FACTORS PREDICTING POSTOPERATIVE FATIGUE AMONG PATIENTS WITH

CLOSED FRACTURE OF LEG UNDERGOING INTERNAL FIXATION

SURGERY IN KHANH HOA GENERAL HOSPITAL, VIETNAM

NGUYEN THI THUY TRANG

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE MASTER DEGREE OF NURSING SCIENCE

(INTERNATIONAL PROGRAM)

FACULTY OF NURSING

BURAPHA UNIVERSITY

AUGUST 2015

COPYRIGHT OF BURAPHA UNIVERSITY

This master thesis has been supported by the master and doctoral thesis

support grant from Burapha University,

fiscal year 2015

ACKNOWLEDGEMENT

Throughout my study as well as the completion of this thesis, there are many

people that I would like to express my gratitude. I would like to express my deep

appreciation to my major advisor, Assistant Professor Dr. Niphawan Samartkit for her

patience, unending guidance, support, encouragements and believing in me. I am

indebted to my co-advisor, Assistant Professor Dr. Pawana Keeratiyutawong for her

countless influential supports. I would like to offer my special gratitude to thesis

examination committee members for providing their suggestions and enriching my

thesis.

I extend my deeply felt gratitude to The South Central Coastal Region

Project for granting me the scholarship for a full time study in master of nursing

science in Thailand. Special thanks to the head nurse and staff of the Traumatology –

Orthopedic department, Khanh Hoa General Hospital for their great contributions.

Without their willingness to share their experiences with me, this thesis would not

have been successful. I am also very grateful to those people who participated in this

study, for taking their time to complete the questionnaires at the hospital.

My sincere thanks also go to colleagues at Khanh Hoa Medical College who

had to take on my responsibilities during my absence from work to study abroad. I

also would like to thank all Faculty members for their academic guidance and staff for

their warm hospitality during my study period here in the Faculty of Nursing, Burapha

University. My special acknowledgement also goes to all of my Vietnamese,

Indonesian, Bhutanese, Thai friends for their supports throughout my study in

Thailand.

Lastly, I am totally indebted to my parents, my parents in law, my younger

sister, my brothers and sisters in law for their strong prayers and blessings during my

two years away from home. My heartfelt thank you goes to my husband for his

support, encouragement and love. I will always remember the sacrifices he made for

me.

Nguyen Thi Thuy Trang

v

56910109: MAJOR: NURSING SCIENCE; M.N.S.

KEYWORDS: CLOSED FRACTURE OF LEG/ POSTOPERATIVE FATIGUE/

PAIN/ ANXIETY/ UNCERTAINTY

NGUYEN THI THUY TRANG: FACTORS PREDICTING

POSTOPERTIVE FATIGUE AMONG PATIENTS WITH CLOSED FRACTURE

OF LEG UNDERGOING INTERNAL FIXATION SURGERY IN KHANH HOA

GENERAL HOSPITAL, VIETNAM. ADVISORY COMMITTEE: NIPHAWAN

SAMARTKIT, Ph.D., PAWANA KEERATIYUTAWONG, Ph.D. 120 P. 2015.

This study was conducted to explore pain, anxiety, uncertainty and

postoperative fatigue as well as to investigate influences of pain, anxiety and

uncertainty on postoperative fatigue among patients with closed fracture of leg

undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam.

The Theory of Unpleasant Symptoms (TOUS) provided a conceptual framework for

this study. A simple random sampling technique was used to recruit 80 samples with

closed facture of leg undergoing internal fixation surgery patients from the

Traumatology – Orthopedic department at Khanh Hoa General Hospital, Vietnam.

Data collection took place during March to April 2015 by using the Patient’s Profile

Record Form, Numeric Pain Rating Scale to measure pain, Hospital Anxiety and

Depression Scale to measure anxiety, the Mishel Uncertainty in Illness Scale to

measure uncertainty and the Identity – Consequence Fatigue Scale to measure fatigue.

Data were analyzed using descriptive statistics and multiple regression analysis.

The results revealed that mean scores of pain, anxiety, uncertainty and

postoperative fatigue were 5.09 (SD = 1.71), 12.29 (SD = 3.78), 82.06 (SD = 10.57)

and 86.58 (SD = 15.06), respectively. Multiple regression analysis indicated that

42% of variance in postoperative fatigue was significantly predicted by pain, anxiety

and uncertainty (R2= .42, p < .001). Pain explained most variance in postoperative

fatigue (β = .35, p < .01), following by anxiety (β = .30, p < .01), and uncertainty

(β = .19, p < .05) respectively. The results provide important information to develop

effective nursing intervention for reducing fatigue among patients with closed

fracture of leg undergoing internal fixation surgery.

CONTENTS

Page

ABSTRACT ............................................................................................................... v

CONTENTS ............................................................................................................... vi

LIST OF FIGURES ................................................................................................... viii

LIST OF TABLES ..................................................................................................... ix

CHAPTER

1 INTRODUCTION ............................................................................................. 1

Background and significance ..................................................................... 1

Research objectives .................................................................................... 7

Research hypothesis ................................................................................... 7

Scope of the study ...................................................................................... 7

Conceptual framework ............................................................................... 7

Definition of terms ..................................................................................... 9

2 LITERATURE REVIEWS ................................................................................ 11

Overview of closed fracture of leg ............................................................. 12

Concepts of postoperative fatigue .............................................................. 21

The theory of unpleasant symptoms ......................................................... 29

Factors predicting postoperative fatigue among patients with closed

fracture of leg ............................................................................................ 32

Conclusion ................................................................................................. 36

3 RESEARCH METHODOLOGY ....................................................................... 37

Research design ......................................................................................... 37

Population and sample ............................................................................... 37

Setting of the study .................................................................................... 39

Research instruments ................................................................................. 40

Translation of the instruments ................................................................... 43

Validity and reliability of the instruments ................................................. 43

Protection of human subjects ..................................................................... 44

Data collection procedure .......................................................................... 44

Data analysis .............................................................................................. 45

vii

CONTENTS (cont.)

CHAPTER Page

4 RESULTS .......................................................................................................... 46

Description of sample characteristics including demographic

characteristics and medical information of the sample .............................. 46

Description of the studied variables including pain, anxiety, uncertainty

and postoperative fatigue ........................................................................... 49

Influence of pain, anxiety and uncertainty on postoperative fatigue among

patients with closed fracture of leg ............................................................ 52

5 CONCLUSION AND DISCUSSION ................................................................ 54

Summary of the study ................................................................................ 54

Discussion .................................................................................................. 56

Implications and recommendations ........................................................... 62

REFERENCES .......................................................................................................... 65

APPENDICES ........................................................................................................... 79

APPENDIX 1 ..................................................................................................... 80

APPENDIX 2 ..................................................................................................... 88

APPENDIX 3 ..................................................................................................... 97

APPENDIX 4 ..................................................................................................... 99

APPENDIX 5 ..................................................................................................... 102

APPENDIX 6 ..................................................................................................... 106

APPENDIX 7 ..................................................................................................... 110

APPENDIX 8 ..................................................................................................... 115

BIOGRAPHY ............................................................................................................ 120

LIST OF TABLES

Tables Page

1 Frequency and percentage of samples’ demographic characteristic .............. 47

2 Frequency and percentage of samples’ medical information ........................ 48

3 Frequency and percentage of sample’s the level of pain in the first three days

after surgery ................................................................................................... 49

4 Frequency and percentage of sample’s level of anxiety in the third day after

surgery ........................................................................................................... 50

5 Range, mean and standard deviation of sample’s studied variables including

pain, anxiety, uncertainty ............................................................................... 50

6 Range, mean, standard deviation and mean percentage of samples’

postoperative fatigue classified by subcategories .......................................... 51

7 Pearson correlation coefficient of samples’ pain, anxiety, uncertainty and

postoperative fatigue ...................................................................................... 52

8 Multiple regression analysis for variables predicting postoperative fatigue . 52

9 Range, mean, standard deviation for each item of HADS ............................. 111

10 Range, mean, standard deviation for each item of MUIS .............................. 111

11 Range, mean, standard deviation for each item of ICFS ............................... 113

LIST OF FIGURES

Figures Page

1 Research framework of the study .................................................................. 9

2 The unpleasant symptom model .................................................................... 32

CHAPTER 1

INTRODUCTION

Background and significance

Lower extremity trauma is common and it is increasing as a result of our

increasing mobile society, high-speed driving, and the influence of alcohol and drugs

(Finkelstein, Corso, & Miller, 2007; Ignatavicius, 2013). In developing countries like

Vietnam, with the high frequency of using motorbike, the rate of lower limb fracture

from traffic accident is even more common. According to statistics from the National

Road Safety Commission (2013), traffic accidents alone contributed to around 30,000

injuries including orthopedic trauma victims in Vietnam. In a survey on traffic

accidents in Can Tho city, the result indicated that a half of the victim of trauma

included lower limb injury. The result also stated that, most of those patients with

lower limb injury were treated with operation (Giang et al., 2013).

It was reported that most of the lower extremity fracture cases occurred

among young age and males groups (Amin et al., 2011; Giang et al., 2013). An

investigation on the incidence of orthopedic surgery intervention in a level I urban

trauma center with motorcycle trauma, Amin et al. (2011) showed that the average age

was 35 years, with men compared to women at a ratio of 8:1. According to the

statistics from World Health Organization [WHO] (2012), the majority of injuries on

the roads in Vietnam are among those aged between 15 and 49 years - the main labor

resource in the family and the most economically active group. Surgical intervention

of lower limb patient is considered as an emergency situation beyond patient’s

preparation and prediction. Potential surgery and negative consequences after surgery

such as limited movement and role obligations of hospitalization directly affect

surgical patients (Karanci & Dirik, 2003). Moreover, lower limb injuries, even when

expertly treated, are known to induce a considerable effect on the patient’s physiology

with the potential to create long-term permanent disabilities (McCarthy & Mackenzie,

2001; McKoy & Hartsock, 2000; Mock et al., 2000; Ponsford, Hill, Karamitsios, &

Bahar-Fuchs, 2008). Many those patients require a variety of treatments and

rehabilitation, which affects their social psychology and impedes their full complete

2

recovery even one year after trauma (Dischinger et al., 2004). Thus, delay in recovery

of post-operative surgery is an increasing burden to patient, family, health care

system, and the society.

Considering the period of time right after surgery, patients undergoing lower

limb surgery, particularly those who are treated with open reduction and internal

fixation (ORIF) operation, have to face with unpleasant symptoms such as pain,

dizziness, vomiting, dry mouth, headache, sleep disturbance, and fatigue (Adlin

Dasima, & Karis, 2013; Long, 2010; Mattila, Toivonen, Janhunen, Rosenberg, &

Hynynen, 2005; Pavlin, Chen, Penaloza, & Buckley, 2004). With high incidence and

longer duration than other symptoms, fatigue is considered as a factor delaying

surgical patient’s recovery in postoperative period (DeCherney, Bachmann, Isaacson,

& Gall, 2002). Postoperative fatigue is often expressed as a feeling of tiredness, strain

or exhaustion in the convalescence phase (Kennedy, 1988). Rubin, Hardy, and Hotopf

(2004 b) defined fatigue as ‘‘unpleasant and distressing symptoms associated with a

major impact on the patient’s quality of life”. Zargar-Shoshtari and Hill (2009)

asserted postoperative fatigue as a collection of physical and psychological symptoms

that delay return to normal activity after surgery. Moreover, postoperative fatigue is

also a kind of subjective feeling of discomfort and a condition with the loss of ability

to engage in normal work or daily life activities (Yu et al., 2015).

Today, despite having an advanced postoperative symptom management,

fatigue is still a common symptom after operation. The result of an investigation on

the prevalence of fatigue in postoperative hysterectomy patients, showed that overall

74 % of patients experienced moderate-to-severe fatigue within the first few weeks

after surgery (DeCherney et al., 2002). Rubin et al. (2004 b) reviewed 91 cohort

studies and confirmed that the prevalence of postoperative fatigue had increased up to

92 %. Long (2010) indicated that tiredness appeared as one of the most problematic

symptoms for three whole days after abdominal surgery among Vietnamese

population. Measuring fatigue by using 0 - 10 Visual Analogue Scale and Numeric

Scale, it was reported that in the first day after laparoscopic cholecystectomy surgery,

the average fatigue score presented at 1 hour was 6; 3 hours was 5 and 24 hours was 4

(Graversen & Sommer, 2013). Comparing fatigue between preoperative and

postoperative period, Yu et al. (2015) showed that the increase of fatigue from mean

3

1.65 (SD = .73) before surgery to mean 7.14 (SD = 0.72) on the first day, mean 4.23

(SD = 1.00) on the 10th

day, and to mean 2.34 (SD = .90) on the 30th

day after surgery.

Postoperative fatigue has a huge impact on physical, psychological, and

social life of patients after undergoing surgery. Physically, postoperative patients’

immobility due to fatigue leads to many complications. Zalon (2004) investigated the

recovery among 60 major abdominal surgery patients and reported that pain,

depression, and fatigue explained 13.4 % of the variation in functional status for three

to five days after surgery; 30.8 % for one month and 29.1 % for three months after

discharge. Moreover, earlier the initiation of rehabilitation treatment after total knee

arthroplasty, the better the outcome (Labraca et al., 2011). However, suffering fatigue

makes patient with leg surgery lose effort to adhere to physical therapy designed for

early rehabilitation phase. Thus, patients with lower limb fracture after operation

showed significantly less joint range of motion, and higher scores for gait and balance

(Ersözlü, Sahin, Ozgür, & Tuncay, 2009; Labraca et al., 2011). Furthermore, it is

extremely challenging for lower limb injury patients to mobilize by using assistive

equipment after surgery because of fatigue (Susilahti, Suominen, & Leino-Kilpi,

2004). Staying in bed or immobility caused by fatigue is considered as a high risk for

the development of incision complication, deep vein thrombosis of the lower

extremity, respiratory decompensation/ pneumonias, pulmonary embolism, urinary

tract infections, sepsis or infection, malunion, muscle atrophy, and delay bone healing

process (Epstein, 2014; Ignatavicius, 2013; Zhang et al., 2012).

In addition to the impact on physical health, fatigue can also be a source

affecting psychological and social aspects of patient’s life. Postoperative fatigue

contributes substantially to feelings of frustration, depression, or hopelessness and to

difficulty in concentrating or being attentive; some patients describe fatigue as a

‘‘change in emotional state’’ (DeCherney et al., 2002). Rubin, Cleare, and Hotopf

(2004 a) also reported that patient’s psychological health has a close relationship with

postoperative fatigue. Moreover, because of physical impairment due to fatigue,

postoperative patients may have longer hospital stay, preventing them from returning

to work. A large numbers of patients report loss of salary as a result of this prolonged

surgical recovery time. Patients miss an average of 6 weeks of work after

uncomplicated abdominal operations (Bisgaard, Klarskov, Rosenberg, & Kehlet,

4

2001; DeCherney et al., 2002). Compare to patients with less fatigue, tired patients

placed significantly greater demands on their primary health care teams (Bisgaard et

al., 2001; DeCherney et al., 2002; Rubin et al., 2004 b). Researchers asserted that

recovery time lasts longer than normal because of fatigue and it also has a similar

impact on caregivers (Bisgaard et al., 2001). With a huge impact on both physical and

emotional health, fatigue after surgery can have a negative effect on patient’s quality

of life (Wijesuriya, Tran, Middleton, & Craig, 2012). If fatigue persists for a long

time, it may delay getting back to recreational activities and prolong the time to return

to normal work (Rubin et al., 2004 b; Wijesuriya et al., 2012).

One of the most important tasks of a surgical nurse is help patient to manage

their fatigue after surgery. In order to do that, understanding the factors influencing

postoperative fatigue is extremely crucial. As mentioned above, fatigue is an

unpleasant symptom and according to Lenz, Pugh, Milligan, Gift, and Suppe (1997), it

can be announced that postoperative fatigue is affected by various factors classified

into three categories, that is physiologic, psychological, and situational antecedents.

However, findings from previous studies in investigating factors influencing

postoperative symptoms have inconsistently supported variables derived from

situational factors (Ai, Wink, & Shearer, 2012; Long, 2010). For physiologic and

psychologic antecedents, researchers have been investigating factors that can affect

postoperative fatigue such as pain, anxiety and uncertainty (Lasker, Sogolow, Olenik,

Sass, & Weinrieb, 2010; Montgomery, Schnur, Erblich, Diefenbach, & Bovbjerg,

2010; Rubin et al., 2004 a).

Derived from physiologic antecedent, pain is considered as an important

factor influencing postoperative fatigue. Pain is defined by International Association

for the Study of Pain as an unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in terms of such damage (Lubkin

& Larsen, 2006). An investigation on 101 breast cancer surgical patients, the result

indicated a positive correlation (r = .36, p < .001) between pain severity and fatigue

(Montgomery et al., 2010). With regard to abdominal surgery population, in the first

and second day after surgery, pain showed correlation with fatigue (r = .39, p < .001

and r = .19, p < .05) (Long, 2010). In another study, it was shown that pain explained

for 20 % of variation in fatigue (Beck, Dudley, & Barsevick, 2005). Saowaluck (2009)

5

asserted that pain was significant predictors of postoperative fatigue (β = .28, p < .01).

It was also indicated that although several variables were found to contribute to the

severity of fatigue, the presence of pain explained up to 7.6 % of variance of fatigue

(Lee, Miller, Townson, Anton, & F2N2 Research Group, 2010). By using multiple

logistic regression models, Garabeli Cavalli Kluthcovsky et al. (2012) showed that the

presence of pain was one of predictive factors for postoperative fatigue (OR = 3.87,

95 % CI = 1.88 - 7.98, p = .000).

In addition to pain, anxiety is a significant psychological predictor for

subjective feeling of fatigue after surgery. Mental disorders such as anxiety and

depression are common in hospital inpatients, with an estimated prevalence of

20 - 40 % in worldwide studies (Grau Martin, Suner Soler, Abuli Picart, & Comas

Casanovas, 2003; Hansen et al., 2001) and especially high in orthopedic trauma

(Becher, Smith, & Ziran, 2014; de Moraes, Jorge, Faloppa, & Belloti, 2010). An

assessment of the relationship between postoperative fatigue and anxiety in 183

surgical patients showed that psychological processes including anxiety may well be

relevant in the etiology of postoperative fatigue (Rubin et al., 2004 a). An examination

in abdominal surgery population, the result indicated that on the second day after

surgery, anxiety had association with tiredness (r = .33, p < .01) (Long, 2010). The

increase in psychological distress is a factor related to worsening fatigue after surgery

(Rotonda, Guillemin, Bonnetain, Velten, & Conroy, 2013). In 180 postoperative

patients with breast cancer, the finding showed that moderate/ severe fatigue was

positively associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05)

(Tan & Xia, 2014). After controlling for all other variables, depression variable was a

significant predictor of postoperative fatigue (β = .40, p < .01) in hysterectomy

population (Saowaluck, 2009).

Another important psychological antecedent of patients’ postoperative

fatigue has been considered is uncertainty. Fracture of leg is often an acute injury,

surgery for treatment of these surgical patients come up unexpectedly. Hence, these

patients do not have any preparation for getting operation, staying in hospital for a

long time up to 7 to 10 days, coping with many postoperative symptoms, leaving

family and work. In addition, being unsatisfied with information getting from

healthcare provider is a common complaint of Vietnamese patients, it makes surgical

6

patients suffer uncertainty (Loi, 2014). Previous research findings proved the

relationship between fatigue and uncertainty. Providing adequate medical information

will reduce illness uncertainty for patients and this in turn is an important strategy in

reducing fatigue (Stiegelis et al., 2004). In heart failure population, the finding also

confirmed a positive association between uncertainty and tiredness (Falk, Swedberg,

Gaston-Johansson, & Ekman, 2007). Conducting a study in 100 female patients

undergoing liver transplantation operation, Lasker et al. (2010) indicated that there

was a significant relationship between uncertainty and fatigue.

Khanh Hoa General Hospital is the biggest general hospital in Khanh Hoa

province. In Traumatology – Orthopedic department, there are many patients

undergoing open reduction and internal fixation (ORIF) surgery. In the postoperative

phase, the problem of caring for this group of patient is that they always stay in bed,

immobilize, delay getting back to activities of daily livings (ADLS) and refuse to take

part in rehabilitation sessions. These are risk factors for the development of many

severe complications. As previously mentioned, fatigue plays an important part in

these performances. Understanding the factors affecting fatigue among fracture

patients following internal fixation surgery is the first crucial step to improve the

quality of postoperative nursing care in Khanh Hoa General Hospital, Vietnam.

In conclusion, the experience of postoperative fatigue varies among

individuals, reflecting their physiological, psychological, and social differences. There

are many factors leading to fatigue after surgery. Among them, pain, anxiety, and

uncertainty have been highlighted as reliable factors and they are supported by

previous research findings. Understanding the characteristics of fatigue and predicting

factors is crucial for nurses to improve the quality of care for postoperative patients.

Nurses will also be able to differentiate the patients who are at higher risk of

experiencing severe fatigue after surgery. However, most of studies reviewed almost

exclusively from abdominal surgery and cancer population; there has been few

researches focusing on postoperative fatigue in orthopedic population (Long, 2010;

Saowaluck, 2009; Tan & Xia, 2014). In addition, with the increasing rate of trauma

and injury by traffic accident in Vietnam and overload of patient admission and longer

hospital stay (7 - 10 days) in the Traumatology – Orthopedic department, Khanh Hoa

General Hospital, a homogeneous model such as lower limb fracture sample needs to

7

be employed. Thus, a study of factors predicting postoperative fatigue among patients

with closed fracture of leg after undergoing internal fixation surgery in Vietnamese

population is necessary.

Research objectives

1. To describe the characteristics of pain, anxiety, uncertainty, and

postoperative fatigue among patients with closed fracture of leg undergoing internal

fixation surgery in Khanh Hoa General Hospital, Vietnam.

2. To examine the influence of pain, anxiety, and uncertainty on

postoperative fatigue among patients with closed fracture of leg undergoing internal

fixation surgery in Khanh Hoa General Hospital, Vietnam.

Research hypothesis

Pain, anxiety, and uncertainty predict postoperative fatigue among patients

with closed fracture of leg undergoing internal fixation surgery in Khanh Hoa General

Hospital, Vietnam.

Scope of the study

This study examined the influence of pain, anxiety, and uncertainty on

postoperative fatigue among patients with closed fracture of leg undergoing internal

fixation surgery. The population of the current study was patients with closed fracture

of femur, tibia and fibula bone undergoing internal fixation surgery. Data collection

was performed at the Traumatology – Orthopedic department of Khanh Hoa General

Hospital in Khanh Hoa province, Vietnam from March to April, 2015.

