Effectiveness of the Instructional Program on Physical and Psychological Status of Patients Undergoing Upper Gastrointestinal Endoscopy at Baghdad Teaching Hospitals

Objective : The present study aims to investigate the effectiveness of instructional program on the physical and psychological status of patients undergoing upper gastrointestinal endoscopy. Methodology: A quasi-experimental study was conducted in the outpatients and medical unite for the Gastroenterology and Hepatology unit in Baghdad teaching hospital and Al-Kindy teaching hospital Imamein Kadhimein Medical City for the period from the 5 th of January 2014 to 17 th August 2014. A non-probability sample was selected and composed of 100 patients divided into (50 patients within the study group who received the instructional program about upper gastrointestinal endoscopy and 50 patients within the control group were not exposed to the instructional program The instructional program was developed by the researcher and consisted of the information domain and trained domain and giving at least 7 day before the endoscopy procedure. A questionnaire was prepared for evaluating of patient physical status (through measuring the intensity of pain during the procedure by visual analogue scale and patient discomfort by (retching, attempt grabs the endoscope, body movement and moaning) and measuring the pulse rate and oxygen saturation blood pressure) during the procedure. While evaluating the psychological status (through measuring (state and trait anxiety) before and after the procedure. Identified validity of the questionnaire and instructional program by a panel of 28


INTRODUCTION
The term "endoscopy" refers to particular technique to look inside the body part."upper digestive tract (GI)" is the part of the gastrointestinal tract, and gastrointestinal tract, including the esophagus, stomach, and duodenum, and Starting small bowel.Esophagus holds food from the mouth to digestive process in the stomach and small intestine (1) Upper gastrointestinal endoscopy also referred to as esophagogastroduodenoscopy (EGD), is implemented by passing a flexible endoscope by mouth into the esophagus, gastric, bulb, and second duodenal.This procedure is the best way to verify upper gastrointestinal mucosa (2).
The upper gastrointestinal (GI) endoscopy is usually use to diagnose and treat patients who suffer from group of conditions and symptoms (3) Upper gastrointestinal endoscopy') is the investigation of choice and disturbances the upper gastrointestinal tract with the ability to treatment and mucosal biopsy.Findings include oesophagitis reflux, gastritis, ulcers and cancer.Osophagogastroduodenoscopy (OGD) curative uses for the treatment of upper GI bleeding and obstruction of both benign and malignant (4) Therapeutic endoscopy is frequently indicated for control of variceal and nonvariceal hemorrhage, dilation of strictures, elimination of some foreign bodies, and palliation of advanced malignancies with stents or tumor ablation, and appointment of a percutaneous gastrostomy tube.In addition to investigative upper gastrointestinal endoscopy are upper abdominal suffering associated with signs or symptoms of organic illness (weight loss, loss of appetite), intractable vomiting of unidentified cause, dysphasia or odynophagia, esophageal reflux symptoms unresponsive to treatment upper gastrointestinal bleeding, when sampling of duodenal or jejunal tissue or fluid is indicated, to get a histological diagnosis for radiographically established stomach or esophageal ulcers, upper intestinal tract strictures, or suspected neoplasm, to monitor for varices so that patients with cirrhosis can be recognized as possible candidates for prophylactic medical or endoscopic treatment, to assess acute injury after scathing ingestion Barrett esophagus and Familial adenomatous polyposis. (5)ctive: The present study aims to investigate the effectiveness of instructional program on the physical and psychological status of patients undergoing upper gastrointestinal endoscopy.

