-

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE-11

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms. NISCHITHA.K.

UNITY COLLEGE OF NURSING

1 Name of the candidate and address
SHEDIGURI, DAMBEL ROAD
(in block letters)
ASHOKNAGAR POST

UNITY ACADEMY OF EDUCATION,

COLLEGE OF NURSING,

2 Name of the institution SHEDIGURI, DAMBEL ROAD

ASHOKNAGAR POST

MANGALORE-575006

M.Sc. NURSING
3 Course of study and subject
CHILD HEALTH NURSING

4 Date of Admission to the course 26/05/2010

5 Title of the study

‘A STUDY TO COMPARE THE EFFECTIVENESS OF BREATHING

EXERCISE USING POP-UP TOYS VERSUS INCENTIVE SPIROMETRY ON
RESPIRATORY EFFICIENCY AMONG POST –OPERATIVE CHILDREN
AGED BETWEEN 6-12 YEARS IN SELECTED HOSPITALS OF
MANGALORE.’
 BRIEF RESUME OF THE INTENDED WORK
6 6.1 INTRODUCTION:
Respiratory failure is either a major cause or a major contributing factor in 50
Percent of postoperative deaths. Treatment to prevent or modify respiratory complications has been
a major focus of care for the operative children. Since 1915, physical therapy has been widely used
to prevent or reverse respiratory complication of surgery and trauma. Pulmonary complications of
post-operative pediatric abdominal surgery observed in the studies were atelectasis, pneumonia,
pleural effusion, pneumothorax, chylothorax, and diaphragmatic paralysis; where as the first two
aforementioned complications are the common ones. 1
Post-operative pulmonary complications were investigated in a total of 41 pediatric
recipients who underwent orthotropic liver transplantation between January, 1990 and March, 1992
at the Royal children’s hospital Brisbane. Atelectasis was seen in 40 cases (98%) of the 41
recipients, and occurred in the left lobe in 28 cases (68%) and in the right upper lobe in 25 cases
(61%).Radiographic pulmonary edema occurred in 18 recipients (45%). Pulmonary edema was
observed just after operation in 9 cases, and in the later stage from them 3rd to 25th post-operative
day in 14 cases. Five recipients experienced 2 episodes of pulmonary edema during their ICU stay.
Pleural effusions were observed in 21 cases (52%), of which 18 had right sided effusion and 3 had
bilateral effusions. Pneumothorax occurred in 3 cases, pyothorax, hemothorax, bronchial asthma
occurred in one case each.2
Anesthesia and medication result in some degree of respiratory depression in
postoperative patients. Transient hypoxemia, is a common finding in the early postoperative hours.
Supplemental oxygen, deep breathing, and coughing are routinely used to prevent Postoperative
pulmonary complications. Despite these preventive efforts patients develop post-operative
pulmonary complications (including atelectasis, which makes up 90 percent of post-operative
pulmonary complications).
A study stated that atelectasis was the most common post-operative pulmonary
complication and it remains so today. The primary causes of atelectasis include hypoventilation
caused by obstruction of airways by secretions, decreased activity of the respiratory muscles, and
decreased expiratory reserve volume. Preoperative medications, anesthetic agents, and drugs given
in the intraoperative period decrease lung compliance, which contributes to diminished lung volume
and atelectasis. Because surgery of the extremities results in less postoperative pulmonary
complication than to abdominal and thoracic procedures, it appears that anesthesia is not the primary
cause of postoperative atelectasis. Other factors that may contribute to atelectasis include
supplemental oxygen delivered to a patient at low lung volumes, increased abdominal girth that
restricts lung expansion , and changes in negative pressure in the thorax.3
Breathing exercises in the pre- and post-operative period is indicated in pediatric
abdominal surgery in order to reduce the risk of pulmonary complications (retention of secretions,
atelectasis and pneumonia) as well as such complications as it contributes to the appropriate
ventilation and successful extubation. Blow bottles, balloon blowing, intermittent positive pressure
breathing (IPPB), and incentive spirometry (IS) have been used in an effort to decrease pulmonary
complications. Breathing exercises (physiotherapy) has an important role in the treatment of these
complications. The review updates the physiotherapy performance in pediatric cardiac surgery.
Many studies reported that incentive spirometry, deep breathing, and intermittent positive-pressure
breathing were equally more effective than no treatment in preventing post-operative pulmonary
complications following abdominal surgery.

