الفهرس 
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Abstract
Constipation following hip surgeries is one of the most common problems encountered by geriatric patients. This is related to a variety of circumstances, including immobility and the use of painkillers. Constipation can cause unpleasant symptoms such as abdominal cramps, loss of taste, anorexia, nausea, fatigue, and halitosis.Constipation prevention after hip surgeries includes both pharmacological and non-pharmacological treatments. Nursing interventions are among the non-pharmacological therapy used to prevent constipation through health education about proper diet, increased amount of fluid intake, Kegel’s exercise, deep breathing, and abdominal contraction exercise, and abdominal massage. These approaches help in the prevention and management of constipation in geriatric patients without the use of pharmaceutical agents such as laxatives. This also reduces the risk of morbidity and mortality, recurrent hospitalization, and overall financial burden linked with negative impacts of constipation.
Aim of the study:
The present study aims to determine the effect of the implementation of nursing interventions program on incidence and severity of constipation among geriatric patients undergoing hip surgeries.
Materials and Method:
A. Materials
Research Design: The study followed a quasi-experimental research design (study group and control group)
Setting: The study was conducted in the inpatient departments of El-Hadara Orthopedic and Traumatology University Hospital, Alexandria, Egypt.
Subjects: The study subjects were selected using the purposive sampling technique and included fifty geriatric patients admitted to the previously mentioned setting for undergoing hip surgeries, age 60 years and more, with intact cognitive function or mild cognitive impairment, have no depression, have no constipation,and not treated with laxatives during his/her stay in the hospital. The selected subjects were divided into two equally matched groups of 25 geriatric patients in each group:
group 1: The study groupreceived the proposed nursing interventions program beside routine hospital care.
group 2: The control group received only conventional routine hospital care.
Tools of the study:Five tools were used for data collection
Tool I: Saint Louis University Mental Status (SLUMS) Examination:
This tool was developed by (Traiq et al., 2006) to identify older adults with cognitive impairment and consist of a 30- point, 11-item. The total score is 30. Scoring in case of “High school education”: a score from 27-30 indicates normal cognitive function, 21 -26 mild neurocognitive disorder, and1-20 dementia. For respondents with less than high school education: a score from 25-30 indicates normal cognitive function, 20-24 mild neurocognitive disorder, and1-19 dementia.Additionally, for Illiterate respondents:a score from 24-30 indicates normal cognitive function, 19-24 mild neurocognitive disorder, and1-18 dementia.
Tool II: Patient Health Questionnaire- 2 (PHQ-2)
This questionnaire is a 2 questions developed by (Chunyu et al., 2007) to assess depressed mood and anhedonia over the past two weeks. A score less than three denotes no depression, and score three and more denotes major depression.
Tool III: Constipation Assessment Scale (CAS)
This scale was developed by (McMillan& Williams, 1989) and consists of eight items to assess the presence and severity of constipation. For the presence of constipation, the score ranges from 0 (no constipation) to 16 (worst constipation). While the severity of constipation is considered mild if the score ranges from 2 to 6, moderate from 7 to 10, and severe from 11 and above.
Tool IV:Socio-demographic characteristics and Clinical Data of Geriatric Patients Undergoing Hip Surgeries Structured Interview Schedule. This tool was developed by the researcher based on review of relevant literature. It included four (4) parts:
Part I: Socio-demographic characteristics such as, age, sex, education, marital status, occupation before retirement, monthly income, and place of residence.
Part II:Clinical data such as, chronic health problems and medication taking.
Part III:Eating pattern and fluid intake such as, usual number of meals consumed per day, regular time of meals, and taking fibers and fluids.
Part IV: Elimination history such as, the usual habit of defecation, past history of constipation, and taking laxatives or enemas.
Tool V: Daily Defecation Record Form: itwas developed by the researcher to record daily defecation of geriatric patients undergoing hip surgeries during the hospitalization period. It included four main items, namely, frequency of defecation, stool consistency, straining or pressure while defecate, and the date of first defecation postoperatively.
B. Method
I- Preparation phase
1. The necessary approvals were obtained from the responsible authorities.
2. The study tools:
The Arabic version of tool I Saint Louis University Mental Status (SLUMS) Examination, tool II Patient Health Questionnaire- 2 (PHQ-2) and tool III Constipation Assessment Scale (CAS) were used in this study in order to select the study subjects.
Tool III Constipation Assessment Scale (CAS) was used for each subject on admission to assess the presence of constipation in order to select the study subjects who have no constipation according to the inclusion criteria and daily throughout hospitalization period until the patient’s discharge from the hospital to study the severity of constipation.
Tool IV (Socio-demographic characteristics and Clinical Data of Geriatric Patients Undergoing Hip Surgeries Structured Interview Schedule) was developed by the researcher based on review of relevant literature.
Tool V (Daily Defecation Record Form) was developed by the researcher and tested for content validity by five experts in the related fields of the study namely, Gerontological nursing and Medical & Surgical nursing. The required modifications were done accordingly.