METHODOLOGY:
A quasi-experimental design was conducted to determine the effectiveness of instructional program on physical and psychological status of patients undergoing upper gastrointestinal endoscopy at Baghdad teaching hospitals the present study starting from 5 th January 2014 to the 17 th August 2014 A non-probability (purposive) sample of 100 adult patients was at age (18 -65) years, who are able to reading and writing and underwent the upper gastrointestinal endoscopy without sedation for the first time.The instructional program is constructing and the questionnaire format in order to reach the aims of the study, the questionnaires composed of instrument of measuring effectiveness of the instructional program physically and psychologically.Physically was consist of (measuring the pain during endoscopy procedure by visual analogue scale (V.A.S.), measuring the discomfort during upper gastrointestinal endoscopic procedure through (number of retching, attempts to grasp the endoscopy, and the number of moaning) and measuring the pulse, oxygen saturation (pre, during and post procedure) and blood pressure (pre and post procedure).psychological status was measure through the state and trait anxiety (fourteen item).Validity of questionnaires determined through panels of experts and reliability coefficient of measuring pain through the (VAS) was (0.86 ), distress through the (number of times retching was (0.88 ), attempts to grasp the endoscope was (0.87), body movement was (0.88 ) and the Moaning was ( 0.84), reliability Cronbach alpha of the state was ( 0.93) and trait anxiety scale was (0.92 ).Descriptive data analysis was done through (frequency, percentage, mean, standard deviation) and inferential data analysis was done by t-test) through application by SPSS version 19.Table (1) analysis of the data founded that the higher proportion (20%) of the study group within the age group (25-31years), while the control group, the highest percentage (20%) within the age group (32-38 years).The majority (52%) of the study group were females, while the control group males and female were equal (50%).Concerning the level of education the table revealed that a high percentage of the study and the control groups were primary school (48%) and (32%) respectively, most (70%) of the study group and (78%) those of the control group were married.

Table (1): Distribution of Case and control groups by
Related to occupational status, (44%) of the study group were housewife, and (34%) of the control of control group were housewife, the majority of the study and the control groups their residence were urban (88%) and (94%) respectively.No statistical significant difference was observed between different variable representing demographic characteristic of both groups To evaluate the pain intensity during upper gastrointestinal endoscopy procedure of the study and the control groups through scoring method of Visual Analog Scale, the data of table (2) revealed that the pain intensity of the study group was less than that of the control group, high statistical significant differences were found between the study and the control groups of Visual Analog Scale score p.value (0.003).Table (3) presented the patient discomfort during the procedure as defined by retching, trying to grab the device endoscopy, body movement and moaning, the results revealed a high statistical differences between the study and the control group related to attempts to grasp the endoscope, the movement of the body and moaning during procedure (p≤0.00), while no statistical difference between the study and the control group related to retching (gag) (p≤0.1)Table (4 ) reveals that the pulse and O2 saturation measurement in pre, intra and post procedure was bettering the study group as compared with the control group, this trend is quite clear during the intra and post procedure.Regarding pulse rate a statistical significant difference is observed only in intra and post procedure (p≤0.001 and p≤0.01) respectively, although high statistical significant differences between study and control group, but rate of pulse increase above normal in both groups in the procedure, concerning the proportions of O2 saturation, the table showed no statistical significant difference between the study and the control groups intra procedure.But, during pre and post procedure, the table revealed a high and a significant difference between study and control groups (p≤0.001 and p≤0.01).Table (5) the presented blood pressure measurement as defined by systolic and diastolic, the results indicated no statistical differences between the study and the control group (p< 0.05) in pre and post procedure level of blood pressure within normal.To evaluate the duration of upper G.I. endoscopy of the study and the control groups, the data of table (6) revealed that the duration time of the study group was less than the control group, high statistical significant differences were founded between the study and the control groups is p.value was(0.002).Table (7) reflected the effectiveness of psychological status regarding the (state Anxiety) from pre to post of patients with upper gastrointestinal endoscopy procedure , As observed from the table, there were a high statistical significant differences from pre to post procedure for the study group related to state anxiety, the p. value was (0.001).While such significant differences were not observed in the control group from pre to post procedure, p. value was (0.1), table (7) shows there is no statistically significant differences between post procedure with regard to trait anxiety for both groups (study and control group).

