الفهرس 
reast CancerOnly 14 pages are availabe for public view
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Abstract
Breast cancer (BC) is the most commonly occurring cancer in women and the second most common cancer overall (World Cancer Research Fund, 2018). LE is one of the most debilitating outcomes of BC treatment (Can et al., 2016). BCRL is an accumulation of lymph fluid in the interstitial spaces of the arm or chest wall, where normal lymphatic flow has been disrupted by axillary node dissection, mastectomy and radiation or chemotherapy (Paula, 2015).
Patients’ education is a dynamic, integrated and multifaceted teaching-learning process in which the nurse and patient work together to change patients’ behaviors through their functional status with medical instruction. Health education is an independent function of nursing practice and a primary nursing responsibility. Many of these nursing activities are accomplished through patients’ education (Hinkle & Cheever, 2014).
Breast cancer related lymphedema self care generally includes wearing a compression garment and/or self-bandaging, conducting self-manual lymphatic drainage, and completing skin care and arm exercises. Lifelong self care is required to slow the progression of lymphedema and reduce negative health out comes. Lymphedema self care practices target swelling and skin; however, self care should also address associated physical and psychosocial symptoms (Ridner et al., 2016).
Oncology nurses are essential members of the interdisciplinary team in the management and treatment of lymphedema. They should encourage self care, provide emotional support, offer patient and lay caregiver education, assess symptoms that patients with lymphedema may be experiencing and develop a plan of management (McCaulley & Smith, 2014).
Aim of the study
This study was aimed to determine the effect of educational instructions on knowledge and self care practices of women with breast cancer related lymphedema.
Research Hypothesis
The current study hypothesized that:
The implementation of educational instructions regarding self care of women with breast cancer related lymphedema will improve their knowledge and self care practices.
Study design
A quasi experimental design used to achieve the aim of the current study.
Setting
The study was conducted in outpatient breast clinic at Oncology Center and Nuclear Medicine affiliated to Ain Shams University Hospitals.
Subjects
A purposive sample of 50 women newly diagnosed with BCRL, were post mastectomy, treated with radiotherapy and free from any other dysfunctional disabilities that might interfere with self care was recruited in this study.
Study tools
1. Structured Interview Questionnaire for Women with Breast Cancer Related Lymphedema (Appendix I)
It included 4 parts as follows:
First part: Socio-demographic data of the women with BCRL. It consisted of 8 MCQ questions as age, marital status, educational level, occupation, monthly income, treatment costs, residence and smoking habits.
Second part: Medical health data of the women with breast cancer related lymphedema. It included the followings:
- Present history (It consisted of 11 closed ended and MCQ questions regarding weight, height, body mass index, chief complaint, medical diagnosis, BC stage, time since BC diagnosis, time since mastectomy, time since starting RT sessions, dominant hand and LE location.
- Past history (It consisted of 4 MCQ and closed ended questions regarding chronic diseases, previous hospitalization, other surgery and medications not related to the disease).
- Family history (It consisted of 2 yes or no questions as family history suffering from the same disease or other oncology disease).
Third part: It was used to assess women’s knowledge regarding breast cancer, breast cancer related lymphedema and lymphedema self care, pre and immediately post implementation of educational instructions. It included 3 sections as follow:
Section 1: BC information (4 items) including definition, risk factors, diagnostic measures and treatment.
Section 2: BCRL information (8 items) including definition, causes, signs and symptoms, sites, when occurred, stages, complications and treatment.
Section 3: Lympedema self care information (8 items) including reduce BCRL, pain control and exercises, hand and arm care, healthy nutrition, safe drugs intake, psychological stress, sexual relation and depression.
Fourth part: It was used to assess women’s information source regarding BCRL, included one MCQ question about BCRL information source.
2. Lymphedema Scale (Appendix II):
This tool was used to assess arm LE staging for women with BCRL pre and post implementation of the educational instructions. It was adopted from International Society of Lymphology, (2013). In this tool LE was staged into 5 stages (stage 0, stage 1, stage 2, stage 3 and stage 4), each stage had specific criteria.
3. Lymphedema Functioning, Disability and Health Questionnaire (Appendix III):
This tool was used to assess the level of LE effects on functional state, activities and participation of women with BCRL pre and post implementation of the educational instructions. It was adapted from Coremans, christiaens, Devoogdt, Kampen & Geraerts (2011), and then translated into Arabic language after its modification. It included 2 parts as follow;
Part I: Impairments in function including physical domain (7 items) and psychological domain (4 items).
Part II: Activity limitations and participation restrictions including household domain (3items), mobility domain (4 items) and life/social domains (6 Items).
