الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Chronic venous insufficiency of lower limbs is one of the most widespread diseases. Venous hypertension secondary to higher reflux or obstruction is an important cause of chronic venous insufficiency (CVI). Venous insufficiency is strongly associated with venous ulceration and hence chronic CVI can result in difficult to heal and recurrent venous ulcers. Patients usually neglect the disease till it impairs the quality of life or limits the overall functioning of lower extremity. The complications of CVI impair the ability of a person to involve in social or routine occupational activities and also result in economic burden on the patient and family (Mahapatra et al., 2018).
Poorly functioning calf muscle pumps compromises venous hypertension, and pump impairments are associated with venous incompetence and venous ulceration in CVI patients (Yim et al., 2014). Home-based exercise programmes which enhance ankle range of motion as well as structured exercise programmes which improve calf muscle pump function and strengthen calf musculature may be beneficial for CVI (Yim et al., 2014; Thakrar et al., 2019).Davies et al. (2007)reported that combination therapy in the form of conventional physiotherapy intervention, like exercises can be used in the management of patient with varicose veins so as to minimize the physical and emotional discomfort.
The aim of this study is to:
Determine the effect of nursing interventions on health outcomes of Patients with lower limbs chronic venous insufficiency.
Materials and method
Materials
Research design:
A quasi experimental research design was utilized to fulfill the aim of this study.
Setting:
The present study was conducted at the vascular surgery outpatient clinics of Alexandria Main University Hospital andAlexandria Vascular Center (AVC).
Subjects:
A convenience sample of 70 adult male and female patients with lower limbs chronic venous insufficiency, admitted to the above mentioned settings. The study sample was selected based on Epi info -7 program which used to estimate the sample size population size 300 over 12 months (2019), expected frequency 50%, maximum error of 5%., confidence coefficient 95%, the minimal sample size 63 patients and the final sample size will be 70 patients.
All available participants of 70 adult patients who followed the inclusion criteria were categorized randomly into two equal groups (study group and control group). Each group comprised of 35 patients:
The first group (control group) was received the routine hospital care as pharmacological treatment, compression stocking and instruction for leg elevation.
The second group (study group) was received the nursing interventions.
Tools of the study:
Seven tools were used for data collection.
Tool I: Physical Activity Readiness Questionnaire (PAR-Q):
This tool was adopted from Warburton et al. (2018). It was used as a screening tool which designed to determine if physical activity was safe for individuals or if they may need medical clearance from a physician.
Additionally: Socio-demographic and clinical data interview schedule:
This tool was developed by the researcher in Arabic language based on a review of relevant literature to collect baseline data. It was consist of two parts:
Part I: Patients’ Socio-demographic data:
This part was used to collect patient’s personal data such as age, gender, marital status, educational level, occupation, marital status, income, area of residence and date of being involved in the study.
Part II: Patients’ Clinical Data:
It was include medical and surgical history for patients such as: associated diseases, data related to previous hospitalization, prescribed and over the counter medications, date of CVI diagnosed, current symptoms of CVI, chief complaints, diagnostic studies, laboratory values, stage of chronic venous insufficiency disease. As well as family history related to CVI.
Tool II: Lower limbs chronic venous insufficiency patients’ knowledge structured interview schedule:
This tool was developed by the researcher in Arabic language based on a review of relevant literature(Van Hecke et al., 2013; Sutzko et al., 2018; Carpentier et al., 2022).That was used to assess baseline knowledge of patients with lower limbs chronic venous insufficiency in relation to the following items:
A. Nature of the disease: Include questions about meaning of chronic venous insufficiency, causes, signs & symptoms, risk factors, stages of CVI, diagnostic studies and different treatment modalities of CVI as medical, surgical treatment and conservative treatments.
B. Medical treatment knowledge: It included questions about medication received action, side effects, tests and precautions that followed during treatment to prevent complications of medications.
C. Surgical treatment knowledge: That structured to assess patient’s knowledge related to different types of surgery as endovenous foam sclerotherapy, thermal ablation, stripping, Valve reconstruction or valve transplant and subfascial endoscopic perforator surgery.
