensatory, partially compensatory, and supportive-educative.
This study focuses on the supportive-educative system. The nurse or health care provider
functioning in this system assists the patient in acquiring skills and knowledge. The
hysterectomy patient has a self-care deficit due to lack of knowledge about the surgery.
The nurse practioner functions in the supportive-educative role by providing the patient
with oral as well as written information, via the pamphlet, to the patient. The pamphlet is
used to help the patient reach her self-care demand and resolve her self-care deficit.
5
Summary
Many women in today’s society will undergo hysterectomy (Berek et al., 1996).
The information given to these women prior to surgery is an important factor in positive
outcomes after surgery (Webb, 1986). These women are often provided with information
about the female body, uterine abnormalities, reasons for surgery and the surgery itself,
but are rarely supplied with information about expectations following surgery
(Ebert-Hampel, & Holzle, 1983). This study was intended to provide a pamphlet for
women prior to hysterectomy to inform them of these post-operative expectations.
Dorothea Orem’s (1991) theory provided support to this study. It emphasized the
importance of the supportive-educative role of health care providers in helping to
promote and support self-care. Providing these women with information they can use to
perform self-care and meet their own therapeutic self-care demands was an important
aspect in a positive hysterectomy experience.
The terms used in this study were defined. The limitations and assumptions were
provided.
6
Chapter 2
Review of Literature
Introduction
The purpose of this project was to design and construct a post-operative
educational pamphlet for hysterectomy patients. The material in the pamphlet pertained
to both vaginal and abdominal hysterectomies.
This literature review addressed female reproductive anatomy and factors
influencing the need for a hysterectomy. It included types of hysterectomies and
post-operative aspects and expectations. Finally, this review examined the literature on
constructing written patient education materials.
Female Reproductive Anatomy
The female reproductive anatomy consists of the vagina, the cervix, the uterus, the
fallopian tubes and the ovaries (Seidel, Ball, Dains, & Benedict, 1995). The vagina is a
muscular tube that carries menstrual flow from the uterus, serves as the terminal portion
of the birth canal, and is the receptive organ for the penis during sexual intercourse
(Seidel et al., 1995). The vagina typically remains unchanged after hysterectomy (Berek
et al., 1996). The uterus opens into the vagina by way of the cervix (Seidel et al., 1995).
The cervix may or may not be removed during hysterectomy depending on the type
performed (Berek et al., 1996). The uterus, a muscular organ in the pelvis, is always
removed during hysterectomy (Berek et al., 1996).
The fallopian tubes are responsible for the transportation of the ovum (egg) to the
uterus (Seidel et al., 1995). The fallopian tubes may or may not be removed during
surgery depending on the type performed (Berek et al., 1996).
The ovaries are a pair of oval organs that secrete estrogen and progesterone and
are responsible for controlling the menstrual cycle and supporting pregnancy (Seidel et
al., 1995). The ovaries may be left untouched or may be removed during surgery
depending on the type being performed (Berek et al., 1996)
7
Factors Influencing Need for Hysterectomy
Hysterectomy may be performed to treat conditions that can affect the uterus
(Berek et al, 1996). These conditions may be treated with medical or surgical
intervention. Hysterectomy is often considered as a last resort treatment for many of
these conditions (Berek et al., 1996).
Uterine fibroids are the most common type of benign uterine tumors and are the
leading indication for hysterectomy (Berek et al., 1996). They are estimated to be present
in at least 20% of all women of reproductive age. They are more common in
African-American women than in Caucasians (Berek et al., 1996). Fibroids that don’t
cause symptoms may be present in 40-50% of women older than 40 years of age. One or
many may be present (Berek et al., 1996). They can cause symptoms from pelvic
pressure to irregular or heavy bleeding from the lining of the uterus with fewer than
one-half producing symptoms at all (Berek et al., 1996). The most common presenting
symptom associated with fibroids and the one that most frequently leads to surgical
intervention is heavy bleeding (Berek et al., 1996). If nonsurgical treatment such as
hormone therapy or removal of the fibroids is not effective, a hysterectomy may need to
be performed (Berek et al., 1996).
Another reason for hysterectomy is cervical cancer. It may also be performed due
to cancer of the lining of the uterus and the ovaries (Berek et al, 1996). Patients who do
not respond to treatment with chemotherapy or radiation are advised to have a
hysterectomy (Berek et al., 1996).
