Health post-operative anxiety were concern about family in (89.6%),

Health is a complete sense of wellbeing in term of physical,
psychological, social, spiritual and mental health and not merely the absence
of disease or disability.(1) The internal environment of human body
composed of physical and psychological components and there is balance in these
components. The objectives of nursing health care delivery is either to
preserve the balance or to restore the lost balance as result of illness or
disease processes.(2) Whenever the balance in the physical and psychological
components are lost i.e illness or disease takes place and peoples usually have
to hospitalized either for the maintenance or continuity of the stat of health.(3)

The process of Hospitalization regardless of the cause create
various reactions in different peoples such as anxiety, fear and depression.
Studies shows that hospitalization for any minor or major surgical procedure
induce stress in patients and they perceive a threat to their health and as a
result different reactions are developed in which some are feeling of unknown,
unfamiliar hospital environment, receiving painful treatment, being away from
family, losing of job and the social stigma of death during anesthesia etc. (3-4)
 A study shows that the
pre-operative anxiety in western population is 60-80% while that in Pakistani
population it is 62% ( 73% in female and 42% in male).( 5-7) A study
conducted in Pakistan by Jawaid M,
et al. on “preoperative anxiety in elective surgeries” shows
that the most common contributing factors for pre and post-operative anxiety
were concern about family in (89.6%), fear of complications in (87%), surgery
results (82.4%), and postoperative pain  was (78.8%), while overall 56% patients experience
that their  anxiety alleviated by
detailed explanation regarding the operation and anesthesia. (8)  

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Surgery is a stressful event that make the patient anxious. Patient
admitted for any surgical procedure imagine the surgery as a pain, loss of
independence and distortion of body image and even threat to his life. Post-operative
pain and anxiety are the two main undesirable consequences of surgery in
surgical patients and if not managed adequately they can leads to delay
recovery and can increase the health care cost and hospital stay.(9) Pain
is the primary complaint of post-operative patient and its severity depends
upon several factors in which one of them is the type of surgery. (10) Pain
is a predictable part of post-operative experience Studies shows that
inadequate pain management in post-operative period will badly effect patient
physiological and psychological will being and will the patient stay prolong
that will over-burden the care givers financially. (11)

Pain derived from Latin word “Poena” means ‘punishment’. According
to International association of pain study “Pain is an acute or potential
danger or describe in terms of such danger. Pain should be viewed form 4 aspects such as
nociception, pain, suffering and pain behavior. The acute pain has meaning and
the underlying pathophysiology is obvious. Postoperative pain is one of the
form of acute pain. (12) The pathophysiology of postoperative pain
is multifactorial, and predominantly of inflammatory nature from skin incision
and tissue damage. Inflammatory cytokines, interleukins and prostaglandins
produced from the arachidonic acid pathway induce a neuro-inflammatory soup,
which sensitizes peripheral A ? and C fibers. Ischemia from retraction of
tissue, as well as disrupted blood supplies, contributes to pain significantly,
and is characterized by low tissue pH and high lactate levels at the site of
incision. (13-14)

It is now well recognized that prolonged insult to the body produces
changes in the nervous system, which alter the normal physiological response to
a noxious stimulus. Therefore pain is divided into three entities,
physiological and pathophysiological or clinical and psychogenic pain. The underlying
process in all the three are totally different. Physiological pain describes
the situation where a noxious stimulus activates peripheral receptors, which
transmit the information via several relays until it reaches the brain and is
recognized as harmful stimulus. This entity can also be often referred as
incisional pain.(12,13)

The factors responsible for development of clinical pain will
result in a stimulus response system that has quite different characteristics
from those of physiological pain. Inflammation or nerve damage gives rise to
changes in sensory processing at peripheral and central level with a resultant
sensitization. Once sensitization occurs the stimulus, which normally do not
produce pain, are perceived as painful and there is an exaggerated response to
painful stimulus. (12-14)

Surgery
in particular, produces biphasic insult on human body, which has implications
for pain management. First of all, during surgery there is trauma to tissue,
which produces noxious stimuli and great nociceptive input. Secondly, after
surgery there is inflammatory process at the site, which is also responsible
for noxious input. Both these processes sensitize the pain pathways. They occur
at peripheral level where there is a reduction in threshold of nociceptive
afferents and at a central level with an increase in excitation of spinal
neurons involved in pain transmission. It has profound implication for
management of acute pain and provoked interest in the use of preemptive
analgesics and new methods of postoperative pain management with new agents of
non-opioid type and in combination with opioid drugs. (11-14)      

Instead of technological advances in surgical techniques and pain
killer medicine, postoperative pain is one of the challenging issue for today
health care providers. Studies shows that pain perceived by surgery patients is
directly proportional to the extent of tissue injury, also it is believe that
pre-operative pain expectation correlate with post-operative pain experience. (15)
The psychological factors mainly anxiety and depression are considered
important predictors of post-operative pain and the perception of control over
pain is one of the psychological factor which has direct correlation with
decrease pain report and increase pain tolerance.(16) Studies also shows that
improper management of post-operative pain will produce greater anxiety in
patients for future medical interventions.(17)

