Table of Contents

I. Introduction

II. Statement of the Problem

Main Problem

Secondary Problems

III. Evidences

IV. Synthesis

Strength

Weaknesses

Answer to the Problem

V. Conclusion

VI. Recommendation

VII. Appendices

References

Curriculum Vitae
I. Introduction

Surgical care is essential for managing diverse health conditions such as injuries,

obstructed labor, malignancy, infections and cardiovascular disease and an

indispensable component of a functioning health system. International organizations,

including the World Health Organization (WHO) and the World Bank, have highlighted

surgery as an important component for global health development. According to the

WHO, it was estimated that 234.2 million operations were performed worldwide in 2004.

Progress in surgical science has been characterized by a continuous cycle of innovation

from bedside to bench to bedside. Beginning 30,000 years ago with the first bone

needles to surgical lasers and robotics of today, each quantum leap has resulted from

the convergence of technical advances and creative surgeons (Krummel, 2011).

After undergoing any kind of major surgery, there may be many side effects that

accompany this seismic life event, not least of which is a crippling depression and

anxiety that can make the patients recovery that much more excruciating. Though this

aspect of surgery is not often given the attention it deserves, it is a very real possibility

for those faced with a serious operation. Coupled with the fact that most surgeons are

mostly concerned with just the patients physical recovery, rather than their mental

status, this post-operative depression may linger a bit longer than is necessary, further

drawing out the recovery process.

Pain has been viewed as a multidimensional experience with sensory, motivational and

affective components. There is the experience of the sensory component which includes

the perception of location, quality and intensity of the noxious stimulus and the
emotional dimension which processes the affective salience or unpleasantness of the

stimulus. When pain and anxiety/depression occur together, they result in worsening of

both conditions.

The aim of this study is to determine the influence of preoperative emotional state on

postoperative pain. Secondarily, researchers would also like to inquire the different

interventions to alleviate anxiety and depression in able to decrease or reduce

postoperative pain, and the other possible complication of anxiety and depression for

postoperative patients

II. Statement of the Problem

Main Problem:

1. What is the influence of preoperative emotional state on postoperative pain?

Secondary Problems:

2. What are the interventions to alleviate anxiety and depression to reduce

postoperative pain?

3., what the other possible complication of anxiety and depression for postoperative

patients?
III. Evidences

1. Influence of preoperative emotional state on postoperative pain following

orthopedic and trauma surgery. (Robleda, 2014)

Introduction: Orthopedic and trauma surgeries are often associated with severe

postoperative pain for two main reasons. First, the surgery often causes intense

nociceptive stimulation of the musculoskeletal tissue. Second, postoperative analgesia

remains inadequate and exposes patients to severe postoperative pain. This situation

can lead to significant patient discomfort and negative physical and psychological

effects as well as a major socio-economic impact by increasing the postoperative

morbidity and hospital stay. Timely prevention, detection and treatment may help reduce

health problems associated with the high prevalence and intensity of postoperative pain.

To analyze the relationship between preoperative emotional state and the

prevalence and intensity of postoperative pain and to explore predictors of

postoperative pain.

Method: Observational retrospective study undertaken among 127 adult patients

of orthopedic and trauma surgery. Postoperative pain was assessed with the verbal

numeric scale and with five variables of emotional state: anxiety, sweating, stress, fear,

and crying. The Chi-squared test, Student's t test or ANOVA and a multivariate logistic

regression analysis were used for the statistical analysis.

Result: The prevalence of immediate postoperative pain was 28%. Anxiety was

the most common emotional factor (72%) and a predictive risk factor for moderate to
severe postoperative pain (OR: 4.60, 95% CI 1.38 to 15.3, p<0.05, AUC: 0.72, 95% CI:

0.62 to 0.83). Age exerted a protective effect (OR 0.96, 95% CI: 0.94-0.99, p<0.01).

Conclusion: In conclusion, the present investigation identified two predictors of

immediate pain during the postoperative period: age and preoperative anxiety.

Consequently, we recommend that young and anxious patients have customized

analgesic regimens to better alleviate their postoperative pain within the first hours after

surgery. The establishment of protocols with specific instruments for assessing and

treating anxiety as a predictor of postoperative pain is encouraged. This intervention

would help health professionals understand and improve the perception of their patients'

pain and optimize pain treatment.