Abnormal uterine bleeding is bleeding for which no specific cause has been found
(Berek et al.. 1996). Abnormal uterine bleeding may be caused by fibroids or hormonal
changes, infection of the uterus or by cancer (Berek et al.. 1996). There are many ways to
treat abnormal uterine bleeding. Hysterectomy may be an option if nonsurgrcal
treatments don’t work (Berek et al., 1996).
8
Pelvic pain encompasses a large proportion of gynecologic complaints and is
among the most challenging to treat (Berek et al., 1996). There are many possible causes
for pelvic pain and treatment is dependent on the cause (Berek et al., 1996). Treatments
vary from observation, to antibiotics, to surgical intervention such as hysterectomy (Berek
et al., 1996).
Endometriosis may cause scarring, adhesions, and pain (Berek et al., 1996). It is
often treated by the least invasive method first, such as hormones, but in severe cases
hysterectomy is advised (Berek et al., 1996).
Types of Hysterectomies
There are four types of hysterectomies: a subtotal or partial hysterectomy, a total
or complete hysterectomy, a total hysterectomy with bilateral or unilateral
salpingoophrectomy, and a radical or “Wertheim’s” hysterectomy (Newall, 1998). The
type of hysterectomy depends upon the condition it is being used to treat (Newall, 1998).
A subtotal or partial hysterectomy removes the uterus, but the cervix is left in
place (Newall, 1998). A total or complete hysterectomy removes the entire uterus
including the cervix. This is the operation most commonly performed (Newall, 1998). A
total hysterectomy with bilateral or unilateral salpingoophrectomy removes the uterus,
cervix, fallopian tubes and one or both of the ovaries (Newall, 1998). Finally, a radical or
“Wertheim’s” hysterectomy removes the uterus, cervix, part of the vagina, fallopian
tubes, peritoneum, the lymph glands and fatty tissue of the pelvis, and possibly one or
both ovaries (Newall, 1998).
There are two main ways to perform a hysterectomy. The most common way is to
remove the uterus through a cut in the lower abdomen or an abdominal hysterectomy
(Newall, 1998). The second, less common, way is to remove the uterus only through a
cut in the top of the vagina or a vaginal hysterectomy (Newall, 1998).
9
Postoperative Aspects and Expectations
The usual post-operative course should be discussed in enough detail
pre-operatively to allow the patient to understand what to expect in the days following
surgery (Berek et al., 1996). The successful outcome of gynecologic surgeiy is based on
thorough evaluation, pre-operative preparation and careful post-operative management of
the patient (Berek et al., 1996). Written information for patients is given a relatively low
priority (Seriven & Tucker, 1997).
A research study was conducted focusing on whether a program of pre-operative
teaching and post-operative rehabilitation/discharge planning would promote optimum
post-operative self-care among women who had undergone mastectomy and hysterectomy
at two points in time: immediately after surgery, and at one month after surgery
(Williams et al., 1998). Sixty adult female surgical patients, 30 mastectomy and 30
hysterectomy, were equally divided into an experimental and control group. The
independent variable, structured teaching, was administered by a nurse clinician before
and after surgery. There were two sets of structured teaching programs. One for each
group, hysterectomy and mastectomy. The hysterectomy patients on their first contact
with the nurse were given a checklist of their knowledge about the surgery, given a
simple explanation of the anatomy and physiology of the uterus and a simple explanation
of surgery including physical preparation, incision, dressing, foley catheter, IVs, diet and
ambulation exercise. On their second visit with the nurse they discussed clinic visits and
home activities (do’s and dont's). The control group did not receive these instructions
(Williams et al., 199S). The dependent variable, self-care, during the immediate
post-operative period, was defined as the performance of three ambulation tasks on day
one. Task performance was rated on three criteria: time interval, amount of prompting
and amount of assistance required for the first complete performance (as demonstrated
and practiced pre-operatively) of each exercise (Williams, et al. 1998). Effects of the
nursing intervention were measured immediately after surgery in terms of performance of
10
.mbuhtion and rehabilitation exercises; as well as one month after surgery, in terms of
performance of self-care activities at home and the incidence of complications (Williams
et al., 1998).
Dorothea Orem’s (1991) theory of self-care was used as a theoretical framework.
