INTRODUCTION

Gastric cancer, also called stomach cancer, occurs when there is an abnormal proliferation of constituent cells in the stomach ¹. It presents disturbing epidemiological values, with approximately one million new cases diagnosed worldwide in 2012 ². In the northern region of Portugal in 2015 it was the fourth malignant tumor to affect more men and women, with an incidence rate of 8.3% and 5.5%, respectively ³. It is a public health problem with a tendency to worsen in the near future, and it is expected that a considerable percentage of population will develop this neoplasm, mainly due to eating, smoking, alcoholic and sedentary habits ⁴.

Gastric cancer has a great personal and social impact due to its hostility as a disease and its aggressiveness towards treatments, leading the client to experience a health/disease transition ⁵. Gastrectomy is the most common treatment for this type of tumor, being a surgical procedure in which there is partial or total removal of the stomach and adjacent lymph nodes ¹.

It is an aggressive surgery that causes anxiety situations in clients resulting from feelings of loss of control, failure and fear ⁶. In addition to the psychological impact, associating the anesthetic and surgical act, there is an effect on respiratory dynamics, contributing to the increased risk of postoperative pulmonary complications ^7,8.

This impairment in respiratory dynamics occurs due to factors intrinsic to the client (age, smoking, obesity, chronic lung disease, malnutrition, state of consciousness, alcoholism, sedentary lifestyle and chest deformities) ^8,9,10,11 and related factors with the surgical procedure (hypoventilation, immobilization, central nervous system depression, intubation, ineffective cough and phrenic nerve inhibition and consequently diaphragmatic paresis) ^11,12,13,14.

There is a consensus that pulmonary complications arising in the postoperative period continue to influence morbidity, mortality and length of hospital stay, despite progress in the intervention of health professionals in the pre, intra and postoperative periods ^11,15,16,17. Respiratory Functional Re-education Programs (RFR) have been increasingly shown to be beneficial, both in the prevention of postoperative pulmonary complications, and in their effective recovery ¹⁸.

RFR, also known as respiratory kinesitherapy, is a therapy that fundamentally uses movement in its intervention and acts on the mechanical phenomena of breathing, that is, on external ventilation and, through it, on alveolar ventilation ¹⁹.

The specialist nurse in rehabilitation nursing assumes a fundamental role here, as it is a professional whose function is to care for, to train and to maximize the functionality of clients throughout the life cycle ²⁰, and can intervene with these skills in preventing or correcting the postoperative pulmonary complications, helping clients to experience a healthy transactional process ⁵.

The aim of this study is to analyze the effects of a pre- and postoperative RFR program on pain, respiratory rate and O2 saturation in the health/disease transition process of the client undergoing scheduled gastrectomy.

In this logic of transactional nursing care and RFR intervention in clients undergoing gastrectomy, the starting question arises: what is the effect of a pre- and postoperative RFR program on pain, respiratory rate and O2 saturation in the health/ disease, of the client undergoing scheduled gastrectomy?

METHOD

To achieve the objective of the study, we developed an investigation that fits into a quantitative, quasi-experimental and longitudinal paradigm.

As a quasi-experimental study, an RFR program was used as an intervention. Its conception was a construct that we prefer to systematize and phase, in order to provide it with methodological and clinical rigor, pertinence, objectivity and applicability. In the first phase, we carried out the construction of the program, using literature analysis. In the second phase, it was analyzed by an individual panel of experts. The third phase referred to the analysis and discussion of the experts' criticisms and suggestions. In the fourth phase, there was a new evaluation of the experts according to the changes resulting from their criticisms, where the program was approved by them. The last phase was the pre-test of 3 customers with positive feedback at the end, so the program design was completed.

The RFR program, conceived according to the above systematization, intended to restore and maximize respiratory performance, avoiding respiratory complications related to the surgical procedure and facilitating the health/disease transition process the client was experiencing.

The RFR program included: rest and relaxation techniques (lying down, sitting and standing); awareness of breathing times and breathing control; abdominal diaphragmatic breathing exercises and bilateral lower costal breathing; opening of rib cage exercises, with a stick; directed cough with containment of the surgical wound; change of position, active body movement and postural correction; and breath control in exertion, walking, and climbing and descending of stairs.

It was carried out by the principal investigator in order to cause as much uniformity as possible. The average duration of the program was 30 to 45 minutes, being adjusted to the client's clinical situation. As for the frequency of exercises, it was a work of agreement between the researcher and the client, taking into account the client's availability and physical condition.