Based on the results of the study, it shows that there is a strong association

between preoperative anxiety and postoperative pain. This study reveal that nearly one

out of three patients undergoing trauma or prosthetic surgery have pain during the

immediate postoperative period and that more than half of these patients have

moderate-to-severe pain within the first 24 hours of the postoperative period. Also in

this study, the results regarding anxiety are consistent with those of previous

investigations and show that anxiety is a predictor of postoperative pain.

2. Risk factors for postoperative anxiety in adults. (Caumo, 2012)

Introduction: Patients submitted to surgery commonly experience anxiety. Peri-

operative anxiety is influenced by the patient's concern about his or her general health,

uncertainty regarding the future, type of surgery and anesthesia to be performed,

postoperative discomfort and pain, incapacitation, loss of independence, and fear of

death. In addition, the extent of this distress may be influenced by previous psychiatric

diseases, such as depression and anxiety.

Method: A prospective cohort study of adult patients was performed in a tertiary

care hospital after approval by the local Ethics Committee. Written informed consent

was obtained from all patients. We studied 712 inpatients (ASA grades IIII) admitted to

the hospital one day prior to elective surgery. Ages ranged from 18 to 60 years. Patients

with a medical history of cerebral damage, mental retardation, not speaking Portuguese,

difficulty in understanding verbal commands, use of pre-anesthetic medications before

the evaluation carried out for the present study, and ophthalmological or cardiac surgery

were not studied. The surgical procedure was classified as minor, Anesthesia, medium

or major according to blood loss, degree of pain, invasiveness, degree of monitoring

required and length of stay in the hospital.

Result: We identified risk factors for postoperative anxiety and quantified their

effect on 712 adults between 18 and 60 years of age (ASA IIII physical status)

undergoing elective surgery under general anaesthesia, neural blockade or both. The

measuring instruments were a structured questionnaire, a pain visual analogue scale,

the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the MontgomeryA

sberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a

SelfPerception of Future Questionnaire. Multivariate conditional regression modelling

taking into account the hierarchical relationship between risk factors revealed that

postoperative anxiety was associated with ASA status III (OR 1.48), history of

smoking (1.62), moderate to intense postoperative pain (OR 2.62) and high pain
rating index (OR 2.35), minor psychiatric disorders (OR 1.87), pre-operative state-

anxiety (OR 2.65), and negative future perception (OR 2.20). Neural block

anesthesia (OR 0.72), systemic multimodal analgesia (OR 0.62) and neuroaxial

opioids with or without local anesthesia (OR 0.63) were found to be protective factors

against postoperative anxiety.

Conclusion: In conclusion, we demonstrated that total pain experience, intensity

of pain, psychiatric disorders, preoperative state-anxiety, poor pre-operative self-

perception of the future, history of smoking and worst physical status (ASA III)

constituted risk factors for postoperative state anxiety. Neural blockade anesthesia,

systemic multimodal analgesia and neuraxial analgesia protected patients from

postoperative state-anxiety. Furthermore, the effect of diazepam, which is commonly

used to control preoperative anxiety, did not protect patients from postoperative anxiety.

The research also discussed about the several factors associated with anxiety,

such as increased postoperative pain and analgesic requirement, prolonged hospital

stay and recovery, decreased patient satisfaction with the peri-operative experience,

increased sympatho-adrenal medullary activity, and impaired immune function with

increased susceptibility to disease.

3. Alleviating Anxiety and Preventing Panic Attacks in the Surgical Patient.

(Evans, 2013)

Introduction: Surgery can be intimidating and can provoke anxiety for any

patient, but for the patient who is prone to anxiety, surgery can be the trigger for a panic
attack. Thus, it is crucial for health care providers to examine and understand the

mental health of patients who are undergoing surgical procedures. Although it is

important to provide anxiety-decreasing interventions for surgical patients solely for

comfort, decreasing anxiety during the perioperative process also has been shown to

produce better patient outcomes. Hospital personnel, especially nurses, should be

aware of the anxiety-prone patient population and take precautions to reduce surgery-

related anxiety. Pharmacological and nonpharmacological interventions can be

implemented to help decrease anxiety and panic disorders experienced by patients.