6.2 NEED FOR THE STUDY:

Upper abdominal surgical procedures are associated with a high
incidence of postoperative pulmonary complications (PPCs), which are defined as pulmonary
abnormalities occurring in the postoperative period producing clinically significant, identifiable
disease or dysfunction that adversely affects the clinical course. The incidence rate depends on the
surgical site, the presence of risk factors, and the criteria used to define a pulmonary complication.
Reported incidence rates for upper abdominal surgery range from 17 to 88%. The basic mechanism
of pulmonary complications is a lack of lung inflation that occurs because of a change in breathing
to a shallow, monotonous breathing pattern without periodic sighs, pro-longed recumbent
positioning, and temporary diaphragmatic dysfunction, mucociliary clearance also is impaired
postoperatively, which ,along with the decreased cough effectiveness, increases risks associated with
retained pulmonary secretions.4
A study showed that postoperative atelectasis is better reduced by taking a deep
breath and holding it for 3 seconds than by taking multiple deep breaths or not holding a deep
breath. The first reports on the use of such sustained maximal inspirations for the treatment of
postsurgical patients aged between 15-20 years, originated in Great Britain. The first major study
showing the benefits of postoperative maximal inspiration was carried out in 343 patients who were
undergoing cholecystectomy. A study documented an incidence of atelectasis (detected via
radiograph) of 42% in control subjects vs 27% in patients treated postoperatively with physical
therapy including deep-breathing exercises. The incidence rate declined further, to 12%, in patients
who received additional preoperative instruction in the breathing exercises.5
A study showed the effects of breathing exercises taught by physical therapists to
40 postoperative upper abdominal surgery patients aged between 10-15 years at USA. The
experimental group received the breathing exercises in addition to the incentive spirometry, balloon
blowing(pop- up toys) ultrasonic nebulization, and routine instructions by nurses in deep breathing
and coughing provided for the control groups A 38 percent post-operative pulmonary
complication rate was found for the control group. The experimental group, whose subjects were
instructed and monitored by physical therapists, had only a 16 percent complication rate. The Post-
operative pulmonary complications were defined as temperature higher than 38.5° C, radiographic
changes, or abnormal breath sounds. This study indicates a need standardize the method of deep
breathing in a manner different from that routinely taught by nurses.6
An incentive spirometer is a device that encourages, through visual and/or audio
feedback, the performance of reproducible, sustained maximal inspiration. Incentive spirometry(IS)
is the treatment technique utilizing incentive spirometers. Bartlett et al developed an incentive
spirometer that both provided visual feedback to the patient and recorded the number of
successful breathing maneuvers. The first specific report of incentive spirometry as a treatment
technique appears to be that of Van de Water et al ,who compared incentive spirometry to
intermittent positive- pressure breathing (IPPB) in 30 patients aged between 15-30 years after
they had undergone abdominal bilateral adrenalectomy. No statistical difference was reported in
the incidence of pulmonary complications between treatment groups. Incentive spirometry remains a
widely used technique for the prophylaxis and treatment of respiratory complications in postsurgical
patients. 5
A study was conducted at USA and the main objective of this study is to
manage respiratory distress and pain of the children who had undergone surgery especially
abdominal surgery. In this study questioners were e-mailed to 109 hemophilia social workers in the
US listed in the CDC directory. The survey consisted of 14 questions, mainly closed-ended.
Nominal and Linker-like scales were used. Twenty-nine workers completed the survey (27%
participation).Twenty-six (93%) of respondents thought that breathing exercises with help of
interesting toys are more effective to manage respiratory distress and pain among children age group
of 3-10 years who had undergone a surgery. Thus finally social work respondents indicated that
distraction by pop-up toys ,sensory toys, light –up toys are most effective to reduce respiratory
distress as well as pain in post-operative children with age group of 3- 10 years.7
The above cited literature shows that pulmonary complications are more
common among the post-operative children. Pain is an unpleasant sensory and emotional experience
arising from actual or potential tissue damage. Pain is just one response to the trauma of surgery.
Pain itself may lead to shallow breathing and cough suppression in an attempt to “splint “the injured
site, followed by retained pulmonary secretions and pneumonia. The management of acute pediatric
pain and respiratory distress in children during post-operative period can be accomplished using a
multimodal approach in which pharmacologic techniques and cognitive-behavioral approaches
complement one another. Traditionally, health care practitioners have approached pain management
in children as an “either/or, “that is, pharmacologic interventions or “alternative “approaches and
specialties defined which approach and intervention were used. Physicians rely primarily on drugs
and invasive techniques to modulate nociceptive processing, whereas nurses, psychologists, and
other nonphysicians primarily rely on nonpharmacologic approaches includes relaxation techniques,
breathing exercises with blowing toys.
Since many studies reported that chest physiotherapy reduces the incidence of
pulmonary complications during postoperative period, there has been acceptance that children
undergoing surgery under general anesthesia require some form of prophylactic physiotherapy.
Attention has been directed towards techniques such as incentive spirometry, breathing exercises
using balloon blowing, bubble blowing etc. It has been observed that incentive spirometry is very
effective in reducing the pulmonary complications in post-operative children. At the same time
breathing exercise with help of interesting toys are equally effective to manage respiratory distress
and to distract pain among children who had undergone surgery. The studies concerning the efficacy
of incentive spirometry and breathing exercise with the help of interesting toys are less. In focusing
this issue the researcher taken an initiation to quantitatively assess the effect of breathing exercise
with the help of pop-up toys in comparison with the effect of breathing exercise using incentive
spirometer.