The supportive-educative nursing role was tested in the study. The role consisted of
pre-operative teaching and discharge planning given by a nurse clinician (Williams et al.,
1988).
Findings showed that for the in-hospital phase, patients in the group given
pre-operative instructions performed at a significantly higher level. They required neither
prompting nor assistance in the initiation and completion of ambulation tasks compared
to the uninstructed group (Williams et al., 1998). During the clinic visit one month after
surgery, instructed patients reported performing self-care activities at home significantly
better than and more frequently than the control or uninstructed group (Williams et al.,
1998). The results of the study showed favorable effects of pre-operative teaching and
discharge planning on patients performance of essential post-operative tasks, such as
ambulation and rehabilitation exercises, and on reported self-care at home. The nurse’s
or clinician’s role in patient-teaching cannot be over-emphasized . The results of the
study attest to the fact that patients can be taught to assume self-care with a general sense
of responsibility for their recovery and the maintenance of their health (Williams et al.,
1988).
The length of stay in the hospital after surgery varied by the type of surgery,
usually two to three days for abdominal hysterectomy and two days for vaginal
hysterectomy (Williams et al., 1988). One can expect to have moderately-severe pain
after surgery and for several days afterward, but options for pain control such as
injections or patient controlled analgesia (PCA) will be discussed between the health care
provider and patient prior to surgery (Berek et al., 1996).
11
Early ambulation decreases the incidence of compile,,™ such as blood clots and
pneumonia (Berek et al., 1996). Patients are encouraged to begin ambulation on their
first post-operative day and increase their time out of bed progressively (Berek et ah,
1996). Movement such as sitting on the edge of the bed or walking in the hahs will also
help the patient to expell the build up of painful gas in the intestines that is a common
side effect of hysterectomy (Newall, 1998).
Post-operative care consists of many different aspects. Immediately following
surgery and for the next 18-24 hours the patient will have a catheter in the bladder to
prevent complications and to drain the bladder (Berek et al., 1996). Patients are typically
allowed ice chips only the day of surgery with resumption of diet on the first
post-operative day, assuming bowel sounds are present. Diet begins with clear liquids
and advances to solid food as the patient tolerates (Berek et al., 1996). The patient can
expect to receive IV antibiotics after surgery to prevent infection. Infections are a major
source of sickness in the post-operative period due to decreased patient mobility and lack
of deep breathing (Berek et al., 1996). The patient will be expected to perform deep
breathing exercises to promote adequate lung expansion following surgery (Newall,
1998). The patient will learn about deep breathing exercises prior to surgery and the
teaching will be reinforced by nurses and respiratory therapists after surgery. The patient
will typically experience some light to moderate vaginal bleeding after surgery, but can
expect it to gradually decrease over a few days (Newall, 1998). After the bleeding
experienced following surgery subsides, the patient can expect her periods to stop (
et al., 1996).
The patient can expect to be discharged from the hospital when specific criteria
are met (Newall, 1998). These criteria include: adequate urination, presence of bowel
sounds and expelling flatus from the body, absence of fever for 24 hours and the ability to
tolerate a regular diet (Newall, 1998).
12
Once at home the patient is advised to limit activities for four to six weeks (Berek
et ah, 1996). The patient win be restricted to less than 20 pounds of lifting, advised not
to push or pull anything for one to two weeks, avoid sexual intercourse, tampons, and
douches for four to six weeks, and will not be allowed to drive for one to two weeks
(Berek et al., 1996). The patient will be tired, but is encouraged to return to normal
activities as soon as she feels comfortable doing so (Berek et al., 1996). The patient may
experience some emotional ups and downs after surgery. This is often due to lack of
estrogen (if the ovaries are removed), the trauma of the surgery, and feelings of loss and
the awareness of no longer being able to bear children (Newall, 1998).
Sexual activity can be resumed after four to six weeks (Berek et al., 1996). Some
women may notice a change in their sexual response after hysterectomy (Berek et al.,
1996). Factors such as less intense orgasms and vaginal dryness can affect a woman’s
sexuality after hysterectomy (Newall, 1998).
Written Patient Education Materials
An essential component of comprehensive health care is education about
preventive health practices (Whitman, Graham, Gleit, and Boyd, 1992). Health care
providers have a major role in this educational process (Whitman et al., 1992).