Method: Researcher use a variety of strategies to help reduce a surgical

patients anxiety. These strategies include the nonpharmacological interventions of

communication, humor, and music as well as pharmacological interventions

Result: Surgery places a great deal of physical stress on the body and

psychological stress on the patients mental state. Increased patient anxiety in the

perioperative period has the potential to initiate panic attacks. Patients with decreased

preoperative anxiety have been shown to have improved postoperative outcomes.

Conclusion: Thus, perioperative nurses should implement all available

strategies to decrease the surgical patients anxiety. Potential nonpharmacological

methods to reduce patient anxiety include communication, humor, and music, all of

which are simple and economical strategies. Pharmacological methods, such as

administration of preoperative medications, are popular among patients. Chosen

anxiety-reducing strategies should be individualized based on each patients needs.

 It was also discussed in the study that excessive preoperative anxiety is

associated with unfavorable physiologic responses, such as tachycardia, hypertension,

cardiac arrhythmias, hyperventilation, and postoperative pain.

4. Preoperative psychologic and demographic predictors of pain perception and

tramadol consumption using intravenous patient-controlled analgesia. (De

Cosmo, 2013)

Introduction: Postoperative pain is characterized by a wide variability of

patients' pain perception and analgesic requirement. The study investigated the extent

to which demographic and psychologic variables may influence postoperative pain

intensity and tramadol consumption using patient-controlled analgesia (PCA) after

cholecystectomy.

Method: Eighty patients, aged 18 to 70 years, with an American Society of

Anesthesiologists physical status I or II and a body mass index between 18.5 and 24.9,

undergoing laparoscopic cholecystectomy were enrolled. Self-rating anxiety scale (SAS)

and self-rating questionnaire for depression (SRQ-D) were used--1 day before surgery--

to assess patients' psychologic status. General anesthesia was standardized. PCA

pump with intravenous tramadol was used for a 24-hour postoperative analgesia. Visual

analog scale at rest (VASr) and after coughing (VASi) and tramadol consumption were

registered. Pearson's and point biserial correlations, analysis of variance, and step-wise

regression were used for statistical analysis.

 Result: Pearson r showed positive correlations between anxiety, depression, and

pain indicators (P<0.05). Moreover, female patients had higher pain indicators (P<0.05).

Analysis of variance showed that anxious (P<0.05) and depressed (P<0.001) patients

had higher pain indicators, which significantly decreased during the postoperative 24

hours (P<0.00001). Regression analysis revealed that tramadol consumption was

predicted by preoperative depression (P<0.001). VASr was predicted by sex and SRQ-

D (P<0.05). VASi was predicted by sex and SAS (P<0.05).

Conclusion: Pain perception intensity was primarily predicted by sex with an

additional role of depression and anxiety in determining VASr and VASi, respectively.

Patients with high depression levels required a larger amount of tramadol.

The study found out that patients with preoperative anxiety and depression had

higher pain intensities postoperatively and larger consumption of tramadol.

5. Does preoperative psychological status of patients affect postoperative pain?

A prospective study from the Caribbean. (Bradshaw, 2016)

Introduction: Patients with high anxiety states in the preoperative period often

have more intense postoperative pain, despite adequate pain control during the

intraoperative period. This study aimed to determine the relationship between the

preoperative psychological status and the pain experienced postoperatively in a sample

of Caribbean patients.

Method: A prospective study was conducted in elective surgical adult patients at

a teaching hospital in the Caribbean. Patients preoperative psychological status was

assessed using Hospital Anxiety and Depression Scale (HADS), and a preoperative

expected pain score was recorded. Postoperatively, observed pain scores at 4 and

24hours and the maximum pain score during 24hours were recorded. Demographic

data and clinical details including data regarding postoperative analgesia were

collected. Expected and observed pain scores were compared between patients with

and without anxiety and depression.

Result: A total of 304 patients were enrolled. The overall prevalence of anxiety

and depression was 43% and 27%, respectively, based on the HADS scores. There

were significant associations between the postoperative pain scores and factors such

as preoperative anxiety and depression (HADS) scores, preoperative expected pain

scores, patient educational level, presence of preoperative pain and surgical duration.