Conceptual framework

The theory of unpleasant symptoms [TOUS] (Lenz et al., 1997) was used as

a framework for this study. The TOUS has three major components: the symptoms

that the individual is experiencing, the influencing factors that give rise to or affect the

nature of the symptom experience, and the consequences of the symptom experience”.

Symptoms have the dimensions of intensity (severity), timing (frequency, duration,

8

and relationship to events), distress (the person’s reaction to the sensation), and

quality (descriptors used to characterize the symptom, location of the symptom, or

response to intervention). These symptom dimensions are influenced by three

categories of variables: physiologic factors, psychologic factors, and situational

factors. Physiological factors are often reflected in unpleasant symptoms associated

with alterations in the normal functioning of bodily systems or the existence of any

pathology. The psychological factors that are antecedents include the individual’s

mental state or mood (depression), affective reaction to illness (mood status),

psychological response to stress (the degree of perceived stress or the level of anxiety)

and degree of uncertainty and knowledge about the symptoms and their possible

meaning (perception of illness experience or symptom experience). Situational/

environmental antecedents include aspects of the social and physical environment that

may affect the individual’s experience and reporting of symptoms (Lenz et al., 1997).

The outcome or consequence of the symptom experience is the final component of the

Theory of Unpleasant Symptoms. Performance is conceptualized to include the

functional status or performance, cognitive functioning, and physical performance.

In the present study, postoperative fatigue is considered as a symptom that

the individual is experiencing. Based on the meaning of antecedent factors, pain

belongs to the physiologic factor; anxiety and uncertainty are the psychologic factor.

According to the theory of unpleasant symptoms (Lenz et al., 1997), those above

factors could relate to the symptom of fatigue among patients following internal

fixation surgery for closed fracture of leg. Moreover, to date, a large body of research

has consistently confirmed the relationship among pain, anxiety, uncertainty and

postoperative fatigue. In abdominal surgery population, in the first and second day

after surgery, pain showed correlation with fatigue (r = .39, p < .001 and r = .19,

p < .05) (Long, 2010). After a hysterectomy operation, pain was a significant predictor

of postoperative fatigue (β = .28, p < .01) (Saowaluck, 2009). In 180 postoperative

patients with breast cancer, the finding showed that moderate/ severe fatigue was

positively associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05)

(Tan & Xia, 2014). After controlling for all other variables, depression variable was a

significant predictor of postoperative fatigue (β = .40, p < .01) in hysterectomy

population (Saowaluck, 2009). Furthermore, the positive association between

9

uncertainty and tiredness was confirmed in heart failure population (Falk et al., 2007).

In patients after liver transplant operation, Lasker et al. (2010) indicated that there was

a significant relationship between uncertainty and fatigue. Therefore, the influence of

pain, anxiety, and uncertainty factors on postoperative fatigue among patients with

closed fracture undergoing internal fixation surgery will be examined in this study as

demonstrated in figure 1.

Independent variables Dependent variable

Figure 1 Research framework of the study

Definition of terms

Postoperative fatigue refers to an unpleasant and distressing symptom with

feeling of tiredness, strain, exhaustion and lack of vigor in the first three days after

internal fixation surgery for patients with closed fracture of leg; being associated with

impacts on concentration, energy and daily activities. In the current study,

postoperative fatigue was measured by using The identity - consequence fatigue scale

developed by Paddison, Booth, Hill, and Cameron (2006).

Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such damage among

patients with closed fracture of leg undergoing internal fixation surgery. In this study,

pain was measured by using numeric pain rating scale (NPRS) (McCaffery & Beebe,

1989).

Physiologic factor

- Pain

Psychologic factors

- Anxiety

- Uncertainty

Postoperative fatigue

among patients with closed

fracture of leg undergoing

internal fixation surgery

10

Anxiety refers to an emotional state involving subjective feelings of tension,

apprehension, nervousness, and worry experienced by patients with closed fracture of

leg undergoing internal fixation surgery. Anxiety in the present study was measured

with the hospital anxiety and depressed scale (HADS) (Zigmond & Snaith, 1983).

Uncertainty is a cognitive state indicating inability to determine the

meaning of illness-related events, occurring when patients with closed fracture of leg

undergoing internal fixation surgery are unable to assign definite value to objects or

events, or are unable to predict outcomes accurately. In this study, uncertainty variable

was measured with the Mishel uncertainty in illness scale (MUIS) (Mishel, 1981).

CHAPTER 2

LITERATURE REVIEWS

This study examines postoperative fatigue and its predicting factors among

patients with closed fracture of leg undergoing internal fixation surgery. The literature

review presents an overview about issues related to the study, including:

1. Overview of closed fracture of leg

1.1 Background of closed fracture of leg

1.2 Pathophysiology of closed fracture of leg

1.3 Principles of treatment for closed fracture of leg

1.4 Symptoms after surgery for closed fracture of leg

2. Concepts of postoperative fatigue

2.1 Definition of postoperative fatigue

2.2 Pathophysiology of postoperative fatigue

2.3 Causes of postoperative fatigue

2.4 Classification of postoperative fatigue

2.5 Impacts of postoperative fatigue

2.6 Management for postoperative fatigue

3. The Theory of Unpleasant Symptoms

4. Factors predicting postoperative fatigue among patients with closed

fracture of leg

4.1 Pain

4.2 Anxiety

4.3 Uncertainty

12

Overview of closed fracture of leg

Background of closed fracture of leg

Closed fracture of leg is a medical condition in which there is a break in the

continuity of the leg bone with overlying skin being intact. It has happened more than

open fracture and caused commonly by trauma such as a fall, road traffic accident,

fight, etc. (Stannard, Duke, & Alonso, 2008).

Lower extremity trauma is increasingly common and leading cause of

physical trauma to patients admitted to hospitals in the United States (Vyrostek,

Annest, & Ryan, 2004). Each year, trauma accounts for 41 million emergency

department visits and 2.3 million hospital admissions across the United States

(National Trauma Institute, 2014). An exploration on incidence of orthopedic surgery

intervention in a level I urban trauma center with motorcycle trauma, Amin et al.

(2011) showed that the most common site of fracture involved the lower extremities

with average age was 35 years, with men compare to women at a ratio of 8:1. In

Vietnam, according to statistics from the National Road Safety Commission (2013),

traffic accidents caused up to 30,000 injured people including orthopedic trauma

victims. A survey on trauma by traffic accident in Can Tho, showed that half of the

victims suffered lower limb trauma, needing surgical treatment (Giang et al., 2013).

Results from this study also reported that 71.4 % patients were men and 66.7 %

victims were the main labor resource in the family and most economically active

group.

Lower limb injuries, even when expertly treated, are known to induce a

considerable effect on the patient’s physiology, they have the potential to create long-

term and permanent disabilities (McCarthy & Mackenzie, 2001; McKoy & Hartsock,

2000; Mock et al., 2000; Ponsford et al., 2008). Many patients with lower limb

injuries require a variety of treatments and rehabilitation, which affects their social

psychology and impedes their full/ complete recovery even one year after trauma.

(Dischinger et al., 2004). In a prospective study of 215 fractured patients after

orthopedic trauma, 1 in 5 met the threshold for psychological distress (Bhandari et al.,

2008). A literature review from two authors, Remizov and Lungu (2008) concluded

that there was reduction in quality of life among patient with lower limb fracture.

A common source of patient complaints and clinical outcome is not only focused on

13

unpleasant symptoms such as pain, fatigue, disturbances of sleep, limitation of

mobility but also functional recovery, complications, mortality, costs and

psychological status following orthopedic trauma (Remizov & Lungu, 2008).

Today, in the modern society closed fracture of lower limb is the most

common health issue, affecting great aspect of the quality of life in trauma population.

It is important to understand the systemic impact of lower extremity injuries in order

to decrease their morbidity and increase the potential function following rehabilitation.

Pathophysiology of closed fracture of leg

A fracture is a break or disruption in the continuity of a bone that often

affects mobility and sensation (Ignatavicius, 2013). It can occur anywhere in the body

and at any age. All fracture has the same basic pathophysiologic mechanism

regardless of fracture type or location. A fracture is described by the extent of

associated soft-tissue damage as open (or compound) or closed (or simple). When a

bone is fractured, vascular disruption with blood dispersing through soft tissue causes

ecchymosis. Over an area of injury, continuous muscle contraction occurs and

considered a protective mechanism of the muscle to splint the injured part (LeMone &

Burke, 2008). In addition, bone fracture fragments cause injury to the soft tissue and

interruption of the venous and lymphatic return system lead to swelling condition at

trauma place. Pain is usually caused by injury to the periosteum, muscle spasm, soft

tissue disruption, and swelling with fascial compartments. Deviation from normal rage

or limitation of motion or muscle strength is noted (Smith, Stahel, Morgan, & Trafton,

2008; Walsh, 2009).

Fractures of the lower two thirds of the femur usually result from trauma

often from a motor vehicle crash (Stannard et al., 2008). Extensive hemorrhage can

occur with femur fracture. Untreated fractures of the lower limbs can lead to

significant blood loss, which may be external and obvious, or covert. The estimated

blood loss for a closed fracture of the femur is 1,000 - 1,500 ml and for a closed

fracture of the tibia is 500 - 1,000 ml. Fractures of the lower limb, particularly the

femur, should be considered a potential cause of hypovolemic shock, especially if

compound (Lee & Porter, 2005). In a few cases in which extensive bone

fragmentation or severe tissue trauma is found. Healing time for a femur fracture may

be 6 months or longer (Ignatavicius, 2013).

14

When a bone is fractured, the body immediately begins the healing process

to repair the injury and restore the body’s equilibrium. Fractures heal in five stages

that are a continuous process not a single stage (Smith et al., 2008). Stage one begins

within 24 to 72 hours after the injury, a hematoma forms at the site of the fracture

because bone is extremely vascular. Stage two occurs in 3 days to 2 weeks when

granulation tissue begins to invade the hematoma. This then prompts the formation of

fibrocartilage, providing the foundation for bone healing. Stage three a bone healing

occurs as a result of vascular and cellular proliferation. The fracture site is surrounded

by new vascular tissue known as a callus within 3 to 6 weeks. Callus formation is the

beginning of a non-bony union. That healing continues is stage four, the callus is

gradually resorbed and transformed into bone. This stage usually takes 3 to 8 weeks.

During the fifth and final stage of healing, consolidation and remodeling of bone

continue to meet mechanical demands. This process may start as early as 4 to 6 weeks

after fracture and can continue for up to 1 year, depending on the severity of the injury

and the age and health of the patient (Ignatavicius, 2013)

Even pathophysiologic mechanism is quite similar for various types of

fractures; the identified treatment is more complicated.

Principles of treatment for closed fracture of leg

deWit and Kumagai (2013) reported that the three principles are used when

treating fractures are reduction, retention, and rehabilitation

1. Reduction

Due to the force of impact or surrounding muscle groups, the normal

alignment of the affected bone may be compromised. If this is the case and the

alignment of the bone is not satisfactory, the position of the fragments will need to be

altered in order to maximize bone healing in the correct position. Not all fractures

result in misalignment, and in these circumstances reduction will not be indicated.

Soft tissue swelling post injury can cause difficulty in reduction and for this reason

there should be no unnecessary delay. There are two types of reduction: closed

reduction and open reduction (deWit & Kumagai, 2013).

1.1 Closed reduction: If the degree of displacement is minimal, or in most

pediatric fractures, the option of closed reduction is preferred. This can be with

repositioning in a regular clinical setting with analgesia or manipulation under

15

anesthetic, where the patient is taken to theatre and the fracture is reduced by the

surgeon with the assistance of X-ray (deWit & Kumagai, 2013).

1.2 Open reduction: Surgical intervention is required if closed reduction

fails, or if initially the degree of displacement is significant. Open reduction is usually

the first stage to internal fixation.

2. Retention

The theory behind retention the fracture is to hold the bone fragments in a

good position for healing, prevent excessive movement that could hamper fracture

union (this may require joint immobilization proximal and/ or distally) and reduce

pain. There is no hard and fast rule for which fracture should be stabilized by which

method. Each fracture is individual and should be managed as such, also taking into

account patient factors. Stabilization falls into two broad categories, conservative and

operative. Methods of fracture retention are discussed respectively (LeMone & Burke,

2008).

2.1 Conservation

2.1.1 Casting, usually with Plaster of Paris is a splint to maintain the

either original or post reduction position.

2.1.2 Traction, a calculated force is applied to the long axis of the

bone, causing opposing fragments to separate and align in the correct position. This is

enabled with specialized equipment using weights to generate the traction force.

Traction can be applied in either of these two methods: skin traction and skeletal

traction. Skin traction where the device is applied superficially, around the skin.

Secondly, skeletal traction where per cutaneous pins are directly attached to the distal

bone fragment.

2.2 Operation

Open reduction and internal fixation (ORIF) is one of the most common

methods of reducing and immobilizing a fracture. Using ORIF surgery may decrease

pain and help broken leg heal correctly, restore the bone to its normal function and

prevent further injury. Furthermore, ORIF is often the preferred surgical method due

to permit early mobilization. Open reduction allows the surgeon to directly view the

fracture site. Internal fixation uses metal pins, crews, rods, plates, or prostheses to

immobilize the fracture during healing. Krishner wires, also known as K-wires is per

16

cutaneous insertion, across the fracture site to maintain alignment. Plates and screws

usually used in conjunction to provide mechanical stability as well as ensuring

maintenance of alignment. Screws can also be used independently, across a fracture

site. Intramedullary nailing, most commonly used in long bones; a nail is passed along

the long axis of the bone, within the cortex, acting as an internal splint. External

fixation provides stability away from the fracture site, without interruption of soft

tissue structures with screws are applied to the proximal and distal fragments of the

bone, and attached to an external frame. The surgeon makes one or more incisions

gain access to the broken bones and implants one or more devices into bone tissue

after each fracture is reduced. After the bone achieves union, the metal hardware may

be removed, depending on the location and type of fracture. If the metal implants are

not bothersome, they may remain in place (deWit & Kumagai, 2013; Stannard et al.,

2008).

3. Rehabilitation

Once the fracture has been stabilized and the healing process is underway,

attention is diverted to functional improvement and a return to normality. Early

mobilization is often encouraged, providing stability is not compromised. This aids in

avoiding joint stiffness, loss of muscle power and edema. Rehabilitation is tailored

according to both the injury and patient circumstance. Multidisciplinary input is used

in varying degree, including the expertise of physiotherapists and occupational

therapists if necessary (deWit & Kumagai, 2013).

The patient’s rehabilitation program was divided into 3 phases: the first

phase is from the first day after surgery to postoperative week 4; phase two is

postoperative time from week 4 to week 8, and the last phase is post surgery week 16

to month 8. The purpose of rehabilitation program for lower limb fracture patients

focuses on immediate weight bearing and progression of gait training, range of

motion, strength, balance, and return to function. In range of this study, it is really

important to understand about the designed rehabilitation sessions for the first phase,

particularly during hospitalization time (Paterno, Archdeacon, Ford, Galvin, &

Hewett, 2006).

Exercises in phase I focus on hip and knee joint mobility, non–weight-

bearing strengthening, and progression of weight bearing during gait. Inpatient

17

physical therapy is ordered twice daily and consisted of gentle range of- motion

activities, initiation of a weight-bearing-as tolerated ambulation program with either a

walker or bilateral axillary crutches, and lower-extremity isometric exercises. Usually,

the patient uses bilateral axillary crutches immediately following surgery. Active-

range-of-motion and passive-range-of-motion exercises of the hip, knee, and ankle are

initiated immediately following surgery in all 3 cardinal planes. The main initial focus

is knee extension. Full knee extension is pursued aggressively immediately following

surgery to decrease the risk of knee flexion contracture. Passive and active assisted

knee flexion exercises are initiated while the patient is in the seated position on a chair

or table. The patient performs posterior lower-extremity stretching, including seated

hamstring muscle stretching and seated gastrocnemius muscle stretching with the

assistance of a towel. In addition, the patient’s involved lower extremity is elevated

with the heel propped up for 10 minutes 3 or 4 times per day. This static heel propping

stretch is intended to provide a low-load, long-duration stretch of the posterior knee

(Paterno et al., 2006).

Orthopedic nurses play an important role in early rehabilitation phase,

especially during the first 3 days after surgery in providing care for lower fracture

patients. In early rehabilitation, effective assessment and management of unpleasant

symptoms bring good quality of care, improve patient satisfaction, and limit post-

surgery complications. Furthermore, the patient with a fracture after surgery is

expected to have no compromise in neurovascular status as evidenced by adequate

circulation, movement, and sensation. Perform neurovascular assessment before and

after fracture treatment is recommended for all health care provider in surgical ward

(Burden, 2007). Additionally, nursing care for postoperative fracture patients in early

rehabilitation phase should increase physical mobility to prevent associated

complications with impaired mobility. The patient is recommended to move

purposefully in his or her own environment independently with or without and

ambulatory device unless restricted by traction or other modality. The use of crutches

or a walker increase mobility and assists in ambulation. In most agencies, the physical

therapist or emergency department/ambulatory care nurse fits the patient for crutches

and teaches him or her how to ambulate with them. Reinforce those instructions, and

evaluate whether the patient is using the crutches correctly (Mamaril, Childs, &

18

Sortman, 2007).

Helping patients reduce the unpleasant symptoms will make them physically,

psychologically and socially able to stay adhered to designed therapeutic program; this

in turn will give them faster and better recovery. In order to do that, the nurses need to

have a sound scientific knowledge of the signs and symptoms troubling their patients

and impeding the healing.

Symptoms after surgery for closed fracture of leg

Despite significant interest in improving postoperative symptoms

management, the rate of symptom clusters is still high. Concerning the first 3 days

after surgery, these symptoms are more severe and make a huge impact on patient

health satisfaction. Literature reviews revealed a wide variance in prevalence of

symptoms following operation including pain, sleep disturbance, fatigue, nausea and

vomiting, dizziness, drowsiness, headache and voiding difficulty (Adlin Dasima &

Karis, 2013; Long, 2010; Mattila et al., 2005; Pavlin et al., 2004).

1. Pain: Orthopedic surgery is often cited as among the most painful of

surgeries (Adlin Dasima & Karis, 2013). It has since been repeatedly confirmed that

30 - 80 % of patients undergoing surgery suffer from inadequately treated pain

(Mwaka, Thikra, & Mung’ayi, 2013; Pavlin et al., 2004; Pitimana-Aree et al., 2005;

Zaslansky et al., 2006). At 4, 24, 48 and 72 hours postoperatively, the incidence of

moderate to severe pain (VAS ≥ 40) at rest is 39 %, 43 %, 27 % and 16 %,

respectively. During the first 24 hours after operation, 88 % of patients experienced

moderate or severe pain at some time and 7 % of them reported unbearable pain

(Svensson, Sjostrom, & Haljamae, 2000). The mean score measured by visual analog

scale in the first two days was 40 (SD = 29) and on the third day was 20 (SD = 26).

In a large Dutch cohort of 1,490 surgical patients who received postoperative pain

treatment, patients still experienced moderate to severe pain on the day of the surgery,

which continued in 15 % at four days after surgery (Sommer et al., 2008; Sommer

et al., 2010). Despite significant advances in the understanding of pain mechanisms

and innovative developments of analgesic and anesthetic agents, acute postoperative

pain control remains a challenge in about one-third of surgical patients (Wu & Raja,

2011).

19

Postoperative pain management in orthopedic surgery

Provision of sufficient post-operative pain therapy is an obligation in the

clinical management of patients. Assessment and evaluation of pain are as important

as the correct use of analgesics and application techniques (Giesa et al., 2007).

Opioids, administered intramuscularly, as epidurals, or IV as patient-controlled

analgesia, are effective for severe pain. Oral opioids are effective for moderate to

severe pain, and tramadol is selected for moderate to moderately severe pain. Opioid-

sparing NSAIDs, such as ketorolac, and COX-2-specific NSAIDS have use in pain

management of hip, knee, and ACL procedures. An individualized regimen of

appropriate analgesics, combined with nonpharmacologic treatments such as physical

therapy or cryotherapy and patient education, can aid orthopedic surgery patients'

recovery (Bourne, 2004).

2. Fatigue: Fatigue is one of the most common symptoms after undergoing

operation and can negatively affect functioning. Upon measuring 63 patients

undergoing major joint arthroplasty 1 week after surgery, the result showed physical

and mental fatigue is less than preoperation but the mean scores of physical fatigue

indicate more than usual (Aarons, Forester, Hall, & Salmon, 1996). To assess the

prevalence and impact of postoperative fatigue from the postoperative hysterectomy

patient's perspective, the result showed that overall, 74 % of patients experienced

moderate-to-severe fatigue within the first few weeks after surgery and fatigue

occurred more frequently and persisted twice as long as pain, the next most frequent

symptom, which was experienced by 63 % of patients overall (DeCherney et al.,

2002). Rubin et al. (2004 b) reviewed 91 cohort studies and reported that the

prevalence of postoperative fatigue was increased up to 92 %. Long (2010) indicated

that tiredness appeared as one of the most problematic symptoms for three whole days

after surgery. Another study on this population, Kahokehr, Broadbent, Wheeler,

Sammour, and Hill (2012) confirmed that fatigue persisted until post-operation for 1

month in both fatigue and fatigue subscale score. Measuring fatigue by 0 - 10 visual

analogue scale and numeric scale, it was reported that in the first day after

laparoscopic cholecystectomy surgery, fatigue presented at 1 hour was 6 (4.5 - 8),

3 hours was 5 (3 - 7) and 24 hours was 4 (2 - 6) (Graversen & Sommer, 2013).

Comparing fatigue between preoperation and postoperation for gastrointestinal

20

surgery, Yu et al. (2015) showed the increase before surgery from mean 1.65 (SD =

.73) to mean 7.14 (SD = .72) (p < .001) on postoperative first day, to mean 4.23 (SD =

1.00) (p < .001), on the 10th

day, and to mean 2.34 (SD = .90) (p < .001) on the 30th

day, respectively.

3. Sleep disturbance: Additionally, lack of sleep is also an important

postoperative symptom. Closs, Briggs, and Everitt (1997) reported that the duration of

sleep after surgery was significantly shorter than before hospitalization. There are

about 42 % of patients complained of unsatisfactory sleep after orthopedic, vascular,

and general surgery versus 28 % the night before surgery, and their sleep remained

unsatisfactory after four days in 23 % of cases (Kain & Caldwell-Andrews, 2003).