Teaching aides such as audio-visual materials, television graphics, games,
demonstrations, and written materials are commonly used to supplement oral
communication (Whitman et al., 1992). Printed educational materials are one of the most
economical and effective instructional mediums available, and provide eff
instructional assistance in the hospital as well as at home (Bernier & Yasko,
)
Printed Educational Materials Development
There is a necessity for needs assessment, an advisee committee, a well defined
goal, and content selection based on what the patient needs to know when developing
printed materials for patient education (Lange, 19S9). Lange (1989) also empt.as.zed the
13
use of figures and diagrams for clarity of content, the repetition of key points, and the use
Of bold letters, underlining and bright colors for patient/reader interest.
Authors creating printed materials for patient education should write simply, use
as few words of more than two syllables as possible, be precise, be accurate, and involve
the reader (Mathis, 1989). The length of the material should be as short as possible, and
the size managable (Mathis, 1989).
While it is estimated that the majority of people in the U.S. read at an eigth grade
level or lower, approximately 68% of the educational materials available are written
above a ninth grade level (Doak, Doak, & Root, 1985). The SMOG Readibility Test
(McLaughlin, 1969) is often used to measure readibility of written materials. It is often
considered one of the easiest and quickest formulas to perform. The EPEM (Evaluating
Patient Education Material) model (Bernier & Yasko, 1991) can be used to evaluate
prepared materials. It serves as a comprehensive checklist. Information written at a level
appropriate to assure patient understanding, increases recall and compliance with
treatment measures (Doak et al., 1985).
Summary
To construct a post-operative educational pamphlet for hysterectomy patients it
was necessary to review the literature on female reproductive anatomy, factors
and post-operative aspects and
influencing need for hysterectomy, types of hysterectomy
was also reviewed.
expectations. The literature on written patient education mate
14
Chapter 3
Methodology
Dorothea Orem's (1991) theory of self-cate provided the theoretical framework
for this project. The EPEM model of preparing printed education materials as well as
literature on developing printed materials for patient education provided the basis for the
development of the pamphlet.
Project Design and Procedures
This project was designed using the ideas of figures and diagrams for clarity of
content, repetition of key points, use of bold letters, underlining and bright colors for
patient/reader interest (Lange, 1989). This pamphlet was written as simply, precisely, and
accurately as possible (Mathis, 1989). The pamphlet was as short as possible with the
readibility at an eighth grade level or lower (Doak et al, 1985).
The five phase EPEM model (Bernier & Yasko, 1991) for the production of
patient education materials was used to design the pamphlet. The pre-design phase
included establishing a purpose, goal, intended audience and objectives. The design
phase contained guidelines for developing content, with emphasis on organization,
motivational features, linguistics, and graphics. The pilot testing phase suggested that
professionals and patients review the materials to provide feedback so that revisions
could be made. Learning potential was maximized during the implementation and
distribution by providing the material at a time when it was needed. The evaluation phase
can be carried out on a formal or an informal basis using either a small, representati
sample of patients or a large, random sample.
The pre-design phase encompassed the design
ing of the pamphlet, the goal of the
pamphlet, the audience or focus group and the objectives,
The design phase involved
verification of content and design by gynecologists, surgical
number of post-hysterectomy patients. The implementatio
nurses, and an undetermined
id distribution phase was
15
mutually decided upon by the gynecologists involved in the design phase and the
pamphlet developer.
A pilot study was conducted on a random group of three post-hysterectomy
patients in an OB/GYN office. Participants were anonymous and comments weren’t
connected to any one participant. Participants were assigned a number to protect their
identity and provide anonymity. The patients verbally explained what they read to the
investigator, thereby acknowledging their understanding of the material. Effectiveness of
the pamphlet was determined by patient opinion of how useful the pamphlet would have
been to them had they received it pre-operatively. Overall the three patients felt that the
pamphlet would have been useful to them in their recovery if they had read it before
surgery. Patient number one felt that the pamphlet should emphasize the tremendous gas
pain one feels after hysterectomy. Patients two and three felt that the pamphlet provided
adequate information. Feedback about the likes and dislikes of the pamphlet was utilized
in the final revision of the pamphlet.
Summary
The five phase EPEM model (Bernier & Yasko, 1991) for designing and
evaluating printed educational materials was used in the construction of the pamphlet.