Age, gender, ethnicity and type of anesthesia did not impact postoperative pain scores.

Conclusion: The presence of preoperative anxiety and depression as indicated

by HADS score may significantly influence postoperative pain. Other factors such as

educational level, presence of preoperative pain and surgical duration may also impact

postoperative pain. Some of these factors may be modifiable and must be addressed in

the preoperative period.

The study suggests that anxiety and depression before surgery can significantly

influence the amount of pain a patient feels after surgery. The findings are potentially

important because they add to the evidence that the subjective experience of pain is

worth considering, both before and after a pain intervention.

6. Depression and postoperative complications: an overview. (Ghoneim, 2016)

 Introduction: The interaction of depression and anesthesia and surgery may

result in significant increases in morbidity and mortality of patients. Major depressive

disorder is a frequent complication of surgery, which may lead to further morbidity and

mortality.

Method: Depression may be identified through the use of Patient Health

Questionnaire-9 or similar instruments.

Conclusion: Depression is a frequent cause of morbidity in surgery patients

suffering from a wide range of conditions. Counseling interventions may be useful in

ameliorating depression, but should be subject to clinical trials.

The available literature suggests that depression is prevalent in patients before

major surgery. Non-alleviated, it may predict increased morbidity and mortality after the

operation. It may be associated with greater postoperative pain, higher incidence of

postoperative infections, progression of malignant tumors, poor health-related quality of

life as well as other complications.

IV. Synthesis

Strengths

Studies strongly shows association of anxiety and depression as an alleviating factor for

postoperative pain of patients. Adequate and recent research data provides strong

correlation between anxiety/depression and postoperative pain.

Weakness
Not being able to recognize anxiety and depression prior to surgery contributes to make

pain worse and much more difficult to manage.

Answer to the Statement of the Problem

1. What is the influence of preoperative emotional state on postoperative pain?

Increasingly, emotional factors play an important role in postoperative pain. Research

have analyzed that anxiety/depression or preoperative anxiety as predictors of

postoperative pain. Studies agree that there is an association between these factors, it

shows that anxiety is a predictor of postoperative pain. The higher the level of anxiety

and depression, the greater manifestation of postoperative pain.

2. What are the interventions to alleviate anxiety and depression in able to decrease or

reduce postoperative pain?

According to studies, nonpharmacological methods to reduce patient anxiety include

communication, humor, and music, all of which are simple and economical strategies.

The following are the nursing interventions for each method:

Communication

Speak in laymans terms.

Provide information in short sessions.
Obtain a complete medical history, including a history of psychiatric illness or

previous panic attack.

Explain the sequence of surgical events.
Ensure that all health care providers (eg, surgeon, anesthesia professional,

nurses) communicate with the patient.

Humor
Maintain cultural sensitivity.
 Allow patients to joke because this may reveal unfounded anxiety and fear

that the nurse can help alleviate.

Promote laughter.

Music

Play soft, soothing music.

Have music in the waiting room, preoperative area, surgical suite, and

postanesthesia care unit.

Allow the patient to bring a personal music player with headphones, if

appropriate.

Medication

Explore a premedication option.

Individualize the medication plan.
Educate the patient about medications that may be an option to prevent or

treat anxiety and panic attacks.

3. Other than increasing the risk for postoperative pain, what are the other possible

complication of anxiety and depression for postoperative patients?

Research shows that total pain experience, intensity of pain, psychiatric disorders,

preoperative state-anxiety, poor pre-operative self-perception of the future, history of

smoking and worst physical status constituted risk factors for postoperative state

anxiety. Furthermore, greater postoperative pain, higher incidence of postoperative

infections, progression of malignant tumors, poor health-related quality of life could be

also one of the effects of anxiety or depression postoperatively. And worst, it may

predict increased morbidity and mortality after the operation.

V. Conclusion

Managing anxiety and depression after or prior to surgery reduces the need for pain

medication therefore contributes in alleviating postoperative pain. Nonpharmacological

methods to reduce patient anxiety include communication, humor, and music. Anxiety

and depression also increases the risk for morbidity and mortality postoperatively.