Sleep disruptions can persist up to three or four nights postsurgery (Cronin, Keifer,

Davies, King, & Bixler, 2001; Krenk, Jennum, & Kehlet, 2012). In one of the recent

reviews, Chouchou, Khoury, Chauny, Denis, and Lavigne (2014) confirmed sleep

disruptions can persist up to three or four nights postsurgery and longer up to several

weeks for cardiac surgery. There is at least 41 % and 19 % of patients presented total

slow wave sleep and rapid eye movement sleep suppression, respectively, during at

least one night after surgery (Chouchou et al., 2014).

4. Nausea and vomiting: Post-operative nausea and vomiting (PONV) is one

of the most common and distressing side effects of surgery (Mace, 2003). The

prevalence of nausea and vomiting in the first 24 hours after surgery was reported by

9.7 % of 1,017 patients (Chung, Un, & Su, 1996). The general incidence of vomiting

is about 30 %, the incidence of nausea is about 50 %, and in a subset of high-risk

patients, the PONV rate can be as high as 80 % (Apfel, Läärä, Koivuranta, Greim, &

Roewer, 1999; Koivuranta, Läärä, Snåre, & Alahuhta, 1997; Sinclair, Chung, &

Mezei, 1999). It was demonstrated that the incidence of PONV increased by

approximately ten times when the length of operation increased from less than 30

minutes to between 151 to 180 minutes (Ku & Ong, 2003). In the research of Mace

(2003), the overall prevalence of nausea among postoperative patients is 66.5%, but

only 34 % actually vomited. Both incidences of nausea and vomiting reach their peaks

at the first two days and might persist for more than six days after surgery (Mace,

2003; Rosén, Clabo, & Matensson, 2009). The incidence and intensity of PONV

largely relies on operative procedure (Rosén et al., 2009). With regard to gender,

21

Mace (2003) reported more females (80 %) suffering from PONV than males (60 %),

and the risk of PONV in females is three times greater than in females.

Besides the majority of symptoms mentioned above, because of effects of

anaesthethic agents as patients were interviewed after surgery, headache (7 - 11 %),

dizziness (49.7 %) and drowsiness/ sleepy (8 - 70 %), difficulty voiding (9 % - 18 %)

occur 24 hours post-surgery. During the first week after surgery, from 1 % to 73 % of

patients complained about dizziness; it appeared to be related to postural hypotension

and is exaggerated on mobilizing (Rosén et al., 2009; Stephenson, 1990). A study with

the sample of 1,017 patients reported that in 24 hours after operation, three most

common symptoms are pain, headache, and drowsiness, respectively. Other small

proportions of patients reported dizziness (9.7 %) and fever (5 %) (Adlin et al., 2013;

Mwaka et al., 2013).

In conclusion, there are many postoperative symptoms that are interfering

surgical patients to reach their health outcome in rehabilitative phase. It is a challenge

for nurses taking care of such patients. Understanding and having advanced strategies

to manage these unpleasant symptoms is essential in caring for patients in order to not

only reduce cost of treatment and increase satisfaction with health care services but

also improve recovery for patients. However, most of patients stay in bed all the time

until discharge day. It is leading to severe complications after surgery for closed

fracture of leg. According to literature review, fatigue is one of the factors playing an

important role, forcing lower limb fracture patient stay bedridden during the day

(Susilahti et al., 2004). Hence, it is extremely necessary to have in depth

understanding of the concept of postoperative fatigue.

Concepts of postoperative fatigue

Definition of postoperative fatigue

Fatigue is an unpleasant and distressing symptom in convalescence that is

often expressed as a feeling of tiredness, strain or exhaustion (Kennedy, 1988).

It describes reduced capacity to sustain force or power output, reduced capacity to

perform multiple tasks over time and simply a subjective experience of feeling

exhausted, tired, weak or having lack of energy (Kaasa, Loge, Knobel, Jordhøy, &

Brenne, 1999). Rubin et al. (2004 b) defined postoperative fatigue as ‘‘unpleasant and

22

distressing symptoms associated with a major impact on the patient’s quality of life’’.

It is a collection of physical and psychological symptoms that delay return to normal

activity after surgery (Zargar-Shoshtari & Hill, 2009). Yu et al. (2015) considered

fatigue as a kind of subjective feeling of discomfort leading to loss of ability to engage

in normal work or daily life activities. Therefore, definition for postoperative fatigue

in this study is considered as an unpleasant and distressing symptom with feeling of

tiredness, strain or exhaustion in the first three days after internal fixation surgery for

closed fracture of leg; being associated with impacts on concentration, energy and

daily life activities.

Pathophysiology of postoperative fatigue

According to the theory of postoperative fatigue from Salmon and Hall

(1997), major surgery is a trauma that provokes a constellation of hormonal,

metabolic, hematological, and immunological responses. There is a marked increase in

secretion of catabolic hormones, which are catecholamines and corticosol together

with suppression of the key anabolic hormone, insulin. This results in mobilization of

substrates, including glucose and amino acids, to maintain key synthetic processes in

the postoperative period. Surgical trauma also rapidly increases circulating white

blood cells and reflecting tissue damage, cytokine secretion, particularly interleukin

(IL)-6. Cytokines produced at the site of surgery enter the blood stream and proceed

through a variety of mechanisms to act directly on the brain. The second method is a

neural route represented by paracrine actions of cytokines on primary afferent neurons,

which innervate the body site where the injury has taken place. Proinflammatory

cytokines such as IL-1b and IL-6 levels in plasma lead to decline in mood, absence of

any other physical symptoms and induce human “sickness behavior,” such as fever,

malaise, pain, fatigue, low mood, and poor concentration. Furthermore, changes in

lymphocyte function are associated with immune suppression. These changes have

been regarded as deleterious: in particular, the marked loss of muscle protein that

inevitably follows major surgery has been largely attributed to catabolic hormone

secretion and regarded as a hindrance to the mobilization and recovery of the patient.

Moreover, tryptophan is the precursor of the neurotransmitter 5-

hydroxytryptamine (5-HT), known to be involved in sleep and fatigue. Free

tryptophan levels in blood are increased after surgery, which is associated with an

23

increased amount of tryptophan entering the brain. This may lead to higher 5-HT

concentrations in some parts of the brain, may contribute to a need for increase in

sleep, and possibly an increase in central fatigue. Subsequently, significant

correlations have been shown between fatigue scores and plasma-free tryptophan

(Yamamoto et al., 1997).

Enhancing nursing care for fatigue among lower limb patients,

understanding about etiology of fatigue is also an essential step.

Causes of postoperative fatigue

In context of lower limb fracture patients, there is a combined etiology for

development of postoperative fatigue. It is the result that is caused by injury, surgical

intervention and prolonged bed rest after operation.

Firstly, injuries to the soft tissue, including muscle, nerves, vessels,

subcutaneous fat and skin, occur to some degree in conjunction with all fractures.

Suffering from high-energy incident leads patients experiencing severe pain caused by

injury to the periosteum, muscle spasm, soft tissue disruption, and swelling within

fascial compartments. Furthermore, any musculoskeletal injury results in blood loss.

Fracture of the closed fracture of the femur is 1,000 - 1,500 ml and for a closed

fracture of the tibia is 500 - 1,000 ml (Lee & Porter, 2005). Suffering injury, facing

with pain and blood loss are the first causes for fatigue among lower limb fracture

patients.

Secondly, after exhausted by injury, lower limb fracture patient have to face

with ORIF surgery. In the surgical setting, surgical trauma is also an important factor

contributes postoperative fatigue. As mentioned, fatigue increases significantly after

major surgery. After undergoing operation, the combination of anesthesia, surgical

intervention and hormonal response lead to changes in whole body protein breakdown

and systematic plasma endocrine-metabolic response that may be involved in the

pathogenesis of postoperative fatigue (Zargar-Shoshtari & Hill, 2009).

Thirdly, there are a number of other physiological changes observed within

muscle fibers, although these have not been shown to correlate with the development

of fatigue, postoperatively. Surgery is followed by a prolonged period of reduced

activity, which can lead to significant impairment of muscle functioning, particularly

endurance, similar to changes seen in volunteers undergoing bed rest. Additionally,

24

cardiovascular fitness also deteriorates after surgery. Objective measures of

cardiovascular fitness and musculoskeletal deterioration both correlate with the

development of fatigue. Therefore, as muscular endurance and cardiac fitness both

decline, patients may need to use more energy to perform a given physical task, which

may lead to sensations of fatigue. These factors are thought to lead to reduced

mobility and contribute to fatigue (Christensen & Kehlet, 1993; Zargar-Shoshtari &

Hill, 2009).

Different from other operations, patients with closed fracture of leg

undergoing internal fixation surgery feel fatigued because of the combination of

multiple causes. It is a consequence of effect lasting from preoperation to

postoperation period. Screening potential factors for fatigue occurrence in these

patients should be considered from resuscitation through rehabilitation.

Based on etiology and mechanism of fatigue, it is recognized that

postoperative fatigue concept not only focused on physical meaning but also related to

mental aspect.

Classification of fatigue

According to Chalder et al. (1993), fatigue is considered as physical and

mental fatigue. In the process of analyzing the concept of fatigue, it is common to

classify fatigue into two types: physical fatigue and mental fatigue.

1. Physical fatigue: Physical fatigue, or muscle fatigue, is the temporary

physical inability of a muscle to perform optimally. The onset of muscle fatigue

during physical activity is gradual, and depends upon an individual's level of physical

fitness, and also upon other factors, such as sleep deprivation and overall health.

Physical fatigue can be caused by a lack of energy in the muscle, by a decrease of the

efficiency of the neuromuscular junction or by a reduction of the drive originating

from the central nervous system (Gandevia, 2001). The central component of fatigue

is triggered by an increase of the level of serotonin in the central nervous system

(Davis, Alderson, & Welsh, 2000). During motor activity, serotonin released in

synapses that contact motoneurons promotes muscle contraction (Perrier & Delgado-

Lezama, 2005). During high level of motor activity, the amount of released serotonin

increases and a spillover occurs. Serotonin binds to extrasynaptic receptors located on

the axon initial segment of motoneurons with the result that nerve impulse initiation

25

and thereby muscle contraction is inhibited (Cotel, Exley, Cragg, & Perrier, 2013).

2. Mental fatigue: Mental fatigue is a temporary inability to maintain optimal

cognitive performance. The onset of mental fatigue during any cognitive activity is

gradual, and depends upon an individual's cognitive ability, and also upon other

factors, such as sleep deprivation and overall health. Mental fatigue has also been

shown to decrease physical performance (Marcora, Staiano, & Manning, 2009). It can

manifest as somnolence, lethargy, or directed attention fatigue. Decreased attention is

known as ego depletion and occurs when the limited 'self-regulatory capacity' is

depleted (Baumeister, 2002). It may also be described as a more or less decreased

level of consciousness. In any case, this can be dangerous when performing tasks that

require constant concentration, such as operating large vehicles. For instance, a person

who is sufficiently somnolent may experience microsleep. However, objective

cognitive testing can be used to differentiate the neurocognitive deficits of brain

disease from those attributable to tiredness. The perception of mental fatigue is

believed to be modulated by the brain's reticular activating system.

It is quite complicated to analyze the etiology and mechanism for

development of fatigue after surgery. However, the presence of fatigue in surgical

population is obvious. It leads to a massive impact on physical, psychological and

social life of postoperative patients.

Impacts of postoperative fatigue

This definition recognizes the fact that postoperative fatigue has a

multimodal etiology and disrupts normal function after surgery and hence is clinically

significant (Rubin et al., 2004 b; Zargar-Shoshtari & Hill, 2009). The impact of

postoperative fatigue can be classified as physiological, psychological and social

impact.

1. Physiological impacts

Following major surgery, patients are fatigued and it might be one of the

main complaints after surgery and may last much longer than pain and wound healing,

even as long as 3 months (DeCherney et al., 2002). According to Susilahti et al.

(2004), because of fatigue after many kinds of surgeries, in the first week after surgery

54 % of patients had to rest during the day, 6.5 % of patients could not cope with their

daily activities and 9,6 % could not feel that resting helps to reduce their fatigue.

26

Zalon (2004) investigated the recovery among 60 patients after abdominal surgery and

reported that pain, depression, and fatigue explained 13.4 % of the variation in

functional status from three to five days after surgery, 30.8 % for one month, and

29.1 % for three months after discharge. Post-surgery fatigue adversely affects

physical functional capacity and role function and significantly declines from

preoperative (baseline) levels during 1 month following major abdominal surgery and

returns to baseline only after 3 months (Tsunoda, Nakao, Hiratsuka, Tsunoda, &

Kusano, 2007) and has impaired physical performance, including reduced work

capacity (Christensen & Kehlet, 1993) and muscular function (Jensen, Houborg,

Nørager, Henriksen, & Laurberg, 2011; Edwards, Rose, & King, 1982).

Furthermore, Labraca et al. (2011) asserted that the earlier initiating

rehabilitation treatment after total knee arthroplasty, the more advantage. However,

because disturbance from fatigue so orthopedic patients are difficult to follow

recommendations for training. Thus, postoperative fatigue patient must be showed

significantly more rehabilitation sessions until medical discharge, more pain, lesser

joint range of motion in flexion and extension reduced strength in quadriceps and

hamstring muscles, and higher scores for gait and balance because of lost afford to

adherence with physical therapy designed for early rehabilitation phase (Ersözlü et al.,

2009; Labraca et al., 2011). In addition, prolonged bed rest or immobility and

immobilization devices are considered as predisposing factors in contributing deep

vein thrombosis, pulmonary thromboembolism and stiffness and contractures (Ohura,

Sanada, & Mino, 2004; Walsh, 2009). Therefore, if fatigue persists in postoperative

patients, the risk for developing these complications is high.

2. Psychological impacts

Not surprisingly, postoperative fatigue may be one of the main complaints

after surgery. A higher degree of postoperative fatigue is followed by worse

emotional, physical, and functional outcomes proved in major joint arthroplasty

(Aarons et al., 1996). Fatigue contributes substantially to feelings of frustration,

depression, or hopelessness and to difficulty in concentrating or being attentive. Some

patients describe fatigue as a ‘‘change in emotional state’’ (DeCherney et al., 2002).

Among patients with lower limb fracture, they can not help themselves to mobilize

because of fatigue. Depending on other people due to immobility remain one of the

27

most frightening and psychological significant components of musculoskeletal

trauma. Fear and powerlessness related to immobility, along with social isolation and

alteration in role performance, and result in an individual’s decreased coping skills

(Walsh, 2009).

3. Social impacts

Postoperative fatigue may prevent otherwise fit patients from returning to

work. Large numbers of patients report loss of salary as a result of this prolonged

surgical recovery time. Patients miss an average of 6 weeks of work after

uncomplicated abdominal operations. It also has a similar impact on caregivers

(Bisgaard et al., 2001, DeCherney et al., 2002). Because of preventing return to

normality, activities of daily living, that can negatively impact on patient’s quality of

life (Rubin et al., 2004 b; Wijesuriya et al., 2012). Fatigue has been negatively

associated with social integration, productive activity and quality of life (McColl et

al., 2003). Postoperative fatigue can also be a source of increased costs to the health

service. It may be a source of increased costs to the health service, with patients who

suffer from fatigue placing significantly greater demands on their primary health care

teams compared with those who feel less tired (Bisgaard et al., 2001; DeCherney et

al., 2002; Rubin et al., 2004 b)

It is no argument that postoperative fatigue is causing burden for patient,

health care system and society. The symptom negatively influences both physical and

mental health of patients thus delaying the recovery. They also increase the cost of

treatment and reduce patient satisfaction with health care services as well. Therefore,

understanding about management for postoperative fatigue symptoms is essential in

caring of patients after surgery.

Management of postoperative fatigue

Postoperative fatigue has a multimodal etiology, and therefore, single

modality interventions seem to have little influence on the progression of

postoperative fatigue. A meta-analysis has assessed various interventions used to

modify postoperative fatigue, and there may be no single intervention to effectively

eliminate postoperative fatigue (Rubin & Hotopf, 2002). However, with the

implementation of multimodal enhanced care pathways, combining strategies, such as

effective management for pain, nausea and vomiting management, early oral intake

28

and psychological intervention achieved significantly and clinically measurable

improvements in postoperative fatigue (Zargar-Shoshtari & Hill, 2009, Fishbain et al.,

2005).

Balanced analgesia reduces the surgical stress response, effective treatment

of pain to facilitate mobilization, and exercise to increase postoperative nutritional

intake (Christensen & Kehlet, 1993). Eleven studies comparing between increased

analgesia and routine care or placebo in reducing postoperative fatigue, the result

confirmed that using increased analgesia reduced post-operative fatigue significantly

(Rubin & Hotopf, 2002). Moreover, opioids are commonly thought to be a very

effective form of analgesia in surgical patients (Shoshtari, 2009).

Additionally, postoperative nausea and vomiting (PONV) are among the

most common adverse events related to surgery and anaesthesia and lead to patient

discomfort, dehydration and electrolyte disturbances as well as delayed oral feeding.

This is the extreme reason for developing postoperative fatigue. A systematic,

multimodal approach may be the most effective method of controlling PONV. This

should consist of decreasing the baseline risk factors for all patients, identifying

patients with high risk of PONV for administration of appropriate prophylactic

therapy and suitable rescue antiemetics if these measures fail (Shoshtari, 2009).

Furthermore, nutrition intake and psychological intervention also

demonstrate the evidence in reducing postoperative fatigue. Early oral feeding and

post-operative dietary supplementation is the most successful strategy has been a fast-

track care program that includes sufficient oral nutrition for reduce fatigue (Kehlet &

Wilmore, 2008). Individual studies have shown that early feeding may decrease

postoperative infections, length of hospital stay, muscle loss and fatigue. Experimental

and clinical studies have demonstrated that early oral feeding, dietary supplementation

can provide added benefits in terms of reduction in fatigue, weight loss and overall

morbidity in normal as well as malnourished patients (Shoshtari, 2009).

In addition, reducing stress and anxiety may reduce post surgery fatigue as

relaxation therapies have been shown to be beneficial in patients undergoing

procedures in many surgical settings (Wilmore, 2002). One found a significant effect:

reduced fatigue was reported during the first post-operative week for cardiac patients

engaged in guided imagery (Rubin & Hotopf, 2002). Soft music may reduce later

29

post-operative pain and fatigue by decreasing the surgical stress response (Graversen

& Sommer, 2013). Forty five minutes relaxation session with a health psychologist

and were given relaxation exercise CDs to take home was proved as effective method

in manage fatigue after laparoscopic cholecystectomy (Kahokehr et al., 2012).

Preoperative counseling is necessary to care for surgical patient (Kehlet & Wilmore,

2008). It is also confirmed that provide enough medical information to let patient take

self-management intervention and reduce illness uncertainty is an important factor in

decreasing fatigue (Stiegelis et al., 2004).

Notably, postoperative fatigue is considered as an unpleasant symptom. So,

to understand this symptom better, it is recommendable to explore the Unpleasant

Symptoms theory by Lenz et al. (1997). This theory had been used and found effective

in explaining the influencing factors, impact, and in finding effective approach to

manage postoperative fatigue.

The theory of unpleasant symptoms

The theory of unpleasant symptoms (TOUS), developed by Lenz et al.

(1997) was first introduced in 1995. The updated version of this middle-range theory

was then presented two years later in 1997. In the original model of the TOUS, one

symptom is depicted and it is a purely linear model. The updated model of the TOUS

(Figure2) proposes that symptoms can occur alone or in isolation from one another but

that, more often, multiple symptoms are experienced simultaneously. Each symptom

is conceptualized to be a multidimensional experience, which can be conceptualized

and measured separately or in combination with other symptoms. In addition,

compared to the original TOUS model, the revised TOUS model more accurately

depicts the relationships among central concepts (influential/ antecedent factors,

symptom experience, and outcomes/ consequences). Therefore, updated version of

TOUS theory was used for this study.

According to Lenz et al. (1997), the TOUS has “three major components: the

symptoms that the individual is experiencing, the influencing factors that give rise to

or affect the nature of the symptom experience, and the consequences of the symptom

experience”. Symptoms are the central focus of the TOUS. Symptoms are defined as

perceived indicators of change in normal functioning as experienced by patients.

30

Symptoms can be considered alone or combination. They are seen as multiplicative,

rather than additive. Symptoms have the dimensions of intensity, timing, distress and

quality. Intensity refers to the severity, strength, or amount of the symptom being

experienced. The time dimension includes the frequency with which an intermittent

symptom occurs, the duration of a persistent symptom, or a combination of frequency

and duration of symptoms. The symptoms can be intermittent but persist over long

periods of time or chronic but varying in intensity. The distress dimension of the

symptom experience refers to the degree to which the person is bothered by the

symptom(s). Symptoms can vary in their quality or the way they are manifested. The

quality of a symptom can include description of the location of a given sensation, as

well as the degree to which a patient responds to a particular intervention (Lenz et al.,

1997).

These symptom dimensions are influenced by three categories of variables:

physiologic factors, psychologic factors, and situational factors (Lenz et al., 1997).

Physiological factors are often reflected in unpleasant symptoms associated with

alterations in the normal functioning of bodily systems or the existence of any

pathology. Physiological antecedents commonly characterize the severity of the

disease, such as comorbidities, abnormal laboratory findings or other pathological

findings (Lenz et al., 1997). Examples of physiological factors include the

mechanisms of head injury, the individual’s immunity and defense functioning, or

physiological response to stress (i.e. the level of stress hormone). The psychological

factors that are antecedents include the individual’s mental state or mood (depression),

affective reaction to illness (mood status), psychological response to stress (the degree

of perceived stress or the level of anxiety) and degree of uncertainty and knowledge

about the symptoms and their possible meaning (perception of illness experience or

symptom experience). Situational/ environmental antecedents include aspects of the

social and physical environment that may affect the individual’s experience and

reporting of symptoms (Lenz et al., 1997). Examples of situational/ environmental

factors include social support, marital status, and resources or any situational events

that may influence symptom experience. All of these factors may impact an

individual’s experience with individual and multiple symptoms. The TOUS asserts

31

that these three factors relate to one another and interact with one another to impact

symptoms.

Performance is the last component of the TOUS. Performance is the result of

symptom experience which includes functional and cognitive activities. It refers to a

broad content which can be considered as the consequence of experiencing symptoms.

Performance could be physical activities, social activities, working role, concentrating,

or problem solving. It is assumed that more numerous or more severe symptom, the

poorer the performance manifested.

Lenz et al. (1997) asserted that the three components of the model are related

and the correlation might be reciprocal. Antecedents/ influential factors can have an

interaction effect in their relation to the symptom experience. The experience of

unpleasant symptoms can change one’s performance which includes the change in

individual physical, psychological, and social status. Furthermore, the symptom

experience can have a moderating or mediating influence on the relationship between

influential factors and outcomes/ performance (Lenz et al., 1997). Additionally, the

performance can also conversely impact on symptoms and the influencing factors. The

revised TOUS model proposes that outcomes (performance) have a reciprocal relation

with the symptom experience. The decreased levels of performance can have a

negative feedback loop to the influential factors (physiological, psychological, and

situational factors).