With this research methodology, using the RFR program presented, we intended to test the following hypotheses:

H 1: The pre- and postoperative RFR program reduces client pain undergoing scheduled gastrectomy;

H 2: The pre- and postoperative RFR program improves respiratory rate of client undergoing scheduled gastrectomy;

H 3: The pre- and postoperative RFR program improves O2 saturation of client undergoing scheduled gastrectomy.

Since the research design is a logical plan, conceived by the researcher, in order to reach valid answers to the formulated hypotheses, we present in Figure 1 the design of our study.

Figure 1 Research design 

The RFR program first took on a phase of teaching clients in the intervention group and evaluating this teaching, right after the preoperative consultation. This program was continued at home, without the investigator. On the day before surgery and during the remaining hospital stay, except for the day of surgery, there was daily intervention of the RFR program with the investigator. After discharge, the RFR program continued without the investigator until the moment of the postoperative consultation, the end of the study.

For this study, the sample was non-probabilistic, accidental, because it consisted of clients who underwent scheduled gastrectomy in the surgical service of a hospital in the north of the country, in the period in which data collection took place (from 1-11-2016 to 17-3-2017) and that met the inclusion criteria defined below: clients with scheduled gastrectomy, with general anesthesia prediction, conscious and oriented in time and space, no pulmonary metastases, no physical dependencies, with more than 18 years-old and who agreed to participate in the study with informed consent.

As this is a study with two groups (intervention and control), the distribution of clients occurred according to the hospital's card number. If odd belonged to intervention group, if even to the control.

The sample consisted of 60 participants, 30 from the intervention group and 30 from the control group.

A data collection instrument was built for the study, consisting of a part of sociodemographic and clinical characterization and another part of recording grids of oxygen saturation, respiratory rate and pain (variables dependent on the study). Pain was assessed using the numerical pain scale.

Statistical analysis of data was performed using SPSS( version 23.0. The accepted significance level was 5%, with a 95% confidence interval.

Data processing was performed in two ways: through descriptive and inferential analysis.

In descriptive statistics of categorical variables, we used tables of absolute and relative frequencies, which were accounted for in each study group. For quantitative variables, we used the minimum, maximum, mean, median, standard deviation and interquartile range.

In the inferential analysis, we performed comparison tests between the two groups. In order to verify whether the two samples under study differed from each other, the chi-square test was used for categorical variables. When the dependent variable was quantitative, to verify differences between groups, the t-Student parametric test was used for two independent samples. When the assumption of normality of the samples was not validated, the non-parametric Mann-Whitney U test was used.

In order to analyze the differences between the various evaluation moments for all the variables of interest, in the case of more than two moments, the ANOVA was used for repeated measures, when the normality assumption was fulfilled, and when it is not found fulfilled, the non-parametric Friedman test was used.

The study was authorized by the institution's ethics committee and board of directors, and informed consent was obtained from all participants.

RESULTS

Regarding age, the clients in the control group had values ​​between 33 and 86 years-old (M=65.30; SD=13.68), those in the intervention group were aged between 40 and 85 years-old (M= 62.73; SD=12.52). There were no significant differences between the two groups in terms of age [t(58)=0.76; p=0.451].

With regard to gender, the control group comprised 18 (60.0%) men and 12 (40.0%) women, the intervention group consisted of 14 (46.7%) men and 16 (53.3 %) women. There were no significant differences between the two groups regarding gender [χ² (1) =1.07; p=0.301].

As in age and gender, in the remaining variables of sociodemographic and clinical characterization, there were no significant differences between the two groups. Due to its extensibility, we do not present the results in detail in this article. For a better explanation of the results, we chose to make a presentation according to the variables under study.

DISCUSSION

As in the previous chapter, we chose to discuss the results according to the dependent variables under study.

CONCLUSIONS

From the literature review carried out, which followed the entire research process, it was quickly realized that the study of rehabilitation nursing in this area is scarce. Internationally, research is carried out on RFR in clients undergoing abdominal surgery, and the studies are mainly carried out by physiatrists or physiotherapists. It should be added that this study was totally innovative in focusing its action only on clients undergoing gastrectomy, which, according to the review carried out, had never been done before.

We summarize the main results of this investigation, concluding that the RFR program:

We conclude that there is an influence of the RFR program on pain and O₂ saturation. This effect is beneficial for the intervention group, being more frequent during the postoperative period, which demonstrates that its continued application brings benefits to clients. This fact reveals the continued importance of the RFR program for this type of customer.

For the enhancement of Rehabilitation Nursing and recognition of its contribution to improving the quality of care provided, it is necessary to develop more research studies in this area, in order to demonstrate, through health gains for the client and for the health service, the impact of the rehabilitation nurse on care.