VI. Recommendation

Researchers recommend to assess and treat anxiety and depression prior

postoperatively in able to avoid the higher risk and contribute more to the postoperative

pain that the patient will experience. Through proper nursing interventions anxiety and

depression could be addressed. Researchers also recommend to have a standardized

tool to measure anxiety and depression. To identify and determine different factors that

contribute to patients anxiety and depression prior to surgery.

VII. Appendices

References
Bradshaw, P., Does preoperative psychological status of patients affect postoperative

pain? A prospective study from the Caribbean. Retrieved from

http://journals.sagepub.com/doi/full/10.1177/2049463716635680. March 2016.

Evans, C., Alleviating Anxiety and Preventing Panic Attacks in the Surgical Patient.

Retrieved from https://www.aorn.org/websitedata/cearticle/pdf_file/CEA13508-

0001.pdf. March 2013.

Robleda, G., Influence of preoperative emotional state on postoperative pain following

orthopedic and trauma surgery. Retrieved from

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-

11692014000500785. October 2014.

Caumo, W., Risk factors for postoperative anxiety in adults. Retrieved from

http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2001.01842.x/pdf.

December 2012.

De Cosmo, G., Preoperative psychologic and demographic predictors of pain

perception and tramadol consumption using intravenous patient-controlled

analgesia. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18496304. June

2012.

Ghoneim, M., Depression and postoperative complications: an overview. Retrieved

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4736276/. February 2016.

 NATIONAL
UNIVERSITY
COLLEGE OF NURSING
551 MF Jhocson Street, Sampaloc Manila

EVIDENCE-BASED PRACTICE
(MIDTERM)
Submitted by:
NUR131 Group 2

Dimaporo, Nor Hazel

Fua, Sean Harvey
Gacayan, Wency
Venus, Paola Marie

Submitted to:
Mr. Fritz Gerald Jabonete, RN ,MAN
Clinical Instructor

January 17, 2017

Date of Submission
 Curriculum Vitae

Dimaporo, Nor Hazel M.

#513 M. Earn Shaw Street Sampaloc Manila
(+63) 09952466099
norhazeldimaporo@yahoo.com

EDUCATION

2013-present NATIONAL UNIVERSITY, Manila.

Bachelor of Science in Nursing

2009-2013 The University of Manila

2003-2009 National University

POSITIONS HELD

2011-2012 Sgt. at Arms

2006-2007 P.R.O in Filipino

School/University

NONE
 Curriculum Vitae

Venus, Paola Marie

#95 D Malvar Street Project 4, Quezon City
(+63)9156016007
paolamarievenus@yahoo.com

EDUCATION

2013-present NATIONAL UNIVERSITY, Manila.

Bachelor of Science in Nursing
Deans List: 1st Semester A.Y. 2015-2016

2009-2013 Jose P. Laurel Sr. High School

2003-2009 Pura V. Kalaw Elementary High School

POSITIONS HELD
2016-2017 National University Nursing Student Council President

2015-2016 National University Supreme Student Council

Nursing Representative

2014-2015 Class President

School/University
Blue Scholar
Photojournalist
Science Feature Editor
Marian youth Movement Member
 Curriculum Vitae

FUA, SEAN HARVEY S.

#123 Osmea St. Tondo Manila
(+63)9361445832
sean_harvey93@yahoo.com

EDUCATION

2016-present NATIONAL UNIVERSITY, Manila.

Bachelor of Science in Nursing

2014-2016 Adamson University

2010-2013 Universidad De Manila

2006-2010 Araullo High School

2002-2006 Holy Child Catholic School

POSITIONS HELD
2015-2016 Class President

2010-2012 Organization President

2005-2006 Organization President

School/University
Choir Member
Rondalla Member
Marian Youth Movement
Vincentian Missionary
 Curriculum Vitae

Gacayan, Wency G.
#562 Main St. Sampaloc, Manila
(+63)9305214459
wencygacayan@yahoo.com
wencgacayan1196@gmail.com

EDUCATION

2013-present NATIONAL UNIVERSITY, Manila.

Bachelor of Science in Nursing

2008-2012 Victorino Mapa High-Scool

2002-2008 Balala Elementary School

POSITIONS HELD
2008-2009 Class Vice President

2010-2012 Class President

2014-2015 Class Representative

School/University
Swimming Athlete
Drum and Lyre Member
Young Mens Christian Association Member
ASG Leader