The literature on developing printed materials for patient education was also used.
16
Chapter 4
Results
This chapter provides the results of the scholarly project relating to the
post-operative educational pamphlet for hysterectomy patients. Demographics and results
of the pilot study are explained. The pamphlet and recommendations for future use are
also described. A post-operative educational pamphlet for hysterectomy patients was
designed to educate women undergoing hysterectomy about their post-operative course;
in order to facilitate satisfaction of stay and improve recovery.
Demographics
The content of the pamphlet was reviewed and verified by three gynecologists in a
local practice, with a total of 35 years of OB/GYN experience between them, and three
medical-surgical nurses in a local hospital. The three nurses have worked on the same
unit for over five years. This hospital unit specializes in care of women undergoing GYN
surgeries. Three post-hysterectomy patients in a local OB/GYN office were involved in
the pilot study.
Pilot Study Results
A pilot study of the post-operative educational pamphlet for hysterectomy patients
was conducted in March 1999. Three post-hysterectomy patients in a local OB/GYN
office were asked to review the pamphlet and verbally explain their likes and dislikes to
the investigator. The patients ranged in age from 45 to 65 and all were Caucasian. Two
of the patients had an abdominal hysterectomy, the third a vaginal hysterectomy. All
three patients stayed in the hospital for three days, none had complications. The patients
were seen in the office four weeks after discharge from the hospital for their follow-up
appointments. The patients were assigned a number to provide anonymity.
Feedback about the likes and dislikes of the pamphlet was written down during
the interview and was used in the final revision of the pamphlet. Patient number one had
a vaginal hysterectomy and she felt that the pamphlet should emphasize the tremendous
17
gas pain one feels after hysterectomy. Patients two and three had abdominal
hysterectomies. They felt that the pamphlet provided adequate information. All of the
patients felt that the pamphlet would have been useful to them if they had read it before
surgery.
Description of the Pamphlet
The pamphlet was designed to provide patients with specific information
regaiding post-operative expectations following hysterectomy. It focused on Dorothea
Orem s (1991) concept of self-care. The goal of the pamphlet was to make the patient
feel like she had some control over her recovery in the hospital. Williams et al (1998)
validated that patients can be taught to assume self-care when adequate information is
given prior to surgery.
The pamphlet focuses on elimination, diet, activity, pain and discharge criteria.
Information about elimination, diet and exercise was also provided to patients in
Williams et al (1998) study. The pamphlet informs patients about urinary catheters, when
they are placed and removed. Their diet as well as criteria for advancement of the diet is
explained. Examples of activity and reasons for it are described. The women in the pilot
study had not realized when they had surgery how soon they were expected to get out of
bed. Pain medication is discussed and examples are provided. The women in the pilot
study liked this idea. It gave them a chance to read about the medications before they
took them. Discharge criteria such as adequate urination, presence of bowel sounds,
flatus, absence of fever and tolerating a regular diet are provided. The women in the pilot
study also liked this part of the pamphlet. They all felt this information would have made
them more prepared when the physician discharged them.
Dorothea Orem’s (1991) self-care deficit theory was validated by the research
study conducted by Williams et al (1998). The study found that patients could be taught
to assume self-care. Orem’s (1991) theory was also supported by comments made by the
women in the pilot study.
18
Summary
This chapter provided information about demographics and the results of the pilot study.
A pilot study was necessary to provide input on the usefulness of the post-operative
educational pamphlet for hysterectomy patients. This chapter also provided a detailed
description of the pamphlet as well as recommendations for future use.
19
HYSTERECTOMY:
WHAT TO EXPECT AFTER SURGERY
A post-operative educational pamphlet
20
Hysterecomy: What To Expect After Surgery
Hysterectomy is the second most frequently performed major surgical procedure
in the United States. Hysterectomy is often performed for common problems such as
uterine fibroids, cancer, abnormal uterine bleeding, pain and endometriosis, Because this
surgery is so common it is important for you to be aware of and participate in the care you
receive post-operatively.
By now you should have discussed the surgery and reason for it
with your gynecologist. This pamphlet is designed to inform you of
post-operative procedures, treatments and expectations.
You are an important part of a positive recovery.
Your full participation and
understanding of what is expected
of you after surgery will enhance your hospital stay.