In present study, postoperative fatigue is considered as unpleasant symptom.

It happens with frequent rate and severity after surgery. Symptom of fatigue occurs

immediately right after surgery but remains persistent for a long time and distress

patients on physiological, psychological and social aspects. It is a subjective

perception caused by many reasons. Even though, in TOUS symptom dimensions are

influenced by three categories of variables: physiologic factors, psychologic factors,

and situational factors. However, previous studies inconsistently supported variables

from situational antecedent in predicting postoperative fatigue. Thus, factors affect

postoperative fatigue derived from physiologic and psychologic antecedents. Among

them, pain belongs to physiologic factor, anxiety and uncertainty are the psychologic

factors. Patients, who experienc fatigue after ORIF surgery, will affect physical,

psychological and social aspects. Studies proved consequences on physiological

32

health including impaired physical performance, reduced work capacity (Christensen

& Kehlet, 1993) and muscular function, psychological health composes feelings of

frustration, depression, or hopelessness and difficulty concentrating or being attentive

(DeCherney et al., 2002). From physical and psychological impact, it leads to an

influence on social life of postoperative fatigue patients such as reduce quality of life,

increase cost for medical care fee, become a burden on family caregivers (Bisgaard et

al., 2001).

Figure 2 The unpleasant symptom model (Lenz et al., 1997, p.17)

Factors predicting postoperative fatigue among patients with closed

fracture of leg

There are multiple factors that affect postoperative fatigue such as age, type

of surgery, gender, preoperative fatigue, nutrition status, nausea, fatigue expectation,

pain, anxiety and uncertainty (Long, 2010; Tolver, Strandfelt, Rosenberg, & Bisgaard,

2013; Yu et al., 2015). Among these factors, pain, anxiety and uncertainty are three

variables which have been studied and have a consistent association with

33

postoperative fatigue.

Pain

Pain and fatigue are the most unpleasant symptoms after surgery and happen

together. Pain is defined as an unpleasant sensory and emotional experience associated

with actual or potential tissue damage, or described in terms of such damage (Lubkin

& Larsen, 2006). The severe pain seen so frequently after orthopedic operation is

largely a result of the nature of the surgical procedure, which often involves

significant muscle and skeletal tissue repair or reconstruction (Pasero & McCaffery,

2007). It has since been repeatedly confirmed that 30 - 80 % of patients undergoing

surgery suffer from inadequately treated pain (Mwaka et al., 2013; Pavlin et al., 2004;

Pitimana-Aree et al., 2005; Zaslansky et al., 2006). Ineffective control of pain after

surgery also causes patient distress, sleep disturbance, mood disorders, and has

adverse effects on the endocrine and immune functions, which can affect wound

healing and fatigue (Chiu et al., 2005; Chouchou et al., 2014; Peters et al., 2007).

There is a close relationship which existing between muscle pain and fatigue.

The links between pain and fatigue included development of fatigue after the

development of pain, and improvement in fatigue with lessening of pain, the longer

pain was present the greater the likelihood of fatigue; the greater the pain experienced

the more certain it was that fatigue occurred (McCarberg & Cole, 2009). A group

using a structured evidence-based review of 17 studies related to the coexistence of

fatigue and pain found that 94 % indicated that there was an association between

fatigue and pain; a subgroup of 13 reports indicated there may be a cause and effect

relationship between pain and fatigue (Fishbain et al., 2003). Concerning about

abdominal surgery population, in the first and second day after surgery, pain proved

correlation with fatigue (r = .39, p < .001 and r = .19, p < .05) respectively (Long,

2010). Investigation on 101 breast cancer surgical patients, the result indicated pain

severity and fatigue have a positive correlation (r = .36, p < .001) (Montgomery et al.,

2010). In another research, it was shown that pain explained for 20 % of variation of

fatigue (Beck et al., 2005). In Saowaluck’s study (2009), the result asserted pain was

significant predictors of postoperative fatigue (β = .28, p < .01). It is reported that

although several variables were found to contribute to the severity of fatigue but the

presence of pain which contributes to explain up to 7.6 % of variance of fatigue

34

(Lee et al., 2010). By using multiple logistic regression models, Garabeli Cavalli

Kluthcovsky et al. (2012) reported that presence pain is one of predictive factors for

postoperative fatigue (OR = 3.87, 95 % CI = 1.88 - 7.98, p = .000).

Anxiety

Mental disorders such as anxiety and depression are common in hospital

inpatients, with an estimated prevalence of 20 - 40 % in worldwide studies (Grau

Martin et al., 2003; Hansen et al., 2001) and especially high in orthopedic trauma

setting (Becher et al., 2014; de Moraes et al., 2010). It is a consequence of changes

and unpredictability in daily life, face many unpleasant symptoms and indefinite

rehabilitation period (Becher et al., 2014). Furthermore, prolonged treatment time, use

of the supportive aids can lead to a breakdown in the routine of family and prevent the

individual from working during the treatment process, which are also important causes

leading to anxiety (de Moraes et al., 2010). Evidence suggests that the more anxious a

patient, the poorer the outcome in terms of hospital length of stay and complications

(Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser, 1988).

Anxiety is a significant factor affecting feeling of fatigue after surgery.

Assessment about the relationship between postoperative fatigue and anxiety on 183

surgical patients, the results indicate that psychological processes including anxiety

may well be relevant in the etiology of postoperative fatigue (Rubin et al., 2004). In

abdominal surgery population, the result was indicated that on the second day after

surgery, anxiety had associated with tiredness (r = .33, p < .01) (Long, 2010). A cross-

sectional study in muscular dystrophy persons 20-89 years old, symptoms of fatigue

are significantly and independently related to depression (Alschuler et al., 2012).

Increase in psychological distress is a factor related to worsening fatigue after surgery

(Rotonda et al., 2013). To describe the relationship of fatigue with psychological

functioning in adults with spinal cord injury, fatigue was an independent factor

associated with depression (Alschuler et al., 2013). In 180 postoperative patients with

breast cancer, the finding showed that moderate/ severe fatigue was positively

associated with anxiety (r = .32, p < .05) and depression (r = .21, p < .05) (Tan & Xia,

2014). After controlling all other variables, depression variable was significant

predictors of postoperative fatigue (β = .40, p < .01) in hysterectomy population

(Saowaluck, 2009).

35

Uncertainty

Uncertainty is a result of experiencing the acute phase of illness or is in a

downward illness trajectory (Mishel, 1988). In circumstance of orthopedic patients, it

was reported that all patients responded similarly in terms of having moderate levels

of uncertainty (Calvin & Lane, 1999). That is considered as a consequence of urgent

operation. Furthermore, hospitalization in long time, up to 7 to 10 days and struggling

with postoperative symptoms are reasons that make patient with lower fracture

suffering uncertainty. Fracture of leg is usually accompanied with a long time

recovery and high risk for long-term disability. That patients feel inability to

determine the meaning of illness-related events, unable to predict outcomes accurately

is easy to happen. In addition, being unsatisfied with information getting from

healthcare provider is a common complaint of Vietnamese patients, making surgical

patient suffering uncertainty (Loi, 2014). According to Mishel (1988), patients with

uncertainty will have negative thoughts and beliefs regarding the disease. It leads to

altered coping, severe cognitive impairment and search for opportunities to get

relevant answers. With both psychological distress and depressive symptoms caused

by uncertainty, it is the reason for the occurrence of postoperative fatigue.

Previous research findings proved the relationship between fatigue and

uncertainty. Providing enough medical information to let patient take self-

management intervention and reduce illness uncertainty before radiotherapy is an

important factor in decreasing fatigue (Stiegelis et al., 2004). To examine the

prevalence and severity of fatigue, conceptualized as a multiple dimensional

symptom, and to determine the influence of sense of coherence and uncertainty on the

fatigue experience in 93 consecutive patients with chronic heart failure, Falk et al.

(2007) asserted that fatigue was a prevalent and distressing experience in patients and

uncertainty was associated positively with tiredness and reduced functional status.

Lasker et al. (2010) conducted a study in 100 female patients undergoing liver

transplantation operation and indicated that even undergoing a life-saving procedure,

uncertainty was still persistent and associated with a reduced quality of life and there

was a significant relationship between uncertainty and fatigue.

36

Conclusion

Lower limb fracture is a common health issue in modern society. ORIF

surgery for management fracture is an advanced management system. However, with

high incidence and longer duration than other after surgery, fatigue is limiting

treatment outcome for fracture of leg. Postoperative fatigue has a huge impact on

physical, psychological and social health. The need for an in-depth understanding of

this concept and predicting factors is necessary. Moreover, evidences from previous

studies have emphasized the consistent relationship between pain, anxiety, uncertainty

and postoperative fatigue. Therefore, in order to enhance the quality of care and

treatment, shorten postoperative period for patients, a study on factors predicting

postoperative fatigue needs to be conducted on patients with closed fracture of leg

undergoing internal fixation in Vietnamese population.

CHAPTER 3

RESEARCH METHODOLOGY

A descriptive predictive design was used in the present study to examine the

influence of pain, anxiety, and uncertainty on postoperative fatigue among patients

with closed fracture of leg undergoing internal fixation surgery. This chapter explains

design and methods used in this study, including description of population and

sample, the research setting, instruments, protection of human subjects, data collection

procedure, and data analysis.

Research design

A descriptive predictive design was used in this study to investigate the

influence of pain, anxiety, uncertainty on postoperative fatigue among patients with

closed fracture of leg undergoing internal fixation surgery in Khanh Hoa General

Hospital, Vietnam.

Population and sample

Population

The target population of this study was the patients who got orthopedic

injury and hospitalized at the Traumatology – Orthopedic department, after

undergoing internal fixation surgery for closed fracture of femur, tibia and fibula in

Khanh Hoa General Hospital, Vietnam in 2015.

Sample

The sample was adult surgical patients who were emergency hospitalization

at the Traumatology - Orthopedic department after undergoing internal fixation

surgery for closed fracture of femur, tibia and fibula in March to April, 2015. They

were selected according to the following inclusion criteria:

1. Age from 18 to 60 years old

2. Be able to communicate and read in Vietnamese

3. Do not have history of mental illness and others serious illness such as

cancer, heart or kidney disease

38

4. Do not have any peri or post operative complications (shock, hemorrhage,

infections, etc.)

5. Do not have any simultaneous operation on other parts of the body.

Sample size

The sample size in this study was calculated based on the formula

recommend by Tabachnick and Fidell (2007) as follows:

N ≥ 50 + 8M

N = sample size

M = independent variables

50 = constant of formula

This study had 3 independent variables

N ≥ 50 + 8 x 3

N ≥ 74

Therefore, the sample size in this study was a minimum of 74 patients.

However, to ensure an adequate sample size at the completion of the study,

it is encouraged to determine to possible attrition rate about 10% for the study (Grove,

Burns, & Gray, 2013). Thus, the sample size of the study was identified as 80 patients.

Sampling technique

Patients with fracture of leg are hospitalized because of accidental events.

Open reduction and internal fixation surgery for fracture was beyond patient’s

expectation and prediction. Therefore, admission of these patients at the Traumatology

– Orthopedic department at Khanh Hoa General Hospital was totally random. The

sample in this study was recruited when they met inclusion criteria over 2 months,

March to April in 2015. The researcher collected data every day from Monday to

Sunday. Each day, at 8AM the researcher asked the head nurse or nurses on shift for

the list of patients with closed fracture of leg on the first day after undergoing internal

fixation surgery who met the inclusion criteria. Then, the research contacted patients

and distributed questionnaire. The desired sample size was reached when a total of at

least 80 cases were completed.

39

Setting of the study

This study was conducted at Khanh Hoa General Hospital, located in Khanh

Hoa province, in the South Central Coast of Vietnam. Khanh Hoa province has a

population of 1,066,300 and spans an area of 5,197 km². It is the economically most

developed province of South Central Vietnam. There are 2 cities and 7 districts in this

province. Khanh Hoa General Hospital is the biggest general hospital, located in the

largest and the capital city of Khanh Hoa province. It has 1000 beds with 20 units. The

Traumatology – Orthopedic department has 70 beds for orthopedic surgery patients.

This department has 16 nurses, 13 surgical doctors. Because it is a tertiary hospital,

most of severe cases in middle south provinces of Vietnam and other areas in Khanh

Hoa province are referred here for advanced care. Moreover, with high prevalence of

traffic accidents in Khanh Hoa province, the number of patient with closed fracture of

leg hospitalized in this hospital is higher compared to other hospitals in Vietnam.

Therefore, the overload condition usually happens in the Traumatology – Orthopedic

department. According to statistics from Khanh Hoa General Hospital, it is estimated

that there are about 70 operations for femur, tibia and fibula fracture per month.

In the Traumatology – Orthopedic department, there are 4 bachelor and 12

diploma nurses. In one day, there are 14 nurses who work for 8 hours per day (from

7AM to 11 AM and 1 PM to 5 PM). Among 14 nurses, there are 2 nurses in charge

who will work continuously for 24 hours, from 7AM today to 7AM the following day

and take a day off on that day. At the weekend (Saturday and Sunday), there are only

2 nurses in charge will work by themselves in 24 hours without other nurses’ support.

Nurses in the Traumatology – Orthopedic department take responsibility in providing

information about regulations of the department for both patients and their caregivers.

Each day, nurses assess patient health, provide health education about nutrition and

rehabilitative regime, giving medication, dressing change, implement other nursing

techniques according to doctor’s treatment and then write in nursing record. Two

nurses in charge will take care of severe patients and admit new patients on that day.

There is no physical therapist to provide rehabilitation for post-operative patients. All

of the instructions for practice to maintain range of motion, walking with supportive

aid come from orthopedic doctors and nurses.

40

To control postoperative pain, according to the protocol of this setting , it is

recommended to use Nonsteroidal anti-inflammatory drug (NSAID) via oral or

intramuscular injection administration (Alphachymotrypsin, Tenoxicam, Meloxicam)

combined with Paracetamol 500 mg for oral administration at 4 hours after surgery

and twice per day at 8AM and 4 PM in following days. If patients report unbearable

pain, nurses may provide analgesic drugs more frequently. As for orthopedic trauma

patients, after being transferred from post-surgery intensive care department, they are

admitted to this ward. After the average length of stay from 7 to 10 days, patients are

discharged.

Research instruments

Instruments used in this study include the patient’s profile record form,

numeric pain rating scale (NPRS) to measure pain, hospital anxiety and depression

scale (HADS) to measure anxiety, the Mishel uncertainty in illness scale (MUIS) to

measure uncertainty and the identity – consequence fatigue scale (ICFS) to measure

fatigue.

1. The patient’s profile record form

This form was developed by the researcher, encompassing two parts: the

Sociodemographic data and the Disease and Treatment data. The Sociodemographic

data included age, gender, marital status, educational level, occupation, income. The

Disease and Treatment data carried the information about patient diseases and

treatment, such as diagnosis, part of bone fracture, type of surgery, co-morbidity and

medication for the 1st, 2

nd and 3

rd day after surgery.

2. Numeric pain rating scale (NPRS)

The NPRS was an unidimensional measure of pain intensity in adults

(McCaffery & Beebe, 1989). Patients verbally select a value that was most in line with

the intensity of pain that they had experienced. The NPRS was an 11-point scale from

0-10: “0” = no pain, “10” = the most intense pain imaginable. A written form was also

frequently used with the numeric values of 0 - 10 written out. Scores range from 0 - 10.

Higher scores indicate greater pain intensity. Pain severity could be categorized into

3 distinct groups as related to pain interference:

41

Score Level

1 - 3 Mild pain

4 - 6 Moderate pain

7 - 10 Severe pain

Herr, Spratt, Mobily, and Richardson (2004) reported its internal consistency

was 0.88. High test - retest reliability had been observed .79 to .92 (Jensen &

McFarland, 1993). For construct validity, the NPRS was shown to be highly

correlated to the Visual Analogue Scale for pain in patients correlations equal to .94

(Bijur, Latimer, & Gallagher, 2003).

3. The hospital anxiety and depression scale (HADS)

The hospital anxiety and depression scale (HADS) was used to determine the

levels of anxiety and depression that a patient was experiencing. It was developed by

Zigmond and Snaith (1983); and back translated to Vietnamese by Long (2010). The

HADS was a patient-reported instrument with 14 items. The fourteen items were

classified into two parts: seven items measure anxiety (HADS-A) and 7 items evaluate

depression (HADS-D). Since this study focused on patient anxiety level, only the

HADS-A was used. Patients were asked to answer seven statements in the

questionnaire by rating in the four points Likert scale. The anxiety score was the total

score for all seven items, ranged from 0 to 21; higher scores represent more anxiety.

Bambauer, Locke, Aupont, Mullan, and McLaughlin (2005) recommended the cutoff

point of 7 for the HADS. Based on that, the anxiety score was interpreted as follows:

Score Level

0 no anxiety

1 - 7 mild anxiety

8 - 14 moderate anxiety

15 - 21 severe anxiety

The Cronbach‘s alpha of the HADS - A was reported to range from .80 to

.93; and the concurrent validity coefficient between HADS – A and state – trait

anxiety inventory was .81 (McDowell, 2006). Long (2010) reported its internal

consistency was .89.

42

4. The Mishel uncertainty in illness scale (MUIS)

The Mishel uncertainty in illness scale (MUIS) was developed by Mishel

(1980) and the result of initial testing was first published in 1981, back translated to

Vietnamese by Loi (2014). The scale had been used to examine uncertainty in

symptomatology, diagnosis, treatment, relationship with caregivers and planning for

the future in multiple patient populations include post myocardial infarction patients,

brain trauma injury. This instrument had 28- item self-administered tool. Each item

was graded on five point Likert scales; ranging from strongly disagree to strongly

agree. Items could be scored on a scale of 1 - 5, giving a global score range of 28 -

140. Higher scores indicated higher levels of uncertainty. The reliability of original

version of MUIS showed good internal consistency with Cronbach’s alpha from .74 to

.92 (Mishel, 1981). Cronbach’s alpha of this instrument in Vietnamese population was

.89 (Loi, 2014).

5. The identity – consequence fatigue scale (ICFS)

The identity – consequence fatigue scale was an instrument used to assess

fatigue and its impact in post-surgical patient. It was developed by Paddison et al.

(2006). It had 25 items and 5 subscales divided into 2 dimensions. Of five subscales,

two feelings namely feeling of fatigue and feeling of vigor belong to a fatigue-identity

dimension of the ICFS, while other three, impacts on concentration, impacts on

energy and impacts on daily activities form the fatigue-consequences dimension. Each

item of the ICFS was rated on 6-point adjectival scales. For all items the anchors

were: not at all (score = 1), almost never (score = 2), some of the time (score = 3),

fairly often (score = 4), very often (score = 5), and all of the time (score = 6). With

possible score for fatigue-identity dimension range of 9 - 54 (items 1 - 9) and fatigue-

consequences dimension range of 16 - 96 (items 10 - 25). Global score range of 25 -

150. Higher score represented more fatigue. The identity - consequence fatigue scale

had been found to be reliable. All subscales showed high internal reliability with

Cronbach’s alpha ranged from .88 to .92 (Paddison et al., 2006).

43

Translation of the instruments

In order to have appropriate instrument in Vietnamese, the Identity –

Consequence Fatigue Scale (ICFS) was translated from English to Vietnamese with

Back – Translation technique (Cha, Kim, & Erlen, 2007).

Step 1 A person who was influent in both English and Vietnamese translated

the English original version into Vietnamese version.

Step 2 The Vietnamese version was back translated to English by another

translator.

Step 3 The original English version and the back translated version were

compared in order to validate the accuracy of the translation process. The necessary

changes in the Vietnamese questionnaires were made after the discussion between

researcher and major advisor in order to get most common and precise instrument.

Validity and reliability of the instruments

Validity

The identity – consequence fatigue scale (ICFS) was original in English. It

needed to be translated into Vietnamese language in order to properly use with the

Vietnamese sample. The process of back translation by Cha et al. (2007) was used to

ensure the validity of the questionnaire of The identity – consequence fatigue scale.

After getting the final Vietnamese version of ICFS questionnaire, to ensure the content

validity, it was tested by 3 Vietnamese experts in nursing science. The item-content

validity index score (CVI) for ICFS was 1.0.

Reliability

The translated measurements include The hospital anxiety and depression

scale (HADS), The Mishel uncertainty in illness scale (MUIS) and The identity –

consequence fatigue scale (ICFS) in Vietnamese language were tested for internal

consistency reliability on 30 patients after undergoing lower limb surgery who had

similar characteristics of the actual samples and met the inclusion criteria of this

study. According to Grove et al. (2013), the acceptable level of Cronbach’s alpha for a

newly developed psychosocial instrument is .07 and .08 for a well-developed

instrument. In this study HADS, MUIS and ICFS were well-developed instrument.

44

The Cronbach’s alpha coefficents of HADS, MUIS and ICFS were .86, .90 and .87,

respectively.

Protection of human subjects

Human subject’s approval was obtained from the institutional review board

(IRB), Faculty of Nursing, Burapha University. Before conducting data collection, this

study was also got permission from the Director of Khanh Hoa General Hospital. In

the process of collecting data, all patients was informed clearly about the aims of the

study, the data collecting procedure, risks that may occur as well as their rights.

Participants volunteered to participate in the study, the consent form was completed

before data collection and they were entitled to withdraw whenever they wanted. The

participant’s anonymity and confidentiality were respected. All the forms were

anonymous. No physical examination or interference was implemented to further

investigate patient’s situation.

Data collection procedure

The data collection procedure in this study was performed by the researcher

as follows:

1. After the proposal was approved by the institutional review board (IRB),

Faculty of Nursing Burapha University to collect data. The researcher approached the

Director of Khanh Hoa General Hospital, Vietnam to get permission for collecting

data.

2. Based on the patient list of the traumatology – orthopedic department, the

researcher visited patients who met the eligibility criteria on the first day after the

surgery day. The researcher introduced herself to build the relationship with the

patients. The researcher then informed patients about the study, ethical issues, and

data collection procedures and invited them to participate in the research. If patients

consented to participate, the pain intensity level was assessed by using The Numeric

Pain Rating Scale (NPRS) questionnaire.

3. On the second day after surgery, the researcher revisited patients to assess

their pain intensity by the instrument of The numeric pain rating scale (NPRS).