6.3 REVIEW OF LITERATURE

A clinical trial including 876 patients aimed at preventing pulmonary
complications after abdominal surgery at Australia and the study excluded those who did not
consent, were under 14 years of age or had a pre-existing pulmonary complication according to their
end-point criteria. Patients either received conventional chest physiotherapy or were encouraged to
perform maximal inspiratory maneuvers for 5 min during each hour while awake, using an incentive
spirometer. The incidence of pulmonary complications did not differ significantly between the
groups: incentive spirometry 68 of 431 (15·8%, 95% Cl 14·0-17·6%), and chest physiotherapy 68 of
445 (15·3%, Cl 13·6-17·0%). Nor was there a difference between the groups in the incidence of
positive clinical signs, pyrexia, abnormal chest radiographs, pathogens in sputum, respiratory failure
(PO2 < 60 mm Hg), or length of stay in hospital. The study concluded that prophylactic incentive
spirometry and chest physiotherapy are of equivalent clinical efficacy in the general management of
patients undergoing abdominal surgery.8
A meta analysis was done at Canada which quantitatively assessed the
conflicting body of literature concerning the efficacy of incentive spirometry (IS), intermittent
positive pressure breathing (IPPB), and deep breathing exercises (DBEX) in the prevention of
postoperative pulmonary complications in patients aged between 14-20 years undergoing upper
abdominal surgery. Computerized searches of MEDLINE and the Cumulative Index to Nursing and
Allied Health databases were performed for the years 1966 through 1992. Citations were selected
based on the following relevance criteria: (1) patients undergoing any type of upper abdominal
surgery; (2) any combination of incentive spirometry, intermittent positive pressure breathing, and
deep breathing exercises; (3) an outcome of pulmonary complications; and (4) randomized trials.
Finally Incentive spirometry and deep breathing exercises appear to be more effective than no
physical therapy intervention in the prevention of postoperative pulmonary complication.9
A study conducted at Cheltenham and the aim of this pilot study was to assess the
effect of pre-operative inspiratory muscle training on respiratory variables in patients aged between
6-18 years undergoing major abdominal surgery .during the study Respiratory muscle strength
(maximum inspiratory and expiratory mouth pressure) and pulmonary functions were measured at
least 2 weeks before surgery in 80 patients awaiting major abdominal surgery. Patients were then
allocated randomly to one of four groups (Group A, control; Group B, deep breathing exercises;
Group C, incentive spirometry; Group D, specific inspiratory muscle training). Patients in groups B,
C and D were asked to train twice daily, each session lasting 15 min, for at least 2 weeks up to the
day before surgery. Outcome measurements were made immediately pre-operatively and
postoperatively .Finally study stated that pre-operative respiratory muscle strength and expiratory
mouth pressure prevents the lung complications during post-operative period. 10
A randomized controlled trials (RCT’s) and quasi-RCT’s was conducted at Canada
that determined the effect of breathing exercises on respiratory distress during post-operative period
in children 0 – 8 years of age, using validated child self-reported pain or observer-reported
assessments of child distress or pain .Study included twenty RCT’s involving 1380 infants and
children(1 month to 11 years of age) in the systematic review. Finally the study suggested that
breathing exercises were effective in reducing children’s self –reported respiratory distress and
pain(standardized mean difference[SMD],-0.43%;95%Cl, -0.76 to -0.09;p=0.01),observer-rated
distress(SMD,-0.40; 95% Cl, -0.68 to -0.11; p=0.007), and nurse-reported distress (SMD, -0.57;
95%Cl, -o.98 to –o.17; p=0.005).Self- reported distress ratings appeared to be lower with breathing
exercises. Thus evidence suggest that breathing exercises are more effective in reducing pain as
well as respiratory distress.11
A study conducted at General Hospital Physiotherapy-FAMERP to determine the
effectiveness of deep breathing exercises in the pre-operative and post –operative pediatric cardiac
surgery in the prevention of pulmonary complications. This study analyzed the treatment for
atelectasis consists of physiotherapy, deep breathing, Spirometry. was observed that breathing
exercises are indicated in cases of atelectasis due to thoracic or upper abdominal surgery, they
improves the respiratory efficiency, increase the diameter of the airways, it helps to prevent alveolar
collapse, and facilitating the expansion of the lung and peripheral airways. Finally it was observed
that breathing exercises are effective in reducing the risk and/or pulmonary complications caused by
surgical procedure in children with congenital heart disease. Thus, more research is in need of
physiotherapy in the pre- and post-operative of pediatric cardiac surgery ,by comparing the different
techniques used by the physiotherapist in order to minimize the frequently post-operative pulmonary
complications.1
A study conducted at London and the main objective of this study to
systematically review the evidence examining the use of incentive spirometry (IS) for the prevention
of postoperative pulmonary complications (PPCs). The search yielded 85 articles. Studies dealing
with the use of incentive spirometry for preventing post-operative pulmonary complications (n = 46)
were accepted for systematic review. Finally this study stated that there was a positive short-term
effect or treatment effect of incentive spirometry following abdominal surgery. Then also supportive
study reported that incentive spirometry, deep breathing, and intermittent positive-pressure breathing
were equally more effective than no treatment in preventing post-operative pulmonary complications
following abdominal surgery.4
A study determined with the aim to prevent or minimize the pulmonary
complications among post-operative children. In this study single blind randomized controlled trial
aims to recruit 184 children aged between 6-14 years following major abdominal surgery. All
subjects received a pre-operative physiotherapy information booklet and randomly allocated, a
treatment group received post-operative physiotherapy with blowing toys (balloon blowing) and a
control group received standard care nursing and medical interventions but no physiotherapy. The
treatment group received a standardized daily physiotherapy programme to prevent respiratory and
musculoskeletal complications. On discharge treatment group subjects received an exercise
programme and exercise dairy to complete. The primary outcome measure was the incidence of
post-operative pulmonary complications, which was determined on a daily basis whilst the patient
was in hospital by a blinded assessor. Secondary outcome measures are the length of post-operative
hospital stay, severity of pain, breathing pattern as measured by the self-reported respiratory distress
and disability index. Results from this study were contributed to the increasing volume of evidence
regarding the effectiveness of physiotherapy in preventing pulmonary complications. 12