There are several important aspects to your
post-operative hospital recovery period. These
include: elimination, diet, activity and pain
ooooooo;
medications.
Immediately after surgery and for the next 18-24 hours you will have a catheter in
the bladder to prevent complications and to help urinary fluids drain away. After it
removed you will be expected to urinate in the bathroom.
You may be allowed ice chips, only, ihe day of surgery with resumplionofyour
diet on the first post-operative day. Your diet will begin with
clear liquids such as jello, juice, tea, coffee and water
and will advanceto solid food as you can tolerate.
Bowel sounds must be present for your diet to increase.
st
21
You will be encouraged to begin walking on your first post-operative day and
increase your time out of bed progressively. This will help prevent blood clots from
developing in your legs. Movement such as sitting on the edge of the bed or walking in
the halls will also help you to expell the build up of painful gas in the intestines that is a
common side effect of hysterectomy.
You will also be expected to perform deep breathing exercises to promote
adequate lung expansion to prevent pneumonia after surgery. Your
nurse will remind you to take deep breaths and change postitions
frequently.
You can expect to experience moderately-severe pain after surgery. Pain control
may be in the form of injectable narcotics such as
Demerol or pill form such as a Tylenol with
codiene.
You may be in the hospital for 2-3 days. Discharge
will depend on specific criteria. These criteria
include: adequate urination, presence of bowel sounds, and expelling gas from the body,
absence of fever for 24 hours, and the ability to tolerate a regular diet.
It is important for you to understand and actively participate in your
post-operative recovery. Your physicians and nurses will provide you with supportive
care and encouragement, but you are ultimately the one who will decide the course of
your recovery
22
References
(1995)'
Berek, J.S., Adashi, E.Y., & Hillard, P.A. (1996). Novak’s gynecology (12th ed)
Baltimore, MD: Williams & Wilkins.
Bernier, M., & Yasko, J. (1991). Designing and evaluating printed education
materials: Model and instrumentation development. Patient Education and CounselinP18.253-262.
Braunwald, E„ Isselbacher, K. J., Peterdorf, R. G., Wilson, J., Martin, J. B„ &
Fauci, A. S. (1987). Harrison’s principles of internal medicine. New York, NY:
McGraw-Hill Book Company.
Chapple, A. (1995). Hysterectomy: British National Health Services and private
patients have very different experiences. Journal of Advanced Nursing, 22, 900-6.
Doak, C., Doak, L., & Root, J. (1985). Teaching patients with low literacy skills
Philadelphia: Lippincott.
Dulaney, P.E., Crawford, V.C., & Turner, G. (1990, July/August). A
comprehensive education and support program for women experiencing hysterectomies.
Journal of Qbstectrical and Gynecological Neonatal Nursing, 12, 319-25.
Ebert-Hampel, B., & Holzle, C. (1983). Knowledge and well-being of patients
before and after preoperative findings disclosed by gynecologic surgery. Geburtshilfe.
Frauenheilkd, 43. 746-54.
Lange, J. (1989). Developing printed materials for patient education.
Dimensions of Critical Care Nursing, 8. (4), 250-259.
Mathis, D. (1989). Writing patient education materials. Orthopaedic Nursing^
(5), 39-42.
McLaughlin, H. (1969). SMOG grading-A new
Reading,J2, 639-645.
readibility formula. Journal of
Newall, L. (1998). What does the operation involve? [On-line]. Available.
http://www.hysterectomy-association.org.uk/info/hyster/operate.titm
St. Louis: Mosby Year
Orem, D. E. (1991). Nursing;
Book.
TS
Scriven, A., & Tucker, C. (1997'j The nnoi t
presented to women undergoing hyste.
,o,.TOl^eS~^y S“ia'
.
P«i«.
Whitman N Graham B, Gleit, C„ & Boyd, M (1992). Teaching in nursing
practice (2nd ed.). Norwalk, CT: Appleton & Lange.
Williams, P. D„ Valderrama, D. M„ Gloria, M. D„ Pascoquin, L. G., Saaverdra,
L. D., De la Rama, D. T., Fetty, T. C., Abaquin, C. M., & Zaldivar, S. B. (1988). Effects
of preparation for mastectomy/hysterectomy on women’s post-operative self-care
behaviors. International Journal of Nursing Studies. 25 (3), 191-206.