45

4. On the third day after surgery, the questionnaire of The numeric pain

rating scale (NPRS), The hospital anxiety and depression scale (HADS), The Mishel

uncertainty in illness scale (MUIS) and The identity - consequence fatigue scale

(ICFS) were distributed for patients self-report.

5. Other necessary information such as diagnosis, co-morbidity, medication

for the 1st, 2

nd and 3

rd day after surgery was obtained from patients' medical record.

6. During data collection, if patients were in the middle of some procedures,

the questionnaire would not be administered until they feel calm and comfortable to

answer.

7. After having all necessary information, data collecting forms were

checked for completeness and prepared for analysis.

Data analysis

The data was analyzed by using statistical package software. The level of

significance was set at an alpha of .05.

1. Descriptive analysis including frequency, percentage, mean, standard

deviation (SD) and mean percentage was used to describe demographic data, pain,

anxiety, uncertainty and fatigue.

2. Multiple regression analysis was used to explore the prediction of pain

(average pain from 3 days assessment), anxiety, uncertainty on postoperative fatigue.

CHAPTER 4

RESULTS

This chapter presents the results of the study from data analysis that describe

factors predicting postoperative fatigue among patients with closed fracture of leg

undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam. This

finding related to objectives and hypotheses are presented with the details in the tables

as follows:

1. Description of sample characteristics including demographic

characteristics and medical information of the sample

2. Description of the studied variable including pain, anxiety, uncertainty

and postoperative fatigue

3. Influence of pain, anxiety and uncertainty on postoperative fatigue among

patients with closed fracture of leg

Description of sample characteristics including demographic

characteristics and medical information of the sample

1. Demographic characteristics of the sample

This section presents the demographics data of participants in this study.

A total of 80 patients who underwent internal fixation surgery for closed fracture of

leg and met the inclusion criteria were recruited from Khanh Hoa General Hospital,

Vietnam. Table 1 illustrates characteristics of the sample including gender, age,

marital status, educational level, occupation and incomes.

47

Table 1 Frequency and percentage of samples’ demographic characteristics (n = 80)

Characteristics n %

Gender

Male 63 78.8

Female 17 21.2

Age (years)

18 - 35 38 47.5

36 - 60 42 52.5

Range: 18 - 60, M = 38.25, SD = 11.92

Marital status

Single 24 30.0

Married 56 70.0

Educational level

No Schooling 1 1.3

Elementary school 8 10.0

Secondary school 35 43.8

High school 23 28.8

Diploma 9 11.2

Bachelor or higher 4 4.9

Occupation

Farmer 28 35.0

Industrial worker 21 26.3

Business person 17 21.3

Government officer 9 11.3

Retired/ Unemployment 3 3.8

Student 2 2.3

48

Table 1 (cont.)

Characteristics n %

Income/ month (USD)

< 150 39 48.8

150 - < 199.9 25 31.2

200 - < 249.9 8 10.0

≥ 250 8 10.0

Table 1 shows that the majority of patients were male (78.8 %). Age of

sample ranged from 18 - 60 with a mean of 38.25 years (SD = 11.92). In marital

status, the married group was the biggest one (70.0 %). Regarding the educational

level, 43.8 % of sample had completed secondary school and 28.8% had finished their

high school. For occupation, farmer was the most common occupation (35 %)

followed by industrial worker (26.3 %). It was also revealed that the majority of

sample (48.8 %) earned less than 150 USD per month, followed by 150 to 199.9 USD

per month (31.2 %).

2. Medical information of the sample

Table 2 Frequency and percentage of samples’ medical information (n = 80)

Characteristics n %

Cause of surgery

Traffic accident 80 100%

Part of bone fracture

Femur 28 35.0

Tibia 30 37.5

Tibia and fibula 22 27.5

Type of surgery

ORIF with plating 31 38.8

ORIF with nailing 49 61.2

49

Table 2 (cont.)

Characteristics n %

Co-morbidity

No 75 93.8

Yes 5 6.2

Hypertension 4 80

Diabetes 1 20

According to the table 2, the most common part of bone fracture was tibia

(37.5 %), followed by femur (35 %). In addition, ORIF with nailing was the major

surgical method used in fixing fractured bone (61.2 %). Notably, 93.8 % of the sample

reported having no co-morbidity. Among patients who demonstrated co-morbidity

(6.2 % of the sample), there were 80 % of them reporting hypertension and 20 % with

diabetes.

Description of the studied variables including pain, anxiety,

uncertainty and postoperative fatigue

Table 3 Frequency and percentage of samples’ the level of pain in the first three days

after surgery (n = 80)

Level of pain Pain in day 1 Pain in day 2 Pain in day 3

n % n % n %

No pain (0) 0 0 0 0 3 3.8

Mild pain (1-3) 1 1.3 19 23.8 45 56.3

Moderate pain (4-6) 31 38.8 46 57.5 26 32.5

Severe pain (7-10) 48 59.9 15 18.7 6 7.4

Table 3 indicates that in the first day after surgery, 59.9 % of the sample got

severe pain, 38.8 % got moderate pain and 1.3 % got mild pain. For the postoperative

50

day two, moderate pain was the most common level of pain accounting for 57.7 %,

followed by mild pain with 23.8 % and severe pain with 18.7 %. In the third day

postoperation, 56.3 % of the sample got mild pain, 32.5 % got moderate pain and

7.4 % got severe pain.

Table 4 Frequency and percentage of samples’ level of anxiety in the third day after

surgery (n = 80)

Level of anxiety n %

Mild anxiety (1 - 7) 11 13.8

Moderate anxiety (8 - 14) 47 58.8

Severe anxiety (15 - 21) 22 27.4

Table 4 showed that 58.8 % of samples reported moderate level of anxiety.

Notably, there were up to 27.4 % had anxiety in severe level.

Table 5 Range, mean and standard deviation of samples’ studied variables including

pain, anxiety, uncertainty (n = 80)

Variables Possible score Actual score M SD

Pain 0 - 10 2 - 8.67 5.09 1.71

Pain in day 1 0 - 10 3 - 10 6.90 1.95

Pain in day 2 0 - 10 2 - 9 4.95 1.74

Pain in day 3 0 - 10 0 - 8 3.43 1.83

Anxiety 0 - 21 3 - 20 12.29 3.78

Uncertainty 28 - 140 60 - 108 82.06 10.57

From table 5, the mean of samples’ pain in the first three days after surgery

was 5.09 (SD = 1.71) which mean pain in the first, second and third day was 6.90

(SD = 1.95), 4.95 (SD = 1.74) and 3.43 (SD = 1.83), respectively. In addition, mean

score of anxiety was in moderate level (M = 12.29, SD = 3.78) and mean score of

uncertainty was quite high (M = 82.06, SD = 10.57).

51

Table 6 Range, mean, standard deviation and mean percentage of samples’

postoperative fatigue classified by subcategories (n = 80)

Postoperative fatigue Possible

range

Actual

range M SD

Mean

%

Fatigue-Identity dimension 9 - 54 19 - 47 34.41 7.22 63.72

Feeling of fatigue 5 - 30 9 - 27 18.13 4.45 60.43

Feeling of lack of vigor 4 - 24 9 - 24 16.29 3.67 67.88

Fatigue-Consequences

dimension 16 - 96 24 - 72 52.16 9.40 54.33

Impacts on concentration 5 - 30 5 - 25 13.98 4.19 46.60

Impacts on energy 6 - 36 10 - 32 21.0 4.48 58.33

Impacts on daily activities 5 - 30 7 - 26 17.19 3.87 57.30

Postoperative fatigue

(overall score) 25 - 150 45 - 117 86.58 15.06

Table 6 shows that mean score of postoperative fatigue was quite high (M =

86.58, SD = 15.06) with mean score of fatigue-identity dimension and fatigue-

consequences dimension as 34.41 (SD = 7.22) and 52.16 (SD = 9.40). Mean

percentage of fatigue-identity dimension (mean % 63.72) was higher than fatigue-

consequences dimension (mean % 54.33). In fatigue – identity dimension, mean score

of feeling of fatigue was 18.13 (SD = 4.45) and feeling of lack of vigor was 16.29

(SD = 3.67) with mean percentage of feeling of lack of vigor (mean % 67.88) higher

than feeling of fatigue (mean % 60.43). In fatigue-consequence dimension, the mean

score of impacts on concentration was 13.98 (SD = 4.19), the impacts on energy was

21.0 (SD = 4.48), and the impacts on daily activities was 17.19 (SD = 3.87) with

highest mean percentage for impacts on energy (mean % 58.33), followed by impacts

on daily activities (mean % 57.30) and impacts on concentration (mean % 46.60)

52

Influence of pain, anxiety and uncertainty on postoperative fatigue

among patients with closed fracture of leg

Because the multiple regression technique was used to test influence of pain,

anxiety, and uncertainty on postoperative fatigue, assumptions of normality, linearity,

homoscedasticity and normality of residuals and multicollinearity were met for all

variables (Tabachnick & Fidell, 2007).

Table 7 Pearson correlation coefficient of samples’ pain, anxiety, uncertainty and

postoperative fatigue (n = 80)

Pain Anxiety Uncertainty Postoperative fatigue

Pain 1.00

Anxiety .50**

1.00

Uncertainty .21 .40**

1.00

Postoperative fatigue .53**

.55**

.38**

1.00

** = p < .01

As demonstrated in the table 7, correlation matrix for predicted variable of

pain, anxiety and uncertainty indicated no correlation to moderate intercorrelations

(r = 0.21 - 0.55). Therefore, multicollinearity was not a problem in this study.

Furthermore, postoperative fatigue were positively associated with pain (r = .53, p <

.01), anxiety (r = .55, p < .01) and uncertainty (r = .38, p < .01). Thus, there was a

linear relationship between variables.

Table 8 Multiple regression analysis for variables predicting postoperative fatigue

(n = 80)

Variables B Beta

Pain 3.05** .35** Intercept = 33.85**

Anxiety 1.18** .30** R2 = .42

Uncertainty .28* .19* F(3,76) = 18.37***

DV = postoperative fatigue, * = p < .05, ** = p < .01, *** = p < .001

53

From table 8, standard multiple regression analysis indicated that pain,

anxiety and uncertainty significantly explained 42 % of the variance in postoperative

fatigue (F(3,76) = 18.37, p < .001). Particularly, pain explained the most variance in

postoperative fatigue (β = .35, p < .01), followed by anxiety (β = .30, p < .01) and

uncertainty (β = .19, p < .05).

The equation was:

postoperative fatigue = 33.85 + 3.05(pain) + 1.18(anxiety) +

0.28(uncertainty)

or

‘Zpostoperative fatigue = .35(Zpain) + .30(Zanxiety) + .19(Zuncertainty)’.

Based on regression model shows that sample who increase 1 score of pain,

could increase 3.05 point in total score of postoperative fatigue. In addition, increase 1

score of anxiety, could increase 1.18 point in total score of postoperative fatigue in the

sample. Finally, the sample who increase 1 score of uncertainty, could increase 0.28

point in total score of postoperative fatigue.

CHAPTER 5

CONCLUSION AND DISCUSSION

This chapter presents a summary and discussion of the study results.

Implication and recommendation of the findings for nursing are also addressed.

Summary of the study

This study aimed to examine the influence of pain, anxiety, and uncertainty

on postoperative fatigue among patients with closed fracture of leg undergoing

internal fixation surgery at Khanh Hoa General Hospital, Vietnam. A sample of 80

patients was recruited from traumatology – orthopedic department of Khanh Hoa

General Hospital, Vietnam. Data were obtained by self-report using 5 instruments.

The patient’s profile record form, The numeric pain rating scale (NPRS), The hospital

anxiety and depression scale (HADS), The Mishel uncertainty in illness scale (MUIS)

and The identity – consequence fatigue scale (ICFS). The ICFS was translated into

Vietnamese by using back translation process. Three experts in nursing science were

consulted about the content validity of Vietnamese version of the instrument and the

CVI was 1. Furthermore, a pilot study was conducted using 30 samples to test the

reliability of measurements. The internal consistency coefficients of HADS, MUIS,

and ICFS were .86, .90 and .87, respectively. Frequency, percentage, mean, standard

deviation, mean percentage, and multiple regression analysis were employed to

analyze the data.

Research findings

1. Characteristics of participants: A majority of samples were male (78.8 %).

The age ranged from 18 to 60 with a mean of 38.25 years (SD = 11.92). There were

70 % of participants who were married, and 43.8 % of participants had completed

secondary school and 28.8 % had finished their high school. Farmer was the major

occupational group accounting for 35 % of the sample, followed by industrial worker

with 26.3 % of the sample. Majority of sample (48.8 %) earned less than 150 USD per

month, followed by the income group of 150 to 199.9 USD per month (31.2 %).

About medical information of the sample, ORIF with intramedullary nailing was the

55

major surgical method used in fixing fractured bone (61.2 %). Operation on tibia was

the most common procedure (37.5 %), followed by femur (35 %). In addition, 93.8 %

of the sample reported co-morbidity. Among patients who demonstrated co-morbidity

(6.2 % of the sample), 80 % of them reported hypertension and 20 % reported

diabetes.

2. Major study variables

On the first day after surgery, most of the sample got severe pain (59.9 %)

and it reduced gradually in the following days with severe pain in the second day and

third day after surgery was 18.7 % and 7.4 %, respectively. Furthermore, the sample

of this study had a moderate level of pain during the first three days after surgery as

presented by the mean of 5.09 (SD = 1.71). Majority of the sample had moderate level

of anxiety in the third day after surgery (58.8 %). Especially, there were up to 27.4 %

with severe level of anxiety. Anxiety score for this sample was also at moderate level

with the mean score of 12.29 (SD = 3.78). Additionally, uncertainty was reported

quite high in this study by the mean of 82.06 (SD = 10.57).

In regard to postoperative fatigue, the participants in this study had a

moderate level of fatigue (M = 86.58, SD = 15.06) with mean score of fatigue-identity

dimension and fatigue-consequences dimension as 34.41 (SD = 7.22) and 52.16

(SD = 9.40). Notably, the mean percentage of fatigue-identity dimension

(mean % 63.72) was higher than fatigue-consequences dimension (mean % 54.33).

In dimension of identifying fatigue, the mean score for feeling of fatigue and feeling

lack of vigor were 18.13 (SD = 4.45) and 16.29 (SD = 3.67), with feeling of lack of

vigor (mean % 67.88) higher than feeling of fatigue (mean % 60.43). Regarding the

consequence of fatigue dimension, impact on energy had the mean score (M = 21,

SD = 4.48), impact on daily activities (M = 17.19, SD = 3.87) and impact on

concentration (M = 13.96, SD = 4.19). The highest mean percentage was for impacts

on energy (mean % 58.33), followed by impacts on daily activities (mean % 57.30)

and impacts on concentration (mean % 46.60).

3. Factors predicting postoperative fatigue

The result from multiple regression analysis suggested that pain, anxiety and

uncertainty were significant predictors of postoperative fatigue (R2 = .42, p < .001).

In addition, pain was the strongest predictor for postoperative fatigue in this sample

56

(β = .35, p < .01), followed by anxiety (β = .30, p < .01) and uncertainty (β = .19, p <

.05).

Discussion

Pain

The study finding indicated that on the first two days after surgery, 100 % of

the sample reported pain. Particularly, on the first day after surgery, 59.9 % of sample

had severe pain and 38.8 % had moderate pain. On the second day, patients with

severe pain accounted for 18.7 % of the sample and moderate pain accounted for

57.7 %. For the third day postoperation, 7.4 % of the respondents got severe pain and

32.5 % got moderate pain. Previous studies also identified the same pattern of pain

occurrence after surgery: pain was most severe on the first day and then gradually

lessened on the following days (Mace, 2003; Rosén et al., 2009). Using visual analog

scale (VAS) to measure pain on patients undergoing elective surgery, Svensson et al.

(2000) reported that 43 %, 27 %, and 16 % patients experience moderate and severe

pain at 24, 48, and 72 hours after surgery, respectively.

The highest percentage of patients suffering severe pain in the first

postoperative day is caused by the combination of stimulation from an injury prior to

surgery and cutting of the skin nerve fibers from operation. These nerve endings send

messages along the nerves into the spinal cord and then up to the brain (Pick,

DeSimone, & Harris, 2010). The daily reduction in the level of pain demonstrates that

postoperative recovery is improving as the body begins to heal. However, all of the

patients in this sample suffered pain in the first two days after surgery, which might

indicate that there is an ineffective pain management. Pain after orthopedic surgery in

the first 3 days is acute pain caused by multiple factors. Many recommendations on

effective acute pain management suggest a continuous opioid drug administration

(Argoff, 2014; Pick et al., 2010). In contrast to these recommendations, it was noted

that the analgesic medications used for those postoperative patients at 4 hours after

surgery and following days were only nonsteroidal anti-inflammatory drug (NSAID)

via oral or intramuscular injection administration (Alphachymotrypsin, Tenoxicam,

Meloxicam) combined with Paracetamol 500 mg for oral administration twice per day

at 8 AM and 4 PM.

57

Moreover, the average pain score of the sample during the first three days

after surgery was in a moderate level as presented by the mean of 5.09 (SD = 1.71)

with the mean score of pain in the first, second and third day as 6.90 (SD = 1.95), 4.95

(SD = 1.74), 3.43 (SD = 1.83), respectively. The current findings showed relatively

higher pain intensity in this sample of postoperative patients. It can be explained by

the combination from damaged muscle and skeletal tissue repair or reconstruction

during pre and post operation (Adlin Dasima & Karis, 2013). Additionally, infective

strategies for pain management must have contributed to the pain severity in this

setting. Measuring pain by 0 - 100 mm VAS, the finding from previous studies had

lower pain score than current study. It was reported that pain score during 48 hours

after general surgery was 26.1 mm (Terry, Niven, Brodie, Jones, & Prowse, 2007).

Wickström, Nordberg, and Johansson (2005) asserted that the mean score after radical

prostatectomy in the first two days was 40 mm (SD = 29) and on the third day was

20mm (SD = 26).

Anxiety

The finding indicated that 100 % patients suffered anxiety on the third day

after surgery. Especially, 58.8 % of samples reported moderate level of anxiety and

27.4 % had anxiety in severe level. The percentage of patients with anxiety was

higher in the current study compared to the anxiety levels reported by previous

studies. Using the same instrument - the hospital anxiety and depression scale on 85

women having major gynecological surgery, Carr, Thomas, and Wilson–Barnet

(2005) reported that the percentage of participants suffering moderate to severe

anxiety in day 2 was 30.6 % and day 4 was 34.1 %. Also with this questionnaire,

de Moraes et al. (2010) indicated that the prevalence of moderate and severe anxiety

was 44 % on 100 orthopedic and trauma inpatients. An explanation for the finding of

higher level of anxiety in sample could be because most of the lower limb fracture

patients were the main labor force in the family as evident from the mean age of the

sample (38.25 years) and male gender majority (78,8 %). Hospitalization makes

patients question about their responsibility of taking care of family members.

Moreover, the sample had high percentage of famers (35 %) with income from mostly

those daily basic jobs; prolonged recovery and rehabilitation related to leg injuries

challenged their source of income and made them anxious.

58

The mean score of anxiety of lower limb fracture patients in the present

study was in moderate level (M = 12.29, SD = 3.78). Notably, score of anxiety in this

study is higher than previous study. The mean score of anxiety in gynecological

surgery for postoperative day 2 was 5.64 (SD = 3.57) and mean score for

postoperative day 4 was 6.08 (SD = 4.44) (Carr et al., 2005). An explanation for the

severity of anxiety in the present study is due to emergency health problem. Patients

got hospital admission from an accidental trauma, which leaves them with no physical

or mental preparedness like in case of medical illness. Struggling with hospitalization

obligation can make fracture patients have no preparation for their own life or for

their families. Separation from family and leaving their work leads to the feeling of

anxiety in those patients. Moreover, in the first three days after surgery, interference

from many unpleasant symptoms cause patients to be more worried (Caumo et al.,

2001; Muglali & Komerik, 2008).

Uncertainty

The respondents in the present study had quite a high score for uncertainty

as reflected by the mean score of 82.06 (SD = 10.57); the possible overall score for

this variable ranged from 28 to 140. A possible explanation for the presence of

uncertainty feeling of leg fracture patients is that operation for this population is a

result of accidental trauma. Timing from admission until operation was very strict,

average time was only 5 hours. Moreover, after surgery in the first three days, as a

consequence of overload condition of patient admission, chances to communicate

between health care providers and fracture patients was less. Hence, insufficiency of

information from health care providers caused patients fall into an unclear situation.

Furthermore, ambiguity about symptomatology, diagnosis, treatment process,

relationship with health care providers and unclear plan for patients’ future can be

considered as important reasons for occurring uncertainty in lower leg fracture

patients (Appendix 7).

The finding of this study was in line with previous study findings mostly

reporting a moderate level of uncertainty in surgical patients. Investigating on 100

patients undergoing abdominal surgery with the same instrument - the Mishel

uncertainty in illness scale - Loi (2014) reported that uncertainty score was 85.70 (SD

= 16.13). On orthopedic population, Calvin and Lane (1999) reported that all of

59

participants responded having moderate levels of uncertainty. Also, moderate level of

uncertainty was indicated in a study on 40 individuals after surgical resection of colon

cancer (Galloway & Graydon, 1996).

Postoperative fatigue

The sample also reported a moderate level of postoperative fatigue. The

mean score was 86.58 (SD = 15.06) with the possible overall score ranging from 25 to

150. In the context of lower limb fracture patients, postoperative fatigue could be

explained by the combination of events lasting from prior to post surgery. Suffering

injury, facing with pain, and blood loss are the first causes for fatigue among lower

limb fracture patients (Ignatavicius, 2013). Moreover, surgical trauma in the surgical

setting with side effect from anesthesia procedure is considered as another important

factor contributing to postoperative fatigue. Finally, insufficient rest caused by

disturbance from inflammatory process and many unpleasant symptoms after surgery

can lead to postoperative fatigue among patients with closed fracture of leg

undergoing ORIF surgery (Zargar-Shoshtari & Hill, 2009).

Similarly, previous studies supported the presence of fatigue in moderate

level in surgical patients. In Vietnamese surgical patients, Long (2010) also indicated

that tiredness appeared as one of the most problematic symptoms in entire three days

after abdominal surgery. Using profile of mood states to measure the intensity of

fatigue feelings among 102 patients after undergoing primary hip arthroplasty in the

first 3 days, the finding showed a mean score of 9.1 (SEM = 0.6) (Hall & Salmon,

2002). Graversen and Sommer (2013) measured fatigue by 0 - 10 numeric scale and

indicated that on the first day after laparoscopic cholecystectomy surgery, fatigue

presented at 24 hours was 4. Yu et al. (2015) showed the mean scores of fatigue on

the first day after surgery was 7.14 (SD = .72) and on the 10th day was 4.23

(SD = 1.00).