3. A pilot study was carried out on five geriatric patients to assess the applicability, clarity, and feasibility of the study tools. Necessary modifications were made accordingly.
4. The researcher designed the proposed nursing interventions program to prevent constipation and/or decrease its severity. It includes; orientation of the selected study subjects about the proposed program, its aim, and its components namely,health teaching, different exercises such as, kegel’s exercise, deep breathing exercise, abdominal muscle contraction exercise, and abdominal massage using extra virgin olive oil.
5. In order to clarify the desired knowledge and skills for the study group, a brochure was developed by the researcher including the main points of the interventions with illustrative colored pictures.
6. Each selected geriatric patient was interviewed individually by the researcher in his\her room after obtaining his\her approval to participate in the study in order to collect the required data.
II- Implementation of the program
1- The control group:
The researcher started the collection of data with the subjects of the control group in order to prevent contamination between participants in the study and the control groups.
The control group received only conventional routine hospital care provided for all patients undergoing hip surgeries. It includes reviewing the prescribed medications, dressing the wound, and taking three meals per day.
The researcher interviewed each subject daily and followed them up during their stay in the hospital in order to assess the incidence and severity of constipation using tools III and V.
The researcher gave each subject in the control group the brochure before his\her hospital discharge in order to ensure that all subjects in both groups were treated fairly.
2-The study group:
The researcher prepared the needed equipment for the implementation of the proposed nursing interventions such as, special containers with olive oil and tissue paper.
The researcher prepared the environment by maintaining privacy using a paravan, closing the ward’s doors and windows, and reducing background noise while performing exercises and abdominal massage.
The proposed nursing interventions program was implemented individually for each geriatric patient in the study group starting from admission until discharge from the hospital. Each geriatric patient was informed about the period and the time allotted for each nursing intervention.
III- Evaluation phase
The researcher evaluated the effectiveness of the proposed nursing interventions program daily by assessing the defecation pattern using tool V Daily Defecation Record Form and assessing the severity of constipation using tool III Constipation Assessment Scale (CAS) among each geriatric patient in both the study and the control groups throughout the perioperative period.
In order to evaluate the effectiveness of the proposed nursing interventions program, the results of the study group were compared with those in the control group using the appropriate statistical analysis.
The data collection started from the mid-August 2022 till the mid December 2022.
Ethical considerations: an informed written consent was obtained from each literate study subject and an informed oral consent from each illiterate study subject after explaining the study purpose. The privacy of the study subjects and the confidentiality of the collected data were maintained. The study subjects were informed that their participation in the study is voluntary and that they can withdraw at any time without any penalty.
The main results obtained were as follows:
The number of females and males in both the study and control groups is equal. Females undergoing hip surgeries constitute 72.0% and males 28.0% in each group. The age of geriatric patients in both groups ranged from60 to 90 years, with a mean of 73.40 ± 8.56 and 71.64 ± 9.04 years in the study and control groups, respectively.
Widows were prevalent in both groups, they constitute 60.0% and 48.0% in the study group and control group, respectively.More than half of the subjects in the study and control groups were illiterates (52.0% and 60.0%, respectively). Furthermore, more than half of the subjects in the study and the control groups (76.0% and 68.0%, respectively) live in urban areas.
The majority of subjects in the study and control groups (68.0% and 72.0%, respectively) suffer from different health problems and consume medications.
During hospitalization, the majority of subjects in the study and control groups (96.0%) became totally dependent either due to a hip problem or a postoperative advice for immobility, and the reminder (4.0%) required some assistance to move, indicating that they were partially dependent.
After the implementation of the proposed nursing interventions, a statistically significant difference is noticed in incidence of constipation between the subjects in both groups P= 0.034. Furthermore, there is no statistically significant difference in the severity of constipation between the subjects in both groups MCP= 0.051.
The proposed nursing interventions are highly effective (effect size = 0.556) than routine hospital care in helping geriatric patients after hip surgeries pass stool sooner during the postoperative period.
The proposed nursing interventions had a low effect on the incidence of constipation (effect size = 0.360) but a high effect on the severity of constipation (effect size = 1.51).
Conclusion:
Based on the results of this study, it can be conclude that the proposed nursing interventions program was beneficial in reducing the incidence and severity of constipation in geriatric patients undergoing hip surgeries.
Recommendations:
In-service training programs for all nurses working in orthopedic hospitals as well as health care providers using the designed educational booklet by hospital responsible authorities to update their knowledge and skills about the use of complementary therapy to care for geriatric patients undergoing orthopedic surgeries to prevent or manage constipation.
Geriatric patients undergoing orthopedic surgeries and their family caregivers being involved in their care. This will be accomplished by teaching them the importance of preventing constipation through a combination of nursing interventions such as diet and fluid intake education, kegel’s exercise, deep breathing and abdominal contraction exercises, and abdominal massage with extra virgin olive oil.