D. Conservative treatment knowledge: It included questions related to exercises types, advantages, warning signs to stop exercise, types and number of sessions per day.
Tool III: Venous Clinical Severity Score (VCSS):
It was adopted fromPassman et al. (2011), it was used to characterize the severity of the patients’ chronic venous insufficiency and to monitor any progression made. The VCSS system includes 10 clinical descriptors (pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use) that was used to assess changes in response to therapy.
Tool IV: Assessment of the muscles strength:
It was adopted from Paternostro-Sluga et al. (2008), to assess muscles strength and the motor ability of the lower limbs chronic venous insufficiency patients.
Tool V: Ankle range of motions assessment:
This tool was adopted fromKonor et al. (2012), it was used to assess range of motion (ROM) for patient`s ankles as dorsiflexion, Planter flexion, inversion and eversion of the affected limb using Myrin goniometer.
Tool VI: SF-36 Short Form Health Survey:
This tool was adopted fromWare and Sherbourne (1992)&Laucis et al. (2015), which was utilized to evaluate an individual’s quality of life through patient self-reporting monitoring and assessment of interventions outcomes in adult patients.SF-36 Item Health Survey consists of eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions.
Tool VII: Lower limbs chronic venous insufficiency patient’s competence and compliance with nursing interventions:
This tool was developed by the researcher based on a review of related literature (Yim et al., 2014; Thakrar et al., 2019). It was used for two purposes: to assess lower limbs chronic venous insufficiency patient’s competence to do exercises alone at home, as well as, to assess lower limbs chronic venous insufficiency patients compliance to exercises.
Method
The study was accomplished as follows:
An approval from The Research Ethics Committee, Faculty of Nursing, Alexandria University was obtained. An official letter was sent to the study setting to take the approval for data collection. Tool I& II& VII was developed by the researcher post reviewing of the relevant literatures. All tools were submitted to 5 experts in the field of medical surgical nursing for content validity and the necessary modifications were carried out accordingly. The reliability of all tools was tested using appropriate statistical test. A pilot study was conducted on 7 patients to test clarity, applicability and feasibility of the tools and necessary modifications was done. Data obtained was excluded from the actual study. The study was carried out on four phases.
Phase I: Assessment Phase:
Initial assessment was carried out of all patients (control and study groups) individually after explaining the purpose of the study using all tools (I,II, III, IV, V and VI) except tool VII to collect baseline patients’ data, health history (past and present), assess physical activity readiness, assessing the patients’ knowledge about lower limbs CVI, clinical status of affected lower limb, lower limbs muscles strengthand ankle range of motions assessment as well as health survey was applied. The initial assessment of lower limbs chronic venous insufficiency patient’s competence to perform physical exercises using tool VII was carried out for control group during the assessment interview, while it was carried out for study group at the end of implementation sessions.
Phase II: Planning phase:
Based on the data collected from the assessment phase and literature review the nursing interventions goals, priorities, contents, and expected outcomes was developed by the-researcher according to the individual needs and problems for patients of the study group (II).A colored booklet was developed in simple Arabic language to be distributed to each patient of the study group.
Phase III: Implementation phase:
Nursing interventions for lower limb chronic venous insufficiency was implemented individually for each patient in the above mentioned settings in 3 sessions per one to two day(s). The first session was required to cover theoretical knowledge, while the second and third sessions for the structured exercises education for each individual patient. The duration of each session lasted approximately from 30 to 45 minutes depending on the degree of tolerance and response of the patients.
Phase IV: Evaluation phase:
The lower limbs chronic venous insufficiency patients was re-evaluated by the researcher after implementation of the nursing interventions after 6weeks and 3months using the tools. Comparison between the findings of two groups was carried out using appropriate statistical analysis in order to determine the impact of the nursing interventions on health outcomes of patients under the study.
Statistical analysis:
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using number and percent. The Shapiro-Wilk test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation, median. Significance of the obtained results was judged at the 5% level.