Factors predicting postoperative fatigue

The regression model assessed that all the three variables of pain, anxiety

and uncertainty constituted the explanatory 42 % of postoperative fatigue in patients

with lower limb fracture undergoing ORIF surgery. This finding was supported by

both theoretical and empirical basis. Theoretically, according to the theory of

unpleasant symptoms (TOUS), these factors are the antecedent factors for

60

postoperative fatigue. They can directly influence on patients’ symptoms. For

empirical evidence, the results of the current study were the same as previous

researchers’ findings (Falk et al., 2007; Long, 2010; Saowaluck, 2009; Tan & Xia,

2014).

The present study points out that pain had a significant impact on patients’

postoperative fatigue. Findings revealed that pain positively influenced on

postoperative fatigue (β = .35, p < .01). The link between pain and fatigue is that

fatigue develops after the development of pain; and an improvement in fatigue will

lessen pain. Similarly, the more severe the pain, the greater the likelihood of fatigue

and the greater the pain experienced the more certain it was that fatigue occurred.

Theoretically, fatigue plays a role as an unpleasant symptom that is influenced by

physiologic factors including pain (Lenz et al., 1997). For empirical evidence, there

are many studies discussing the impacts of ineffective pain management. Among

them, sleep disturbance, mood disorders such as anxiety, fear and depression occurred

as the most common problems (Chiu et al., 2005; Chouchou et al., 2014). Thus, these

could be considered as reasons for the presence of fatigue. On the other hand, adverse

effects on the endocrine and immune functions resulting from ineffective pain

management can also lead to fatigue (Peters et al., 2007).

Findings from many other studies also supported the finding of the present

study. There is a close relationship existing between pain and fatigue. In Saowaluck’s

study (2009), the result asserted pain was a significant predictor of postoperative

fatigue (β = .28, p < .01) among hysterectomy patients. It is also reported that

although several variables were found to contribute to the severity of fatigue, the

presence of pain contributed to 7.6 % of variance of fatigue (Lee et al., 2010). By

using multiple logistic regression models, Garabeli Cavalli Kluthcovsky et al. (2012)

reported that the presence of pain is one of the predictive factors for postoperative

fatigue (OR = 3.87, 95 % CI = 1.88 - 7.98, p = .000). Thus, pain constituted one of the

most important factors affecting postoperative fatigue among lower limb fracture

patients. Nurses should be mindful that patients will benefit from nursing

intervention, focusing on effective pain management that can reduce postoperative

fatigue.

61

The results also identified that anxiety constituted another explanatory factor

of postoperative fatigue (β = .30, p < .01). This finding was supported by both

theoretical and research findings. This finding was supported by both theoretical and

studied basis. According Lenz et al. (1997), the psychological factors including the

individual’s mental state or mood (depression), affective reaction to illness (mood

status) and psychological response to stress (the degree of perceived stress or the level

of anxiety) can affect unpleasant symptoms. Moreover, anxiety increases the release

of epinephrine into the circulation which causes blood vessel constriction, increased

heart rate and force of contractility, enhancing blood pressure and temperature,

flushing and sweating (Vaughn, Wichowski, & Bosworth, 2007). Level of anxiety

may alter a patient’s surgical course and cause increased postoperative pain (Caumo

et al., 2002; Katz et al., 2005; Vaughn et al., 2007). Furthermore, negative emotions

such as anxiety can affect immunomodulatory behaviors, causing poor sleep patterns

and poor nutrition. In addition, the patient may have a heightened sense of touch,

smell or hearing and being placed in unfamiliar surroundings can make the individual

feel even more unwell and uncomfortable (Pritchard, 2009). These consequences of

anxiety contribute to the development of fatigue after surgery.

The influence of anxiety on postoperative fatigue is consistent with previous

studies. In abdominal surgery population, the result indicated that on the second day

after surgery, anxiety was associated with tiredness (r = .33, p < .01) (Long, 2010).

Increase in psychological distress is a factor related to worsening fatigue after surgery

(Rotonda et al., 2013). To describe the relationship of fatigue with psychological

functioning in adults with spinal cord injury, anxiety was an independent factor that

was associated with fatigue (Alschuler et al., 2013). On 180 postoperative patients

with breast cancer, the finding showed that moderate/ severe fatigue was positively

associated with anxiety (r = .32, p < .05) (Tan & Xia, 2014).

Uncertainty was identified as another important determinant of postoperative

fatigue for leg fracture patients (β = .19, p < .05). The links between uncertainty and

fatigue included the development of fatigue after the development of uncertainty; the

more severe uncertainty was present, the greater the likelihood of fatigue. This was in

line with both the theoretical basis and previous research results. Based on the Theory

of Unpleasant Symptoms (Lenz et al., 1997), an unpleasant symptom such as

62

postoperative fatigue is influenced by psychological antecedents including the degree

of uncertainty and knowledge about the symptoms and patient’s possible meaning

(perception of illness experience or symptom experience). Additionally, according to

Mishel (1988), patients with uncertainty will have negative thoughts and beliefs

regarding the disease, leading to altered coping, severe cognitive impairment.

Furthermore, if uncertainty keeps developing, it makes patients fall into conditions of

stress and anxiety. Therefore, the psychological distress and depressive symptoms

caused by uncertainty are the reason for occurrence of postoperative fatigue.

The current study result is similar with finding from the previous studies.

Falk et al. (2007) asserted that there was a positive association between uncertainty

and tiredness among heart chronic failure patients. Lasker et al. (2010) conducted a

study on 100 female patients undergoing liver transplantation operation and indicated

that there was a significant relationship between uncertainty and fatigue. Moreover,

for cancer patients undergoing radiotherapy, Stiegelis et al. (2004) indicated that

reduction in illness uncertainty was an important factor in decreasing fatigue.

The results imply that the presence of three variables including pain, anxiety

and uncertainty can explain 42 % variance of postoperative fatigue among patients

with closed fracture of leg undergoing internal fixation surgery in the first three days.

If nurses focus on controlling pain by using effective pain management and reducing

patient’s feeling of anxiety and uncertainty, it will be a good strategy to decrease

fatigue after surgery. These will in turn help patient recover well and get discharged

in the short time.

Implications and recommendations

Results of this study demonstrated that fatigue, pain, anxiety and uncertainty

occurred frequently during first three postoperative days. Moreover, pain, anxiety and

uncertainty constituted as the important determinants of postoperative fatigue for

patients with closed fracture of leg undergoing internal fixation surgery. The findings

of this study can be applied for nursing clinical practice, education and research as

follows:

63

Implications and recommendations for clinical practice

1. Nurses should be aware of the presence of fatigue in patients with lower

limb fracture undergoing ORIF surgery. Additionally, nurses should know that factors

affecting postoperative fatigue are pain, anxiety and uncertainty.

2. Nurses should regularly assess the occurrence of pain, anxiety,

uncertainty and fatigue after surgery and make a good nursing care plan to prevent as

well as manage these symptoms effectively.

3. Nurse administrators can provide an in-service training on postoperative

fatigue assessment and management to their staff, focusing on prevention and

management of pain, anxiety and uncertainty. In addition, provision of the

refreshment courses should be set regularly to all staff nurses who are taking care of

postoperative patients.

Implications and recommendations for education

1. Results of this study can be used to integrate into a nursing curriculum,

focusing on the presence of fatigue after surgery and predicting factors to this

symptom that are pain, anxiety and uncertainty among lower limb fracture patients

undergoing ORIF surgery.

2. Teaching nursing students to understand and realize the presence of

fatigue postoperatively and associated factors is recommended. In addition, nursing

teachers should educate student in assessing postoperative fatigue and provide proper

strategies to prevent and manage this unpleasant symptom by managing pain, anxiety

and uncertainty.

Implications and recommendations for research

It could be said that this study is the confirmation of the Theory of

Unpleasant Symptoms. The associations among symptoms and between symptoms

and antecedents as hypothesized by Lenz et al. (1997) had been proved in the present

study. It is meaningful because the model was tested in a different culture from

Western societies. Adding up to the previous studies, this research affirms that the

Theory of Unpleasant Symptoms is the reliable and applicable theoretical guide for

nursing practice and nursing research. According to the findings, further studies are

recommended:

64

1. A fatigue management program should be developed and tested

empirically. An experimental research on symptom management should focus on

alleviating postoperative fatigue.

2. Clinical guideline for nursing practice in terms of assessing and

managing postoperative fatigue by intervening in pain, anxiety and uncertainty.

3. Since this study is limited only to lower limb fracture surgery patients

who were admitted in Khanh Hoa General hospital, Vietnam; the findings cannot be

generalized to those undergoing other types of surgery and also to those who staying

in other regions in Vietnam. Hence, replication of this study among other types of

surgery and other setting is recommended to validate the results of this study.

REFERENCES

Aarons, H., Forester, A., Hall, G., & Salmon, P. (1996). Fatigue after major joint

arthroplasty: Relationship to preoperative fatigue and postoperative

emotional state. Journal of Psychosomatic Research, 41(3), 225-233.

Adlin Dasima, A. K., & Karis, M. (2013). The prevalence of postoperative symptoms

within 24 hours after ambulatory surgery in a university hospital. Journal

of Surgical Academia, 3(2), 32-38.

Ai, A. L., Wink, P., & Shearer, M. (2012). Fatigue of survivors following cardiac

surgery: Positive influences of preoperative prayer coping. British Journal of

Health Psychology, 17(4), 724-742. doi:10.1111/j.2044-8287.2012.02068

Alschuler, K. N., Jensen, M. P., Goetz, M. C., Smith, A. E., Verrall, A. M., & Molton,

I. R. (2012). Effects of pain and fatigue on physical and psychological

functioning in persons with muscular dystrophy. Disability and Health

Journal, 5(4), 277–283.

Alschuler, K. N., Jensen, M. P., Sullivan-Singh, S. J., Borson, S., Smith, A. E., &

Molton, I. R. (2013). The association of age, pain, and fatigue with physical

functioning and depressive symptoms in persons with spinal cord injury. The

Journal of Spinal Cord Medicine, 36(5), 483-491.

Amin, N. H., Jakoi, A., Katsman, A., Harding, S. P., Tom, J. A., & Cerynik, D. L.

(2011). Incidence of orthopedic surgery intervention in a level I urban

trauma center with motorcycle trauma. The Journal of Trauma, 71(4), 948-

951.

Apfel, C. C., Läärä, E., Koivuranta, M., Greim, C. A., & Roewer, N. (1999). A

simplified risk score for predicting postoperative nausea and vomiting:

Onclusions from cross-validations between two centers. Anesthesiology,

91(3), 693-700.

Argoff, C. E. (2014). Recent management advances in acute postoperative pain. Pain

Practice, 14(5), 477-87.

Bambauer, K., Locke, S. E., Aupont, O., Mullan, M., & McLaughlin, T. (2005).

Using the hospital anxiety and depression scale to screen for depression in

cardiac patients. General Hospital Psychiatry, 27(4), 275-284.

66

Baumeister, R. F. (2002). Ego depletion and self-control failure: An energy model

of the self’s executive function. Self and Identity, 1(2), 129-136.

Becher, S., Smith, M., & Ziran, B. (2014). Orthopaedic trauma patients and

depression: A prospective cohort. Journal of Orthopaedic Trauma, 28(10),

e242-e246.

Beck, S., Dudley, W., & Barsevick, A. (2005). Pain, sleep disturbance and fatigue in

patients with cancer: Using a mediation model to test a symptom cluster.

Oncology Nursing Forum, 32(3), E48-E55.

Bhandari, M., Busse, J. W., Hanson, B. P., Leece, P. R., Ayeni, O. R., Emil, H., &

Schemitsch, E. H. (2008). Psychological distress and quality of life after

orthopedic trauma: An observational study. Canadian Journal of Surgery,

51(1), 15-22.

Bijur, P. E., Latimer, C. T., & Gallagher, E. J. (2003). Validation of a verbally

administered numerical rating scale of acute pain for use in the emergency

department. Academic Emergency Medicine, 10(4), 390-392.

Bisgaard, T., Klarskov, B., Rosenberg, J., & Kehlet, H. (2001). Factors determining

convalescence after uncomplicated laparoscopic cholecystectomy. Archives

of Surgery, 136(8), 917-921.

Bourne, M. H. (2004). Analgesics for orthopedic postoperative pain. American

Journal of Orthopedics, 33(3), 128-135.

Burden, N. (2007). Care of the orthopaedic patient in the ambulatory surgery setting.

Journal of Perianesthesia Nursing, 22(3), 207-210.

Calvin, R. L., & Lane, P. L. (1999). Perioperative uncertainty and state anxiety of

orthopaedic surgical patients. Orthopedic Nursing, 18(6), 61-66.

Carr, E., Thomas, V., & Wilson–Barnet, J. (2005). Patient experiences of anxiety,

depression, and acute pain after surgery: A longitudinal perspective.

International Journal of Nursing Studies, 42(5), 521–530

Caumo, W., Schmidt, A. P., Schneider, C. N., Bergmann, J., Iwamoto, C. W.,

Adamatti, L. C., Bandeira, D., & Ferreira, M. B. (2002). Preoperative

predictors of moderate to intense acute postoperative pain in patients

undergoing abdominal surgery. Acta Anaesthesiologica Scandinavica,

46(10), 1265-1271.

67

Caumo, W., Schmidt, A. P., Schneider, C. N., Bergmann, J., Iwamoto, C. W.,

Adamatti, L. C., Bandeira, D., & Ferreira, M. B. (2001). Risk factors for

postoperative anxiety in adults. Anaesthesia, 56(8), 720-728.

Cha, E., Kim, K., & Erlen, J. (2007). Translation of scales in cross-cultural research:

Issues and techniques. Journal of Advanced Nursing, 58(4), 386–395.

Chalder, T., Berelowitz, G., Pawlikowska, T., Watts, L., Wessely, S., Wright, D., &

Wallace, E. P. (1993). Development of a fatigue scale. Journal of

Psychosomatic Research, 37(2), 147-153.

Chiu, Y. H., Silman, A. J., Macfarlane, G. J., Ray, D., Gupta, A., Dickens, C.,

Morriss, R., & McBeth, J. (2005). Poor sleep and depression are

independently associated with a reduced pain threshold: Results of a

population based study. Pain, 115(3), 316-321.

Chouchou, F., Khoury, S., Chauny, J. M., Denis, R., & Lavigne, G. J. (2014).

Postoperative sleep disruptions: A potential catalyst of acute pain? Sleep

Medicine Reviews, 18(3), 273-282.

Christensen, T., & Kehlet, H. (1993). Postoperative fatigue. World Journal of

Surgery, 17(2), 220-225.

Chung, F., Un, V., & Su, J. (1996). Postoperative symptoms 24 hours after

ambulatory anaesthesia. Canadian Journal of Anaesthesia, 43(11), 1121-

1127.

Closs, J., Briggs, M., & Everitt, V. (1997). Night-time pain, sleep and anxiety in

postoperative orthopaedic patients. Journal of Orthopaedic Nursing, 1(2),

59-66.

Cotel, F., Exley, R., Cragg, S. J., & Perrier, J. F. (2013). Serotonin spillover onto the

axon initial segment of motoneurons induces central fatigue by inhibiting

action potential initiation. The Proceedings of the National Academy of

Sciences of the United States of America (PNAS), 110(12), 4774–4779.

Cronin, A. J., Keifer, J. C., Davies, M. F., King, T. S., & Bixler, E. O. (2001).

Postoperative sleep disturbance: Influences of opioids and pain in humans.

Sleep, 24(1), 39-44.

68

Davis, J. M., Alderson, N. L., & Welsh, R. S. (2000). Serotonin and central nervous

system fatigue: Nutritional considerations. The American Journal of Clinical

Nutrition, 72(2), 573S–578S.

de Moraes, V. Y., Jorge, M. R., Faloppa, F., & Belloti, J. C. (2010). Anxiety and

depression in Brazilian orthopaedics inpatients: A cross sectional study with

a clinical sample comparison. Journal of Clinical Psychology in Medical

Settings, 17(1), 31-37.

DeCherney, A. H., Bachmann, G., Isaacson, K., & Gall, S. (2002). Postoperative

fatigue negatively impacts the daily lives of patients recovering from

hysterectomy. Obstetrics and Gynecology, 99(1), 51-57.

deWit, S. C., & Kumagai, C. K. (2013). Medical-surgical nursing: Concepts &

practice (2nd

ed.). Missouri, MO: Saunders.

Dischinger, P. C., Read, K. M., Kufera, J. A., Kerns, T. J., Burch, C. A., Jawed, N., &

Ho, S. M. (2004). Consequences and costs of lower extremity injuries.

Annals of Advances in Automotive Medicine, 48, 339-353.

Edwards, H., Rose, E. A., & King, T. C. (1982). Postoperative deterioration in

muscular function. Archives of Surgery, 117(7), 899-901.

Epstein, N. E. (2014). A review article on the benefits of early mobilization following

spinal surgery and other medical/ surgical procedures. Surgical Neurology

International, 5(3), S66-S73. doi:10.4103/2152-7806.130674

Ersözlü, S., Sahin, O., Ozgür, A. F., & Tuncay, I. C. (2009). The effects of two

different continuous passive motion protocols on knee range of motion after

total knee arthroplasty: A prospective analysis. Acta Orthopaedica et

Traumatolgica Turcica, 43(5), 412-418.

Falk, K., Swedberg, K., Gaston-Johansson, F., & Ekman, I. (2007). Fatigue is a

prevalent and severe symptom associated with uncertainty and sense of

coherence in patients with chronic heart failure. European Journal of

Cardiovascular Nursing, 6(2), 99-104.

Fishbain, D. A., Lewis, J., Cole, B., Cutler, B., Smets, E., Rosomoff, H., & Rosomoff,

R. S. (2005). Multidisciplinary pain facility treatment outcome for pain-

associated fatigue. Pain Medicine, 6(4), 299-304.

69

Fishbain, D. A., Cole, B., Cutler, R. B., Lewis, J., Rosomoff, H. L., & Fosomoff, R. S.

(2003). Is pain fatiguing? A structured evidence-base review. Pain

Medication, 4(1), 51-62.

Finkelstein, E. A., Corso, P. S., & Miller, T. R. (2007). The incidence and economic

burden of injuries in the United States. Journal of Epidemiol Community

Health, 61(10), 926-927. doi:10.1136/jech.2007.059717

Galloway, S. C., & Graydon, J. E. (1996). Uncertainty, symptom distress, and

information needs after surgery for cancer of the colon. Cancer Nursing,

19(2), 112-117.

Gandevia, S. C. (2001). Spinal and supraspinal factors in human muscle fatigue.

Physiological Reviews, 81(4), 1725-1789.

Garabeli Cavalli Kluthcovsky, A. C., Urbanetz, A. A., de Carvalho, D. S., Pereira

Maluf, E. M., Schlickmann Sylvestre, G. C., & Bonatto Hatschbach, S. B.

(2012). Fatigue after treatment in breast cancer survivors: Prevalence,

determinants and impact on health-related quality of life. Supportive Care in

Cancer, 20(8), 1901-1909.

Giang, D. T., Huy, L. D., Huyen, P. N., Khanh, D. N. D., Khue, N. D., Kieu, N. T. T.,

Lien, N. N., Linh, V. T. T., Mon, L. H., & Nhung, P. T. H. (2013). Injury

accident. Retrieved from http://www.slideshare.net/duykhuetv/bo-co-tnh

-hnh-tai-nn-thng-tch?related=2

Giesa, M., Decking, J., Roth, K. E., Heid, F., Jage, J., & Meurer, A. (2007). Acute

pain management after orthopaedic surgery. Schmerz, 21(1), 73-82.

Grau Martin, A., SunerSoler, R., AbuliPicart, P., & Comas Casanovas, P. (2003).

Anxiety and depression levels in medical levels in medical inpatients and

their relation to the severity of illness. Medicina Clinica (Barcelona),

120(10), 370–375.

Graversen, M., & Sommer, T. (2013). Perioperative music may reduce pain and

fatigue in patients undergoing laparoscopic cholecystectomy. Acta

Anaesthesiologica Scandinavica, 57(8), 1010-1016.

Grove, S. K., Burns, N., & Gray, J. (2013). The practice of nursing research:

Appraisal, synthesis, and generation of evidence (7th

ed.). St. Louis, MO:

Saunders Elsevier.

70

Hall, G. M, & Salmon, P. (2002). Physiological and psychological influences on

postoperative fatigue. Anesthesia and Analgesia, 95(5), 1446-1450.

Hansen, M. S., Fink, P., Frydenberg, M., Oxhoj, M., Sondergaard, L., & Munk-

Jorgensen, P. (2001). Prevalence and treatment of medical inpatients

Prevalence, detection, and treatment status. Journal of Psychosomatic

Research, 50(4), 199-204.

Herr, K. A., Spratt, K., Mobily, P. R., & Richardson, G. (2004). Pain intensity

assessment in older adults: Use of experimental pain to compare

psychometric properties and usability of selected pain scales with younger

adults. The Clinical Journal of Pain, 20(4), 207-219.

Ignatavicius, D. D. (2013). Care of patients with musculoskeletal trauma. In D. D.

Ignatavicius & M. L. Workman (Eds.), Medical – surgical nursing: Patient-

centered collaborative care (7th

ed., pp. 1143-1176). St. Louis, MO: Mosby

Elsevier.

Jensen, M. B., Houborg, K. B., Nørager, C. B., Henriksen, M. G., & Laurberg, S.

(2011). Postoperative changes in fatigue, physical function and body

composition: An analysis of the amalgamated data from five randomized

trials on patients undergoing colorectal surgery. Colorectal Disease, 13(5),

588-593.

Jensen, M. P., & McFarland, C. A. (1993). Increasing the reliability and validity of

pain intensity measurement in chronic pain patients. Pain, 55(2), 195-203.

Kaasa, S., Loge, J. H., Knobel, H., Jordhøy, M. S., Brenne, E. (1999). Fatigue:

Measures and relation to pain. Acta Anaesthesiologica Scandinavica, 43(9),

939-947.

Kahokehr, A., Broadbent, E., Wheeler, B. R., Sammour, T., & Hill, A. G. (2012). The

effect of perioperative psychological intervention on fatigue after

laparoscopic cholecystectomy: A randomized controlled trial. Surgical

Endoscopy, 26(6), 1730-1736.

Kain, Z. N., & Caldwell-Andrews, A. A. (2003). Sleeping characteristics of adults

undergoing outpatient elective surgery: A cohort study. Journal of Clinical

Anesthesia, 15(7), 505-509.