4. Upper Limb Functional Index (ULFX) (Appendix IV): this tool was used to assess function of the affected arm on self care practices after BCRL pre and post implementation of the educational instructions. It included 23 items. This tool was adapted from Philip et al., (2006), and then translated into Arabic language after its modification.
5. Lymphedema Self Care Practices Questionnaire: (Appendix IV): This tool was used to assess women self care practices after BCRL pre and post the educational instructions. It included 10 parts as follow; self care practices including reduce BCRL (7 items), skin care (10 items), skin wound or burn care (8items), control of pain (4items), healthy nutrition (7 items), safe drug use (3 items), use of compression bandages (4 Items) general exercises (7 Items) sexual relation (8 Items) controlling of psychological pressures (9 Items).
Ethical consideration
The research approval obtained from the ethical committee in faculty of nursing, Ain Shams University before starting the study.
The researcher clarified the objectives and aim of the study to women before obtaining their consent to participate in the study.
The researcher assured maintaining anonymity and confidentiality of subjected data.
Women were informed that they are allowed to choose either to participate or withdraw from the study at any time.
Values, cultures and benefits were respect.
Pilot study
A pilot study was conducted on 10% of the study subjects (5 women with BCRL) in order to test the applicability of the study tools, the clarity of the study tools, as well as estimating the average time needed to complete the tools. Accordingly, necessary modifications were made for the final development of the study tools. Women selected for the pilot study were excluded from the study subjects.
Field work
The collection of data and application of educational instructions lasted over a period of twelve months; starting at October 2016 and ending in October 2017.
The researcher visited the out patient breast clinic three days in Saturday, Monday, Wednesday during morning shifts (9.00 am to 2.00 pm).
The women who fulfilled the inclusion criteria were selected.
Filling in the previously mentioned tools was done by the researcher before implementation of the educational instructions.
Lymphedema stages were determined through the tool used for this (Lymphedema scale), also through bilateral upper extremities circumference measurements.
All information collected through data collection tools were interpreted for identifying individualized teaching needs.
The researcher set up teaching plan covering all objectives; then starting instructions sessions was detected and scheduled with the women.
The teaching sessions were conducted in the rooms at out patient breast clinic and total number of the sessions of educational instructions was 8 sessions. Each session of them had taken one and half hour/ day for 3 days per week.
Implementation of educational instructions lasted over a period of 6 months for all women.
The researcher evaluated the effect of the educational instructions on knowledge and self care for women with BCRL through pre/post assessment using the previously mentioned tools, concerning knowledge, was assessed pre and immediately after implementation of the educational instructions and self care was assessed pre and three months after implementation of the educational instructions and comparing the collected data before and after application of educational instructions.
Results
The important findings obtained from the study can be summarized as following:
• The mean age of the studied women was 47.71±7.16 years, 86% were married, 38% of them had medium education, and 62 % of them were housewives.
• Concerning allover studied women knowledge, 12% of them had satisfactory level of total knowledge pre implementation of self care instructions which improved to 88% with a highly significant difference post implementation of self care instructions (P≤ 0.001).
• Regarding to lymphedema stage, 60% of the studied women had stage I of lymphedema and 20% had stage II (early) of lymphedema pre implementation of self care instructions which improved to (22% & 0% respectively) with a highly significant difference post implementation of self care instructions (P≤ 0.001).
• As redard to effects of lymphedema, 50% of the studied women had moderated and 50% had strong effects of lymphedema pre implementation of self care instructions which improved to (22% & 0% respectively) with a highly significant difference post implementation of self care instructions (P≤ 0.001).
• In relation to upper limb function, 20% of the studied women had high functional ability of upper limb pre implementation of self care instructions which improved to 92% with a highly significant difference post implementation of self care instructions at (P≤ 0.001).
• Concerning lymphedema self care practices, 8% of the studied women had adequate level of total lymphedema self care practices pre implementation of self care instructions which improved to 92% with a highly significant difference post implementation of self care instructions at (P≤ 0.001).
• There was correlation between women’s total scores of knowledge, lymphedema scale, level of lymphedema effects, upper limb function and lymphedema self care practices post implementation of self care instructions at (P≤ 0.001).
• There was a statistically significant relation between women’s total level of knowledge and their educational level at (P< 0.05) post implementation of self care instructions.
• There was there was significant relation between studied women’s level of lymphedema effect and their marital status at (P< 0.05) post implementation of self care instructions.
• There was a statiscally significant relation between studied women’s activity level regarding total score of upper limb function and their educational level at (P< 0.05) post implementation of self care instructions.
• There was a statiscally significant relation between studied women’s lymphedema self care practices and their educational level at (P< 0.05) post implementation of self care instructions.