DISCUSSION:
, 7, 8, 9) Data analysis had revealed that the implementation of the instructional program had a positive effect on patients undergoing upper gastrointestinal endoscopy procedure, through measuring the pain intensity by visual analogue scale, where the results showed that the mean score of the study group was less than the mean score of the control group and highly statistically significant between the two groups.
These results agree with the evidence is available in the study that founded that the mean of VAS score for comparing the severity of ache between the two groups because the result represents the severity of moderate to severe pain for each patient (12)   .Another study reported that the self-reported Scott-Huskisson Visual Analog Scale be used as a subjective assessment of pain (13) .
Data analysis had revealed that the study group of upper gastrointestinal endoscopy procedure provides an instructional program has less discomfort during the procedure, and a highly statistically significant difference has been observed between the study and the control groups.The mean score of numbers of episodes of the study group was less than the control groups related to attempt to grab the endoscopy, the patient's body movement, and the moaning, while no statistically significant has been observed between the study and the control groups concerning retching.
Concerning retching the analysis of the researcher is that the medical instructions are given for the patient before the procedure may not benefit most patients because when entering endoscopy in the patient pharyngeal is stimulation of cranial nerve IX (glossopharyngeal nerve) automatically occurs and leads to vomiting.
The benefit of participants with in the study group for guidance and advice provided by the researcher before the procedure more than the control group Effectiveness of the instructional program and the emphasized by giving the patient pamphlet is clearly observed through the results of table (4) as table shows the mean score of pulse rate in intra and post procedure, as less in the study group than the control group; the findings show statistical and highly statistically significant differences intra and post procedure (p<0.01) and (p<0.001)respectively For measuring, the oxygen saturation in intra and post procedure the present results show no statistical significant differences intra procedure (p<0.3),but there are high statistically significant differences post procedure (p<0.007) between the study and the control groups.The present results agree with the evidence is available in the study that stated there was a significant increase in pulse rate for both groups as in (84.5 versus 94 min-1) (p < 0.0001) and as in (81 versus 88.5 min-1) (p = 0.001) during endoscopy, as compared with the pre-endoscopy pulse rate (15) .
Another study reported that there is no statistically significant decrease in the oxygen saturation levels through upper G.I. endoscopy in the group without sedation, and a statistically significant decrease was found in the sedation group (P =0.00).In comparing both groups (16) Regarding the results of blood pressure measurement before and after the upper gastroinstinal endoscopy procedure indicate the absence of statistically significant difference between systolic and diastolic blood pressure before and after the upper gastroinstinal endoscopy procedure.This result supported with the evidence is available in the study that indicates the mean of systolic blood does not alter significantly in upper endoscopy, and none of their patients, with high blood pressure develop any cardiovascular or cerebrovascular (17) Researcher emphasized the mean and standard deviation of the upper endoscopies procedure duration of the study group are (6.60 ± 3.2) minutes, and the control group are (8.98±3.9)minutes.The present results are consistent with evidence is available in the study that state the mean and standard deviation of the un sedated upper endoscopies procedure duration are (4.3±2.1)minutes (18) .
No difference was detected in mean trait anxiety scores between pre and post procedure for the study and the control groups of patients undergoing upper endoscopy.Mean trait anxiety scores were (45.5) pre procedure and (44.7) post procedure to the study group (p=0.2) and (40.90) pre procedure and (41.3) post procedure to the control group(p=0.5)(Table 7) researcher confirms the interpretation of the result is that all participants are the people who do not have any psychological status by mean of trait anxiety value and this express in pre and post procedure test for the study and the control groups.This results have the same opinion with the prior study Who stated that a positive trend was evident for the relief of -endoscopic anxiety by the preparatory education program (19,20) And also constant with another study who established in their research that the comparison between the baseline and before-procedural state and trait anxiety scores of upper endoscopy, there was a moderate increase but significant degree of concern in the state before the upper gastrointestinal endoscopy, but without a change in personality traits degree of concern. (21).

CONCLUSION:
1. Analysis of demographic characteristics ensure equivalence in both groups; there are no significant differences between study and control groups in age ,sex, marital status, educational level occupation and residency p≤ 0.05.2. Concerning the physical status such as (pain intensity, Patient discomfort, Pulse rate and oxygen saturation), presence of statistical significance between case and control groups, while no presence statistical significance regarding blood pressure between each groups.3. Presence of the relationship between the two groups within the state of anxiety, there is a highly statistical significance between the two groups before and after the procedure, 4. Patients' trait of anxiety are two groups concern me (before and after the procedure); the results reveal that there is no statistical significance between the two groups.

RECOMMENDATIONS:
1. Provide teaching hospitals affiliated to the Ministry of Health educational booklet prepared by the researcher and to reduce the physical and psychological suffering.2. Provide room of endoscopies with devices to measuring the pulse, oxygen saturation and blood pressure and to monitor condition of the patient during the procedure.