71

Karanci, A. N., & Dirik, G. (2003). Predictors of pre- and postoperative anxiety in

emergency surgery patients. Journal of Psychosomatic Research, 55(4),

363-369.

Katz, J., Poleshuck, E. L., Andrus, C. H., Hogan, L. A., Jung, B. F., Kulick, D. I., &

Dworkin, R. H. (2005). Risk factors for acute pain and its persistence

following breast cancer surgery. Pain, 119(1-3), 16-25.

Kehlet, H., & Wilmore, D. W. (2008). Evidence-based surgical care and the evolution

of fast-track surgery. Annals of Surgery, 248(2), 189-198.

Kennedy, H. G. (1988). Fatigue and fatigability. The British Journal of Psychiatry,

153(1), 1-5.

Kiecolt-Glaser, J. K., Page, G. G., Marucha, P. T., MacCallum, R. C., & Glaser, R.

(1998). Psychological influences on surgical recovery: Perspectives from

psychoneuroimmunology. The American Psychologist, 53(11), 1209-1218.

Koivuranta, M., Läärä, E., Snåre, L., & Alahuhta, S. (1997). A survey of

postoperative nausea and vomiting. Anaesthesia, 52(5), 443-449.

Krenk, L., Jennum, P., & Kehlet, H. (2012). Sleep disturbances after fast-track hip

and knee arthroplasty. British Journal of Anaesthesia, 109(5), 769-775.

Ku, C., & Ong, B. (2003). Postoperative nausea and vomiting: A review of current

literature. Singapore Medical Journal, 44(7), 366-374.

Labraca, N. S., Castro-Sánchez, A. M., Matarán-Peñarrocha, G. A., Arroyo-Morales,

M., Sánchez-JoyaMdel, M., & Moreno-Lorenzo, C. (2011). Benefits of

starting rehabilitation within 24 hours of primary total knee arthroplasty:

Randomized clinical trial. Clinical Rehabilitation, 25(6), 557-566.

Lasker, J. N., Sogolow, E. D., Olenik, J. M., Sass, D. A., & Weinrieb, R. M. (2010).

Uncertainty and liver transplantation: Women with primary biliary cirrhosis

before and after transplant. Women & Health, 50(4), 359-375.

Lee, A. K., Miller, W. C., Townson, A. F., Anton, H. A., & F2N2 Research Group.

(2010). Medication use is associated with fatigue in a sample of community-

living individuals who have a spinal cord injury: A chart review. Spinal

Cord, 48(5), 429-433. doi:10.1038/sc.2009.145

Lee, C., & Porter, K. M. (2005). Prehospital care: Prehospital management of lower

limb fractures. Emergency Medicine Journal, 22(9), 660-663.

72

LeMone, P., & Burke, K. (Eds). (2008). Nursing care of clients with musculoskeletal

trauma. New Jersey, NJ: Pearson Education.

Lenz, E., Pugh, L., Milligan, R., Gift, A., & Suppe, F. (1997). The middle-range

theory of unpleasant symptoms: An update. Advances in Nursing Science,

19(3), 14-27.

Loi, T. V. (2014). Factors related to preoperative anxiety among patients undergoing

abdominal surgery in Thai Nguyen Hospital, Vietnam. Master’s thesis,

International program, Faculty of Nursing, Burapha University.

Long, N. H. (2010). Factors related to postoperative symptoms among patients

undergoing abdominal surgery. Master’s thesis, International program,

Faculty of Nursing, Burapha University.

Lubkin, I. M., & Larsen, P. D. (2006). Chronic illness: Impact and intervention (6th

ed.). Boston, MA: Jones and Bartlett Publishers.

Mace, L. (2003). An audit of postoperative nausea and vomiting, following cardiac

surgery: Scope of the problem. Nursing in Critical Care, 8(5), 187-196.

Mamaril, M. E., Childs, S. G., & Sortman, S. (2007). Care of the orthopaedic trauma

patient. Journal of Perianesthesia Nursing, 22(3), 184-194.

Marcora, S. M., Staiano, W., & Manning, V. (2009). Mental fatigue impairs physical

performance in humans. Journal of Applied Physiology, 106 (3), 857-864.

Mattila, K., Toivonen, J., Janhunen, L., Rosenberg, P. H., & Hynynen, M. (2005).

Postdischarge symptoms after ambulatory surgery: First-week incidence,

intensity and risk factors. Anesthesia Analgesia, 101(6), 1643-1650.

McCaffery, M., & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St.

Louis, MO: Mosby Elsevier.

McCarberg, B., & Cole. B. E. (2009). Pain in the older person. In R. J. Moore (Ed.),

Biobehavioral approaches to pain (pp. 195-214). New York, NY: Springer.

McCarthy, M. L., & Mackenzie, E. J. (2001). Predicting ambulatory function

following lower extremity trauma using the functional capacity index.

Accident Analysis and Prevention, 33(6), 821-831.

McColl, M. A., Arnold, R., Charlifue, S., Glass, C., Savic, G., & Frankel, H. (2003).

Aging, spinal cord injury, and quality of life: Structural relationships.

Archives of Physical Medicine and Rehabilitation, 84(8), 1137-1144.

73

McDowell, I. (2006). Measuring health: A guide to rating scales and questionnaires

(3rd

ed.). Oxford: Oxford University Press.

McKoy, B. E., & Hartsock, L. A. (2000). Physical impairment and functional

outcome in patients having lower extremity fractures after age 65. Journal of

the Southern Orthopaedic Association, 9(3), 161-168.

Mishel, M. H. (1981).The measurement of uncertainty in illness. Nursing Research,

30(5), 258-263.

Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing

Scholarship, 20(4), 225-232.

Mock, C., MacKenzie, E., Jurkovich, G., Burgess, A., Cushing, B., deLateur, B.,

McAndrew, M., Morris, J., & Swiontkowski, M. (2000). Determinants of

disability after lower extremity fracture. The Journal of Trauma, 49(6),

1002-1011.

Montgomery, G. H., Schnur, J. B., Erblich, J., Diefenbach, M. A., & Bovbjerg, D. H.

(2010). Presurgery psychological factors predict pain, nausea, and fatigue

one week after breast cancer surgery. Journal of Pain and Symptom

Management, 39(6), 1043-1052.

Muglali, M., & Komerik, N. (2008). Factors related to patients' anxiety before and

after oral surgery. Journal of Oral and Maxillofacial Surgery, 66(5), 870-

877.

Mwaka, G., Thikra, S., & Mung’ayi, V. (2013).The prevalence of postoperative pain

in the first 48 hours following day surgery at a tertiary hospital in Nairobi.

African Health Sciences, 13(3), 768-776.

National Road Safety Commission. (2013). Numbers of traffic accidents in 2013.

Retrieved from http://hanoimoi.com.vn/Tin-tuc/giao-thong/657500/nam-

2013-ca-nuoc-xay-ra-29385-vu-tai-nan-giao-thong

National Trauma Institute. (2014). Trauma statistics. Retrieved from

http://www.nationaltraumainstitute.org/home/trauma_statistics.html

Ohura, T., Sanada, H., & Mino, Y. (2004). Clinical study using activity-based costing

to assess cost-effectiveness of a wound management system utilizing

modern dressings in comparison with traditional wound care. Nihon Ronen

IgakkaiZasshi, 41(1), 82-91.

74

Paddison, J. S., Booth, R. J., Hill, A. G., & Cameron, L. D. (2006). Comprehensive

assessment of peri-operative fatigue: Development of the identity-

consequence fatigue scale. Journal of Psychosomatic Research, 60(6),

615- 622.

Paddison, J. S., Booth, R. J., Cameron, L. D., Robinson, E., Frizelle, F. A., & Hill,

A. G. (2009). Fatigue after colorectal surgery and its relationship to patient

expectations. Journal of Surgical Research, 151(1), 145-152.

Pasero, C., & McCaffery, M. (2007). Orthopaedic postoperative pain management.

Journal of Perianesthesia Nursing, 22(3), 160-172.

Paterno, M. V., Archdeacon, M. T., Ford, K. R., Galvin, D., & Hewett, T. E. (2006).

Early rehabilitation following surgical fixation of a femoral shaft fracture.

Physical Therapy, 86(4), 558-572.

Pavlin, D. J., Chen, C., Penaloza, D. A., & Buckley, F. P. (2004). A survey of pain

and other symptoms that affect the recovery process after discharge from an

ambulatory surgery unit. Journal of Clinical Anaesthesia, 16(3), 200-206.

Perrier, J. F., & Delgado-Lezama, R. (2005). Synaptic release of serotonin induced by

stimulation of the raphe nucleus promotes plateau potentials in spinal

motoneurons of the adult turtle. The Journal of Neuroscience, 25(35),

7993-7999.

Peters, M., Sommer, M., de Rijke, J., Kessels, F., Heineman, E., Patijn, J., Marcus, M.

A., Vlaeyen, J. W., & van Kleef, M. (2007). Somatic and psychologic

predictors of long term unfavorable outcome after surgical intervention.

Annals of Surgery, 245(3), 487-494.

Pick, A. M., DeSimone, E. M., & Harris, J. L. (2010). The management of acute

postoperative pain. US Pharma, 35(5), HS2-HS7.

Pitimana-Aree, S., Visalyaputra, S., Komoltri, C., Muangman, S., Tiviraj, S.,

Puangchan S., & Immark, P. (2005). An economic evaluation of

bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled

epidural analgesia after total-knee replacement procedure: A double-blinded

randomized study. Regional Anesthesia and Pain Medicine, 30(5), 446-451.

Ponsford, J., Hill, B., Karamitsios, M., & Bahar-Fuchs, A. (2008). Factors influencing

outcome after orthopedic trauma. The Journal of Trauma, 64(4), 1001-1009.

75

Pritchard, M. J. (2009). Identifying and assessing anxiety in pre-operative patients.

Nursing Standard, 23(51), 35-40.

Remizov, V. B., & Lungu. E. (2008). Quality of life in patients with orthopedic

trauma. Journal of Preventive Medicine, 16(1-2), 3-9.

Rosén, H., Clabo, L., & Matensson, L. (2009). Symptoms following day surgery: A

review of the literature. Journal of Advanced Perioperative Care, 4(1), 7-18.

Rotonda, C., Guillemin, F., Bonnetain, F., Velten, M., & Conroy, T. (2013). Factors

associated with fatigue after surgery in women with early-stage invasive

breast cancer. The Oncologist, 18(4), 467-475.

Rubin, G. J., Cleare, A., & Hotopf, M. (2004 a). Psychological factors in postoperative

fatigue. Psychosomatic Medicine, 66(6), 959-964.

Rubin, G. J., Hardy, R., & Hotopf, M. (2004 b). A systematic review and meta-

analysis of the incidence and severity of postoperative fatigue. Journal of

Psychosomatic Research, 57(3), 317-326.

Rubin, G. J., & Hotopf, M. (2002). Systematic review and meta-analysis of

interventions for postoperative fatigue. British Journal of Surgery, 89(8),

971-984.

Salmon, P., & Hall, G. M. (1997). A theory of postoperative fatigue: An interaction of

biological, psychological, and social processes. Pharmacology Biochemistry

and Behavior, 56(4), 623-628.

Saowaluck, P. (2009). Fatigue and factors related to fatigue after hysterectomy.

Master’s thesis, Adult Nursing, Faculty of Nursing, Mahidol University.

Sinclair, D., Chung, F., & Mezei, G. (1999). Can postoperative nausea and vomiting

be predicted? Anesthesiology, 91(1), 109-118.

Shoshtari, K. Z. (2009). Multimodal interventions for improving convalescence

following major colonic surgery. Doctoral dissertation, Medicine in

Surgery, Faculty of Medicine, University of Auckland.

Smith, W. R., Stahel, P. F., Morgan, S. J., & Trafton, P. G. (2008). Lower extremity.

In D. V. Feliciano, K. L. Mattox, & E. E. Moore (Eds.), Trauma (6th

ed., pp.

907-940). New York, NY: McGraw-Hill.

76

Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G., Peters, M. L., Geurts, J.

W., Gramke, H. F., & Marcus M. A. (2008). The prevalence of

postoperative pain in a sample of 1490 surgical inpatients. European

Journal of Anaesthesiol, 25(4), 267-274.

Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G., Peters, M. L., Geurts, J.

W., Patijn, J., Gramke, H. F., & Marcus M. A. (2010). Predictors of acute

postoperative pain after elective surgery. The Clinical Journal of Pain,

26(2), 87-94.

Stannard, J. P., Duke N. J., & Alonso, J. E. (2008). Fractures of the lower extremity.

In L. Flint, J. W. Meredith, C. W. Schwab, D. D. Trunkey, L. Rue, & P. A.

Taheri (Eds.). Trauma: Contemporary principles and therapy (pp. 537-

552). Philadelphia, PA. Lippincott Williams & Wilkins.

Stephenson, M. (1990). Discharge criteria in day surgery. Journal of Advanced

Nursing, 15(5), 601-613.

Stiegelis, H. E., Hagedoorn, M., Sanderman, R., Bennenbroek, F. T., Buunk, B.

P., van den Bergh, A. C., Botke, G., & Ranchor, A. V. (2004). The impact of

an informational self-management intervention on the association between

control and illness uncertainty before and psychological distress after

radiotherapy. Psychooncology, 13(4), 248-159.

Susilahti, H., Suominen, T., & Leino-Kilpi, H. (2004). Recovery of finish short-stay

surgery patients. Medical-Surgical Nursing Journal, 13(5), 326-335.

Svensson, I., Sjostrom, B., & Haljamae, H. (2000). Assessment of pain experience

after elective surgery. Journal of Pain and Symptom Management, 20(3),

193-201.

Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th

ed.).

Boston, MA: Allyn & Bacon/ Pearson Education.

Tan, X. F., & Xia, F. (2014). Long-term fatigue state in postoperative patients with

breast cancer. Chinese Journal of Cancer Research, 26(1), 12-16.

Tolver, M. A., Strandfelt, P., Rosenberg, J., & Bisgaard, T. (2013). Female gender is a

risk factor for pain, discomfort ,and fatigue after laparoscopic groin hernia

repair. Hernia, 17(3), 321–327.

77

Terry, R., Niven, C., Brodie, E., Jones, R., & Prowse, M. (2007). An exploration of

the relationship between anxiety, expectations and memory for postoperative

pain. Acute Pain, 9(3), 135-143.

Tsunoda, A., Nakao, K., Hiratsuka, K., Tsunoda, Y., & Kusano, M. (2007).

Prospective analysis of quality of life in the first year after colorectal cancer

surgery. Acta Oncologica Journal, 46(1), 77-82.

Vaughn, F., Wichowski, H., & Bosworth, G. (2007). Does preoperative anxiety level

predict postoperative pain? Association of Perioperative Registered Nurses

Journal, 85(3), 589-604.

Vyrostek, S. B., Annest, J. L., & Ryan, G. W. (2004). Surveillance for fatal and

nonfatal injuries United States, 2001. Morbidity and Mortality Weekly

Report, 53(7), 2-11.

Walsh, C. R. (2009). Musculoskeletal injuries. In K. A. McQuillan, M. B. F. Makic,

E. Whalen (Eds.), Trauma nursing: From resuscitation through

rehabilitation (4th

ed., pp. 735-777). St. Louis, MO: Saunders.

Wickström, K., Nordberg, G., & Johansson, F. (2005). Predictors and barriers to

adequate treatment of postoperative pain after radical prostatectomy. Acute

Pain, 7(4), 167-217.

Wijesuriya, N., Tran, Y., Middleton, J., & Craig, A. (2012). Impact of fatigue on the

health-related quality of life in persons with spinal cord injury. Archives of

Physical Medicine Rehabilitation, 93(2), 319-324.

Wilmore, D. W. (2002). From Cuthbertson to fast-track surgery: 70 years of progress

in reducing stress in surgical patients. Annals of Surgery, 236(5), 643-648.

World Health Organization [WHO]. (2012). Violence and injury prevention: Road

safety in Vietnam. Retrieved from http://www.who.int/violence_injury

_prevention/road_traffic/countrywork/vietnam_2012.pdf?ua=1

Wu, C. L., & Raja, S. N. (2011). Treatment of acute postoperative pain. Lancet,

377(9784), 2215-2225.

Yamamoto, T., Castell, L. M., Botella, J., Powell, H., Hall, G. M., Young, A., &

Newsholme, E. A. (1997). Changes in the albumin binding of tryptophan

during postoperative recovery: A possible link with central fatigue? Brain

Research Bulletin, 43(1), 43-46.

78

Yu, J., Zhuang, C. L., Shao, S. J., Liu, S., Chen, W. Z., Chen, B. C., Shen, X., & Yu,

Z. (2015). Risk factors for postoperative fatigue after gastrointestinal

surgery. The Journal of Surgical Research, 194(1), 114-119.

Zalon, L. (2004). Correlates of recovery among older adults after major abdominal

surgery. Nursing Research, 53(2), 99-106.

Zargar-Shoshtari, K., & Hill, A. G. (2009). Postoperative fatigue: A review. World

Journal of Surgery, 33(4), 738-745.

Zaslansky, R., Eisenberg, E., Peskin, B., Sprecher, E., Reis, D. N., Zinman, C., &

Brill, S. (2006). Early administration of oral morphine to orthopaedic

patients after surgery. Journal of Opioid Management, 2(2), 88-92.

Zhang, B., Dai, M., Tang, Y., Zou, F., Liu, H., & Nie, T. (2012). Influence of

integration of fracture treatment and exercise rehabilitation on effectiveness

in patients with intertrochanteric fracture of femur. Chinese Journal of

Reparative and Reconstructive Surgery, 26(12), 1453-1456.

Zigmond, A., & Snaith, R. (1983). The hospital anxiety and depression scale. Acta

Psychiatrica Scandinavica, 67, 361-370.

APPENDICES

APPENDIX 1

Instruments (English version)

81

SOCIODEMOGRAPHIC INFORMATION

1. Age: …........years

2. Gender

3. Marital status

4. Educational level

oling

school

Secondary school

High school

5. Occupation:

Farmer

Business person

Government officer

Industrial worker

Retired/ Unemployment

Student

6. Income/ month (USD)

< 150

– < 199.9

200 – < 249.9

250

82

DISEASES AND TREATMENT INFORMATION

This form includes data related to patient disease and treatment. The

information is collected by the investigator from patient record profile.

1. Date of admission: ………/……../……..

2. Date of surgery: ………/……../………..

3. Cause of injury: ………………………………………………………………

4. Diagnosis: ………………………………………………………………………

5. Part of bone fracture

Right femur

Left femur

Right tibia

Left tibia

Right fibula

Left fibula

6. Type of surgery

ORIF with plating

ORIF with nailing

7. Co-morbidity:

(specific)…………………………………………………….........................

8. Medications used during the first three days postoperatively

Day one

Type/ name of drugs Dose Route Time

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

83

Day two

Type/ name of drugs Dose Route Time

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

Day three

Type/ name of drugs Dose Route Time

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

…………………….. ……………………. …………………… ……………….

84

NUMERIC PAIN RATING SCALE

This is the Numeric Pain Rating Scale includes a horizontal 10 lines with

anchor indicating the extremes of pain. The value on the pain scale corresponds to

pain levels as follows:

Please place a mark X on the number that most likely your pain level

occurred to you IN THE LAST 24 HOURS in average.

85

THE ANXIETY MEASUREMENT (HADS-A)

This questionnaire has seven questions. Please read carefully each question

and then mark to the answer that most likely occurs to you during the last three days.

1. I feel tense or ‘wound up’

2. I get a sort of frightened feeling as if something awful is about to happen

t at all

....................................................................................................................................

............................................................

............................................................

............................................................

............................................................

7. I get sudden feelings of panic

Very often indeed

Quite often

Not very often

Not at all

86

THE MISHEL UNCERTAINTY IN ILLNESS (ADULT)

Please read each statement. Take your time and think about what each

statement says. Then circle the appropriate number to the right that most closely

measures how you are feeling today. If you agree with a statement, then you would

mark under either “Strongly Agree” or “Agree.” If you disagree with a statement, then

mark under either “Strongly Disagree” or “Disagree.” If you are undecided about how

you feel, then mark under “Undecided” for that statement. Please respond to every

statement.

□ 1= Strongly Disagree □ 2 = Disagree

□ 3= Undecided □ 4= Agree

□ 5= Strongly Agree

No

The Mishel Uncertainty in Illness

Levels

1 2 3 4 5

1 I do not know what is wrong with me 1 2 3 4 5

2 I have a lot of questions without answers 1 2 3 4 5

… ……………………………………………………………….

… ……………………………………………………………….

… ……………………………………………………………….

… ……………………………………………………………….

13 It is difficult to know if the treatments or medications I am

getting are helping

1 2 3 4 5

… ……………………………………………………………….

… ……………………………………………………………….

… …………………………………………………………….....

… …………………………………………………………….....

… …………………………………………………………….....

28 The doctors and nurses use everyday language so I can

understand what they are saying

1 2 3 4 5

87

THE IDENTITY-CONSEQUENCE FATIGUE SCALE

I would like to know more about any problems you have had with feeling

tired, weak or lacking in energy in the last 3 days. Please answer ALL the questions

by ticking the answer which applies to you most closely.

Please tick only one box per line.

No not

at

all

almost

never

some

of the

time

fairly

often,

very

often

all

of

the

time

1 2 3 4 5 6

1 I have been feeling drained

… ……………………………..

… ……………………………..

… …………………………….

10 I have been able to concentrate

on things

… ………………………………...

… …………………………………

… …………………………………

… ………………………………..

… ………………………………..

… …………………………………

23 I lack the energy to engage in

leisure or recreational activities

such as listening to radio, music,

reading newspaper or book

… …………………………………

… …………………………………

25 I lack the energy to follow

exercise for rehabilitation.

APPENDIX 2

Instruments (Vietnamese versions)

89

CÁC THÔNG TIN CHUNG VỀ NGƯỜI BỆNH

1. Tuổi: …........

2. Giới

ữ

3. Tình trạng hôn nhân

ộc thân

ết hôn

ồng hoặc vợ đã mất

ị/ ly thân

4. Trình độ giáo dục

Cấp 1

Cấp 2

Cấp 3

ấp/ cao đẳng

ại học hoặc sau đại học

5. Nghề nghiệp:

Nông dân

Người làm kinh doanh

Cán bộ viên chức nhà nước

Công nhân

Về hưu/ Thất nghiệp

Sinh viên

6. Thu nhập

D/tháng

– < 3.999.999 VND/ tháng

– < 4.999.999 VND/ tháng

90

CÁC THÔNG TIN VỀ BỆNH VÀ ĐIỀU TRỊ

Phiếu này bao gồm các dữ liệu liên quan đến điều trị và tình hình bệnh tật

của bệnh nhân. Những thông tin trong phiếu này được thu thập từ bệnh án của bệnh

nhân.