Anxiety is define as the feeling of tension, nerviness, fear,
apprehension and high level of autonomic activity that fluctuate over time both
in degree and intensity. Also it is a non-pleasant emotional state or feeling
that a patient usually experience during a plain surgical procedure. It is an
emerging state that is usually result as a response against perceiving threat
that disrupt the bodily balance. Studies show that increased level of anxiety
in pre-operative stage leads to tachycardia, hypertension, and arrhythmia and
also increases postoperative pain. Anxiety has two components, i.e stat and
trait. Trait is the type of anxiety usually present in personality while stat
anxiety is a situational component of anxiety i.e it is because of some
specific situation or stat. As anxiety has both essential and non-essential
impact on human body. Low level of anxiety is good for health in sense of all
the body system work well. While one of the negative effect of increase level
of anxiety is pain. Studies show that anxiety modulate pain and as a result of
post-operative need of pain killer is increased. In the pre-operative period
high level of anxiety will increases pain intensity in post-operative period
and inversely it will make difficult the pain control. (3)
Similarly increased level of pain is associated with anxiety and fear and thus
effect the quality of life

                  Improper
management of pain in the post-operative stage is a well-known problem
throughout the world. Instead of technological advances in the field of
medicine, development of new standard for pain management and increase focus on
pain literature shows that there is still 75% patients suffer from
post-operative pain moderate to severely.(7) Studies show that
post-operative pain is the most undesirable outcome of surgery and if
inadequately managed (which is common) can leads to profound implication such
as delay recovery, increase hospital stay, increase mortality and morbidity as
well as cost and decrease quality of life.( )  Another study revealed that  Unrelieved post-operative pain leads to
negative clinical outcomes which includes deep vein thrombosis, pulmonary
embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound
healing, insomnia and demoralization. ( ) 
Other associated negative outcomes were extended length of stay,
readmission, and patient dissatisfaction with medical care. ( )

                  Early
discharge from hospital is becoming more common, largely due to economic
considerations. Postoperative recovery is a process beginning directly after
surgery and extending beyond discharge from hospital. Postoperative pain has
been found to interfere with the ability to function after surgery, being one
prime factor influencing the time of discharge from hospital. The recovery of
patients from surgery depends on both physical and psychological factors. Physical
factors include the resumption of bowel function, adequate pain management and
physical activity. These factors also depend on the patient’s knowledge as well
as the ability or courage to leave the hospital.

                  The
provision of adequate information pre- and postoperatively, as well as the
experience of a safe follow-up after hospitalization, is of great importance
for a shortened length of stay and avoidance of readmission. (15) Research
shows that preoperative information can lead to better care and recovery after
surgery. The patient should receive preoperative information as soon as the
operation is scheduled because it is more likely that the patient can absorb
the information before hospitalization.

                  Studies
shows that provision of pre-operative information to the patients regarding
hospital stay and his own role in recovery are helpful to decrease anxiety,
reduce length of stay and the patient develop a better compliance with care
plan after his surgery 7. Similarly preoperative counseling contribute
towards early mobilization that will reduce complications following abdominal
surgery. Counseling regarding surgical procedures is commonly employed at every
setup but less importance is given to additional counseling regarding postoperative
management. A study show that 31% of patients are unaware about their
pre-operative procedures and similarly 14% patient does not know about the
post-operative procedure. Also 95% patients need to be acknowledged about their
surgical procedures.(6)

Nurses play a vital role in the supervision and care of the patient
in pain and throughout the treatment process as compared to other health team
personals. Nurses utilize a various strategies such as administer pain
medications, pre-operative education and counselling, mind diversion therapies
and other copping strategies to tackle the pain and anxiety and monitor the
effects of their action. Empowerment can be defined as an established relationship between a nurse
and a patient in which there is a transfer of some power and control to the
patient (Sahlsten et al. 2008). In terms of empowerment, nurses and patients
can work together to identify the information, resources and support necessary
for patients to optimize their health and acquire a sense of purpose and
autonomy in their lives. To avoid a sense of power imbalance between nurses and
patients, it is important for patients to receive an explanation of why
treatment is necessary before it is executed (Spence Laschinger et al., 2010).
For the patient to participate actively in the process, it is important that
the nurse sees the patient as an individual. Information should not be given
solely by standardized procedures, but based on individual needs, combined with
appropriate explanations (Eld et al., 2006).

Technological
advancement in the field of medicine and allied health sciences provide
solution to complicated medical problem and develop treatment options but on
the other hand it also increase health care cost. Peoples living in third world
countries fail to get on time proper treatment for their medical problems
because of Expensive medical intervention and treatment. Therefore health care
providers trying alternative therapies to decrease health care cost, easily
applicable, have less side effects, alleviate financial burden and improve
patient care. In literature these therapies are called alternative medicine.
They are meditation, Yoga, counselling/patient education, guided imagery and
music therapy etc.

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