The main result of the study:
• Regarding to sex, more than half of patients in both studied groups were females, 40% of the control group 48.6% of the study group were aged 50-60 years old, and there were no statistically significant differences between both groups.
• 51.4% of the control group and 37.1% of the study group had secondary level of education.
• As regards the occupation, less than half of both groups had cleric work. Concerning the marital status, nearly three quarters of studied patients were married. Also, around two thirds of them lived in urban.
• As regards to associated disease, 17.1% of studied patients had hypertension. 14.3%, 8.6 % of control and study groups had diabetes mellitus.
• 71.4% of the control group and 77.1 % of the study group received the prescribed medications related to current illness.
• In relation to the onset of the disease, the majority of both control and study group (82.9, 85.7 % respectively) diagnosed when the severity of symptoms were increased.
• Concerning the duration of illness, the majority of control and study groups (77.1, 85.7 % respectively) had CVI less than 3 months.
• Concerning symptoms related to CVI, all of the studied patients (100%) had skin changes. The majority of both groups (94.3, 88.6 % respectively) suffered from pain and weakness of calf muscles, (85.7, 80%) had complaining of impaired physical mobility. 65.7% of control group and 71.4% of study group had limb edema.
• 51.4, 42.9 % of control and study groups had stage of C2 CVI, 74.3%, 77.1% of control and study patients sometimes feeling better with treatment.
• 60% of controlled patients, 48.6% of the studied patients were previously hospitalized. The majority of both groups (77.1, 77.4 % respectively) complying with prescribed medications.
• Concerning overall knowledge about chronic venous insufficiency the study group patients showed improvement in their knowledge level post implementation of nursing interventions with significant difference (P<0.001*). Furthermore, it was observed that there was significant difference between control and study group patients post implementation of nursing interventions P<0.001*).
• Regarding total score of Venous Clinical Severity assessment, there was significant difference between the study and control group after 3 months of implementing the nursing interventions (P=0.027*).
• In relation to total muscle strength scores, there was statistically significant difference between the controlled and studied patients 3 months post implementation of the nursing interventions for both right and left side.
• There was an improvement in bilateral total muscle strength scores significantly in the studied patients post nursing interventions implementation indicating a significant difference between pre and post 6 weeks and 3months (P>0.001*).
• As regard the total ankle range of motions assessment reveals that there was statistically significant difference in right and left sides (P<0.019*, P<0.010*) between controlled and studied patients post 3 months of implementation of nursing interventions.
• There was an improvement in total ankle range of motions assessment score in the studied patients post implementation nursing interventions indicating a significant difference between pre and post 6 weeks / 3months for both right and left side (P=26.462*, P=29.429*).
• Regarding average score of health survey, there were statistically significant differences between the control and study groups regarding physical functioning, role limitations due to physical health, energy / fatigue, social functioning, bodily pain and general health domains post 3 months of implementing the nursing interventions.
• As regard themean percent score of overall competence /compliance level of exercises, it was found statistically significant difference in study patients immediately after the sessions, post 6 weeks and post 3 months of the nursing interventions implementation (<0.001*).
• In summary, this study confirmed that the nursing interventions affect positively on health outcomes of patients with lower limbs chronic venous insufficiency.
Based on the findings of this study, the following recommendations are suggested;
Recommendations for patients:
1. The developed colored illustrated educational booklet should be available and distributed to each patients with lower limbs chronic venous insufficiency.
2. Application of educational sessions for patients to improve their knowledge about CVI, treatment methods, health practices and structured exercises that support disease management.
Recommendations for nurses:
1. An in-service training program should be carried out for nurses who worked at vascular department about structured exercises programs for CVI patients.
2. Nurses should be receiving updated instructional guidelines about CVI management.
3. Periodic scientific meetings among physicians and nurses must be conducted to discuss patient’s problems and establish a comprehensive plan to meet CVI patients’ needs.
Recommendations for further studies:
1. Develop of a standard program for nurses about management of patients with lower limbs chronic venous insufficiency.
2. The present study should be replicated on larger study populations and in different settings in Egypt for generalization of the results.