1. Ngày giờ vào viện: ………/……../……..

2. Ngày giờ phẫu thuật: ………/……../……..

3. Nguyên nhân chấn thương: ………………………………………………..

4. Chẩn đoán: ………………………………………………………………………

5. Bộ phận gãy xương

Xương đùi phải

ải

ải

6. Loại phẫu thuật

Cố định trong bằng phương pháp nẹp vít

ố định trong bằng phương pháp đóng đinh nội tủy

7. Bệnh kèm theo

(Cụ thể )…………………………………………………….........................

8. Thuốc được sử dụng trong suốt 3 ngày sau mổ

Ngày thứ nhất

Tên/ loại thuốc Liều Đường dùng Thời gian

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

91

Ngày thứ hai

Tên/ loại thuốc Liều Đường dùng Thời gian

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

Ngày thứ ba

Tên/ loại thuốc Liều Đường dùng Thời gian

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

…………………… ……………………. ………………….. ……………..

92

CÔNG CỤ ĐO ĐAU TRÊN BỆNH NHÂN

Đây là thang điểm để đo đau gồm 10 điểm. Gía trị trên thang đâu phản ánh

mức độ đau như hình vẽ. Vui lòng đánh dấu X trên con số mà đau xuất hiện trung

bình trong suốt 24 giờ qua.

Không đau Đau vừa Đau kinh

khủng

93

BỘ CÂU HỎI ĐÁNH GIÁ MỨC ĐỘ LO LẮNG CỦA

NGƯỜI BỆNH

Bộ câu hỏi này gồm 7 câu. Xin anh/ chị vui lòng đọc kỹ và chọn câu trả lời

phù hợp nhất tình trạng của anh chị trong suốt 3 ngày qua bằng cách đánh x vào ô phù

hợp.

1. Tôi cảm thấy căng thẳng

ề

ỉnh thoảng, lúc cảm thấy lúc không

ờng xuyên

ầu như mọi lúc

2. Tôi thấy lo sợ rằng hình như sẽ có chuyện chẳng lành xảy ra

ề

ột chút, nhưng không ảnh hưởng gì

ợ

ều và rất lo sợ

....................................................................................................................................

............................................................

............................................................

............................................................

............................................................

7. Tôi đột nhiên thấy giật mình hoảng hốt

ề

ỉnh thoảng

ờng xuyên

ất thường xuyên

94

BỘ CÂU HỎI ĐÁNH GIÁ VỀ SỰ KHÔNG CHẮC CHẮN VỀ

BỆNH (PHIÊN BẢN NGƯỜI LỚN)

Xin vui lòng đọc từng câu. Hãy dành thời gian để suy nghĩ về nội dung ở mỗi

câu. Sau đó khoanh tròn số thích hợp đo lường gần nhất những gì mà anh/chị đang

cảm thấy ngày hôm nay. Nếu anh/chị đồng ý, anh/chị sẽ đánh dấu vào các ô hoặc là

“rất đồng ý” hoặc đồng ý. Nếu các anh chị không đồng ý, anh/ chị sẽ đánh dấu vào các

ô “rất không đồng ý” và “không đồng ý”. Nếu anh/ chị không xác định được anh chị

cảm thấy như thế nào, anh/ chị đánh dấu vào ô “không xác định” cho câu đó. Xin vui

lòng trả lời cho mỗi câu.

□ 1= Rất không đồng ý □ 2= Không đồng ý

□ 3= Không xác định □ 4= Đồng ý

□ 5= Rất đồng ý

Số Sự không chắc chắn về bệnh Mức độ

1 2 3 4 5

1 Tôi không biết diễn biến bệnh của mình 1 2 3 4 5

2 Tôi có rất nhiều câu hỏi nhưng vẫn chưa có câu trả lời 1 2 3 4 5

… ………………………………………………………………..

… ………………………………………………………………..

… ………………………………………………………………..

13 Rất khó để biết được phương pháp điều trị hoặc thuốc tôi

đang uống.

1 2 3 4 5

… ………………………………………………………………..

… ………………………………………………………………..

… ………………………………………………………………..

… ………………………………………………………………..

… ………………………………………………………………..

28 Bác sĩ và điều dưỡng sử dụng ngôn ngữ hằng ngày nên tôi có

thể hiểu được những gì họ đang nói.

1 2 3 4 5

95

THANG ĐIỂM MỆT MỎI VÀ HẬU QUẢ CỦA MỆT MỎI

Tôi muốn biết về bất cứ vấn để mà anh/ chị đã trải qua về cảm giác mệt mỏi,

yếu, thiếu năng lượng và hậu quả của những cảm giác đó trong 3 ngày qua. Vui lòng

trả lời tất cả các câu hỏi bằng cách đánh dấu X vào câu trả lời mà anh chị cảm thấy

phù hợp nhất

Số Không

hề

Hầu

như

không

Thỉnh

thoảng

Khá

thường

xuyên

Rất

thường

xuyên

Luôn

luôn

1 2 3 4 5 6

1 Tôi cảm thấy không

còn năng lượng

… ………………….

… ………………….

… ………………….

10 Tôi có thể tập trung

để làm mọi việc

… …………………..

… …………………..

… …………………..

… …………………..

… …………………..

… …………………..

23 Tôi không đủ sức để

tham gia vào những

hoạt động giải trí

như nghe đài, nghe

nhạc, đọc sách báo.

… ………………….

… ………………….

96

Số Không

hề

Hầu

như

không

Thỉnh

thoảng

Khá

thường

xuyên

Rất

thường

xuyên

Luôn

luôn

25 Tôi không đủ sức để

theo những bài tập

phục hồi chức năng

sau mổ.

APPENDIX 3

Institutional review board approval

98

APPENDIX 4

Letter of asking permission for data collection

100

101

APPENDIX 5

Patient consent form (English version)

103

INFORMATION SHEET

Dear Sir/Madam,

My name is Nguyen Thi Thuy Trang, a student of Master of Adult Nursing,

Faculty of Nursing, Burapha University, Thailand. I am conducting a study entitled

“Factors predicting postoperative fatigue among patients with closed fracture of

leg undergoing internal fixation surgery in Khanh Hoa General hospital,

Vietnam”. This study will be conducted in order to describe the characteristics of

pain, anxiety, uncertainty, and postoperative fatigue and examine the influence of pain,

anxiety, and uncertainty on postoperative fatigue among patients with closed fracture

of leg undergoing internal fixation surgery in Khanh Hoa General Hospital, Vietnam.

The findings of the study will provide the basic knowledge for surgical nurses to

assess postoperative fatigue among orthopedic trauma patients and further researches

for developing the interventions in order to prevent and manage postoperative fatigue

and to improve quality of care and quality of life in orthopedic trauma patients.

If you agree to participate in this study, the researcher will distribute for you 1

questionnaire taking 1 minute to finish in the first and second day after surgery. On the

third operation day, five questionnaires will be distributed to complete within about 30

minutes. There are no identified risks with participating in this study. Participation is

voluntary. You have the right to refuse to answer any questions and may withdraw at

any time without any penalty. Anonymity and confidentiality will be assured, and no

personal information will be revealed to any other person. All data will be stored in a

secure place and will be only utilized for the purposes of the study. You will receive a

complete explanation of the nature of the study if you wish to.

If you agree to join this study, please sign your name below to indicate that you

are informed, and you understand all necessary information related to the study, and to

prove your consent to participate in this study as well.

104

The study will be conducted by me. If you have any questions, please contact

me at +84 1696 962 313 or by e-mail: trangkhmc@gmail.com or my major adviser

Assist. Prof. Dr. Niphawan Samartkit, e-mail: nsamartkit@gmail.com

Thank you very much for your cooperation.

Nguyen Thi Thuy Trang

105

INFORMED CONSENT

Title: “Factors predicting postoperative fatigue among patients with closed

fracture of leg undergoing internal fixation surgery in Khanh Hoa General

hospital, Vietnam”.

IRB approval number:…………………………..

Date of collection data ……………Month ………….Years………………

Before I give signature in below, I already be informed and explained by the

researcher, Ms Nguyen Thi Thuy Trang about purposes, method, procedures, and

benefits of this study, and I understood all of that explanation.

I agree to be as a participant of this study.

I’m Ms Nguyen Thi Thuy Trang, as a researcher has explained all of

explanation about purposes, method, procedures, and benefits of this study to the

participant with honestly; then, all of information of the participants will only be used

for purpose of this research study.

______________________ ________________________

Name and Signature of the Participant Date

______________________ ________________________

Name and Signature of witness Name and Signature of the researcher

Nguyen Thi Thuy Trang

APPENDIX 6

Patient consent form (Vietnamese version)

107

GIẤY ĐỒNG Ý THAM GIA NGHIÊN CỨU

Chào anh/chị

Tôi tên là Nguyễn Thị Thùy Trang, là sinh viên thạc sĩ chuyên ngành điều

dưỡng người lớn tại khoa điều dưỡng, trường đại học Burapha, Thái Lan. Tôi đang

thực hiện một nghiên cứu tên là “Những yếu tố ảnh hưởng đến mệt mỏi sau mổ trên

bệnh nhân gãy kín xương chi dưới trải qua phẫu thuật cố định trong tại bệnh

viện đa khoa tỉnh Khánh Hòa, Việt Nam”. Nghiên cứu này được thực hiện nhằm

mục đích mô tả đặc điểm của đau, lo lắng, sự không chắc chắn, mệt mỏi sau mổ và

kiểm tra sự ảnh hưởng của đau, lo lắng, không chắc chắn lên mệt mỏi sau mổ của

những bệnh nhân gãy kín xương chi dưới tại bệnh viện đa khoa tỉnh Khánh Hòa, Việt

Nam. Kết quả từ nghiên cứu này sẽ cung cấp những kiến thức cơ bản cho điều dưỡng

ngoại khoa để nhận định mệt mỏi sau mổ trên những bệnh nhân chấn thương chỉnh

hình và phát triển những can thiệp để ngăn ngừa và kiểm soát mệt mỏi sau mổ. Ngoài

ra, kết quả nghiên cứu này còn giúp cải thiển chất lượng chăm sóc và chất lượng sống

trên bệnh nhân chấn thương chỉnh hình.

Nếu anh/chị đồng ý tham gia nghiên cứu này, tôi sẽ phát cho anh chị 5 bảng câu

hỏi trong khoảng 30 phút. Khi tham gia nghiên cứu này, anh chị không bị ảnh hưởng

nguy hiểm nào. Sự tham gia là hoàn toàn tự nguyện. Anh/chị có quyền từ chối trả lời

bất kì câu hỏi nào và có thể dừng tham gia trả lời câu hỏi vào bất cứ thời điểm nào mà

không bị ảnh hưởng gì. Khi tham gia nghiên cứu, tôi sẽ đảm bảo sự dấu tên và tuyệt

mật về thông tin cá nhân của anh/chị. Tất cả các dữ liệu sẽ được cất giữ một nơi an toàn

và sẽ chỉ được sử dụng cho mục đích của nghiên cứu này. Nếu muốn, anh/chị sẽ nhận

sự giải thích cặn kẽ về đặc điểm của nghiên cứu.

Nếu anh chị đồng ý tham gia nghiên cứu, xin vui lòng kí tên bên dưới để chỉ ra

rằng anh chị đã được giải thích và hiểu tất cả các thông tin cần thiết liên qua đến nghiên

cứu, và cũng để chứng minh sự đồng thuận tham gia trong nghiên cứu này.

108

Nghiên cứu này sẽ được thực hiện bởi tôi. Nếu anh/chị có bất kì thắc mắc gì,

vui lòng liên hệ tôi với số điện thoại +84 1696 962 313 hoặc qua địa chỉ email

trangkhmc@gmail.com hoặc người hướng dẫn của tôi: Phó giáo sư Tiến sĩ Niphawan

Samartkit địa chỉ email: nsamartkit@gmail.com

Cảm ơn rất nhiều vì sự hợp tác của anh/chị

Nguyễn Thị Thùy Trang

109

GIẤY ĐỒNG Ý

Tên nghiên cứu “Những yếu tố ảnh hưởng đến mệt mỏi sau mổ trên bệnh

nhân gãy kín xương chi dưới trải qua phẫu thuật cố định trong tại bệnh viện đa

khoa tỉnh Khánh Hòa, Việt Nam”.

Số chứng nhận của IRB:…………………………..

Ngày thu thập số liệu: Ngày ……………tháng ………….năm………………

Trước khi tôi kí bên dưới, tôi đã được thông báo và giải thích bởi nghiên cứu

viên, Nguyễn Thị Thùy Trang về mục đích, phương pháp, quy trình, và lợi ích của

nghiên cứu này và tôi hiểu tất cả những lời giải thích đó.

Tôi đồng ý là một người tham gia của nghiên cứu này.

Tôi là Nguyễn Thị Thùy Trang là nghiên cứu viên đã giải thích thành thật tất cả

những thông tin về mục đích, phương pháp, quy trình, và lợi ích của nghiên cứu cho

người tham gia, sau đó, tất của những thông tin của người tham gia nghiên cứu sẽ chỉ

được sử dụng cho mục đích của nghiên cứu này.

______________________ ________________________

Tên và chữ ký của người tham gia Ngày

______________________ ________________________

Tên và chứ ký của người làm chứng Tên và chữ ký của nghiên cứu viên

Nguyễn Thị Thùy Trang

APPENDIX 7

The scores for each item of the hospital anxiety and depression scale (HADS), the

Mishel uncertainty in illness scale (MUIS) the identity - consequence fatigue scale

(ICFS)

111

Table 9 Range, mean, standard deviation for each item of HADS (n = 80)

No Questions Range Mean SD

1 I feel tense or ‘wound up’ 0 – 3 1.63 .83

2 I get a sort of frightened feeling as if something awful

is about to happen

0 – 3 1.49 .97

3 Worrying thoughts go through my mind 0 – 3 1.84 .86

4 I can sit at ease and feel relaxed 0 – 3 1.75 .86

5 I get a sort of frightened feeling like ‘butterflies’ in

the stomach

0 – 3 1.90 .77

6 I feel restless as if I have to be on the move 0 – 3 1.74 .87

7 I get sudden feelings of panic 0 – 3 1.95 .91

Table 10 Range, mean, standard deviation for each item of MUIS (n = 80)

No Questions Range Mean SD

1 I do not know what is wrong with me 1 – 5 2.73 1.01

2 I have a lot of questions without answers 1 – 5 2.94 1.06

3 I am unsure if my illness is getting better or worse 1 – 5 3.06 .99

4 It is unclear how bad my pain will be 1 – 5 3.09 1.06

5 The explanations they give about my condition seen

hazy to me

1 – 5 2.79 1.00

6 The purpose of each treatment is clear to me 1 – 5 3.00 1.01

7 When I have pain, I know what this means about

my condition

1 – 5 2.95 .99

8 I do not know when to expect things will be done to

me

1 – 5 3.00 .93

9 My symptoms continue to change unpredictably 1 – 5 2.81 1.08

10 I understand everything explained to me 1 – 5 2.94 1.01

11 The doctors say things to me that could have

meanings

1 – 5 2.95 .87

112

Table 10 (cont.)

No Questions Range Mean SD

12 My treatment is too complex to figure out 1 – 5 3.00 .96

13 It is difficult to know if the treatments or

medications I am getting are helping

1 – 5 2.75 .97

14 There are so many different types of staff, it is

unclear who is responsible for what

1 – 5 2.78 .87

15 Because of the unpredictability of my illness, I

cannot plan for the future

1 – 5 2.86 .92

16 The course of my illness keeps changing. I have

good and bad days

1 – 5 2.81 .89

17 It is vague to me how I will manage my care after I

leave the hospital

1 – 5 2.89 .97

18 I have been given many differing opinions about

what is wrong with me

1 – 5 2.84 .99

19 It is not clear what is going to happen to me 1 – 5 2.86 1.05

20 The results of my tests are inconsistent 1 – 5 2.71 .83

21 The effectiveness of the treatment is undetermined 1 – 5 2.83 1.02

22 It is difficult to determine how long it will be before

I can care for myself

1 – 5 3.04 1.04

23 Because of the treatment, what I can do and cannot

do keeps changing

1 – 5 2.94 .97

24 The treatment I am receiving has a known

probability of success

1 – 5 3.03 .95

25 They have not given me a specific diagnosis 1 – 5 2.98 1.07

26 I can depend on the nurses to be there when I need

them

1 – 5 3.15 1.08

27 The seriousness of my illness has been determined 1 – 5 3.16 1.11

28 The doctors and nurses use everyday language so I

can understand what they are saying

1 – 5 3.20 1.07

113

Table 11 Range, mean, standard deviation for each item of ICFS (n = 80)

No Questions Range Mean SD

1 I have been feeling drained 1 – 6 3.44 1.18

2 I have been feeling fatigue 1 – 6 3.59 1.17

3 I have been feeling worn out 1 – 6 3.53 1.29

4 Physically, I have felt tired 1 – 6 3.84 1.21

5 My body has been feeling heavy all over 1 – 6 3.74 1.25

6 I have been feeling refreshed 1 – 6 4.16 1.22

7 I have been feeling lively 1 – 6 4.18 1.19

8 I have been feeling vigorous 1 – 6 4.05 1.09

9 I have been feeling energetic 1 – 6 3.90 1.17

10 I have been able to concentrate on things 1 – 6 2.89 1.11

11 I have made more mistakes than usual 1 – 6 2.79 1.13

12 My thoughts have wandered easily 1 – 6 2.79 1.17

13 I have been forgetful 1 – 6 2.66 1.10

14 I have had trouble paying attention 1 – 6 2.85 1.10

15 It has been hard to get motivated to do my regular

activities

1 – 6 3.35 1.12

16 I do very little in a day 1 – 6 3.43 1.32

17 I have had to restrict how much I try to do in a day 1 – 6 3.65 1.22

18 I have had the energy to do lots of things 1 – 6 3.71 1.20

19 I start things without difficulty and then get tired 1 – 6 3.38 1.12

20 I lack the energy to do things I normally do 1 – 6 3.49 1.18

21 I lack the energy to eating 1 – 6 3.43 1.39

22 I lack the energy to talking or chatting with other

people.

1 – 6 3.23 1.08

23 I lack the energy to engage in leisure or recreational

activities such as listening to radio, music, reading

newspaper or book

1 – 6 3.19 1.16

114

Table 11 (cont.)

No Questions Range Mean SD

24 I lack the energy to walk around or go to bathroom

by using supportive aids

1 – 6 3.46 1.21

25 I lack the energy to follow exercise for

rehabilitation.

1 – 6 3.89 1.30

APPENDIX 8

Letter of permission for using the research instruments

116

PERMISSION FOR USING ENGLISH VERSION OF THE

INDENTITY-CONSEQUENCE FATIGUE SCALE

Date: January 23rd

, 2015

From: trangkhmc@gmail.com

To: johanna.paddison@health.sa.gov.au

Dear Dr Johanna Susan Paddison,

My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,

Burapha university, Thailand. To fulfill the requirements for master degree of nursing

science, I have conducted a thesis with title" Factors predicting postoperative fatigue

among patients with closed fracture of leg undergoing internal fixation surgery". To

measure postoperative fatigue, I am really interested in using the Identity –

Consequence Fatigue Scale. So, it would be grateful if I have your permission for

using this instrument.

Any further information about changes or modifies of this instrument I will let you

know.

I am looking forward to receiving permission from you.

Thank you so much.

Best regards.

Trang

…………………………………………………………………………………………

Date: January 23rd

, 2015

From: johanna.paddison@health.sa.gov.au

To: trangkhmc@gmail.com

Hi Trang,

You are most welcome and have my permission to use the scale.

Kind regards,

Johanna.

117

PERMISSION FOR USING VIETNAMMESE VERSION OF THE

HOSPITAL ANXIETY AND DEPRESSION SCALE

Date: January 23rd

, 2015

From: trangkhmc@gmail.com

To: long.51@hotmail.com

Dear Mr Nguyen Hoang Long

My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,

Burapha university. Thailand. To fulfill the requirements for master degree of nursing

science,I have conducted a thesis with title" Factors related to postoperative fatigue

among patients with closed fracture of leg undergoing internal fixation surgery". With

one of my thesis variable is anxiety, I would like to ask your permission for using

Vietnamese version of "The Hospital Anxiety and Depression Scale (HADS)"

questionnaire. It would be so great if I had your comments and suggestions about

using this instrument.

I am looking forward to hear response from you soon.

Sincerely,

Trang

…………………………………………………………………………………………

Date: January 19th

, 2015

From: long.51@hotmail.com

To: trangkhmc@gmail.com

Dear Nguyen Thi Thuy Trang,

Nice to hear from you. I am so happy to learn that more and more Vietnamese nurses

are pursuing their postgraduate studies on clinical problems. Your thesis topic is very

interesting. I do believe that you would see many valuable information while doing

this.

Yes, you can use the Vietnamese version of the Hospital Anxiety and Depression

Scale which was translated in my thesis. Please notify the copyright holder of the

English scale for the use of this instrument if necessary.

Wish you success on your study. Hope to see you someday in Vietnam.

Sincerely,

118

--------------------------

Nguyen Hoang Long RN, M.N.S

Acting Head,

Division of Nursing, Faculty of Health Science

Thang Long University, Ha Noi, Vietnam

Mobile: + 84 904 99 52 53

PhD Candidate, Faculty of Nursing

Chulalongkorn University, Bangkok, Thailand

119

PERMISSION FOR USING VIETNAMESE VERSION OF THE

MISHEL UNCERTAINTY IN ILLNESS

Date: January 18th

, 2015

From: trangkhmc@gmail.com

To: loicdyttn@gmail.com

Dear Mr Tran Van Loi,

My name is Nguyen Thi Thuy Trang, international student at Faculty of nursing,

Burapha university. To fulfill the requirements for master degree of nursing science,I

have conducted a thesis with title" Factors related to postoperative fatigue among

patients with closed fracture of leg undergoing internal fixation surgery". With one of

my thesis variable is uncertainty, I would like to ask your permission for using

Vietnamese version of "Mishel uncertainty in illness" questionnaire. It would be so

great if I had your comments and suggestions about using this instrument.

I am looking forward to hear response from you soon.

Sincerely,

Trang

…………………………………………………………………………………………

Date: January 21st, 2015

From: loicdyttn@gmail.com

To: trangkhmc@gmail.com

Dear Mrs Trang

You have my permission to use the scale. Enjoy using it.

Mr. Loi

--------------------------

Tran Van Loi

Department of surgery

Thai Nguyen Medical college

Telephone number: +84915145268

+66876125383