6.4 PROBLEM STATEMENT

A STUDY TO COMPARE THE EFFECTIVENESS OF BREATHING EXERCISE USING POP-
UP TOYS VERSUS INCENTIVE SPIROMETRY ON RESPIRATORY EFFICIENCY AMONG
POST-OPERATIVE CHILDREN AGED BETWEEN 6-12 YEARS IN SELECTED
HOSPITALS OF MANGALORE.

6.5 OBJECTIVES

The objectives of the study are to:-

 evaluate the effectiveness of breathing exercise using pop-up toys on respiratory

efficiency among the post-operative children aged between 6-12 years using child self-
reported and observer-reported respiratory efficiency scale.
  evaluate the effectiveness of breathing exercise using incentive spirometry on respiratory
efficiency among the post-operative children aged between 6-12 years using child self-
reported and observer –reported respiratory efficiency scale.

 compare the effectiveness of pop-up toys versus incentive spirometry on respiratory

efficiency among post-operative children aged between 6-12 years.

 find out the association between the respiratory efficiency scores of pop-up toys versus
incentive spirometry with selected variables of post-operative children aged between 6-12
year.

6.6 OPERATIONAL DEFINITIONS

EFFECTIVENESS

In this study effectiveness refers to the efficacy of pop-up toys versus incentive spirometry
in improving respiratory efficiency and promoting lung expansion through breathing exercise among
post-operative children aged between 6-12 years as measured using validated child self-reported
and observer-reported respiratory efficiency scale.

BREATHING EXERCISE

In this study it refers to a specific number of blowing exercises designed to improve

respiratory efficiency, promote expansion of the lungs and strengthen respiratory muscles of the
children aged between 6-12 years, who had undergone surgery under general anesthesia exclusive of
thoracic, open-heart, cranial and any spinal surgeries, admitted to post-operative wards of selected
pediatric hospitals of Mangalore.

POP-UP TOYS

In this study it refers to a blowing toy used for breathing exercise among children aged
between 6-12 years who had undergone surgery under general anesthesia, exclusive of thoracic,
open-heart, spinal and cranial surgeries, used twice a day, each session involves 10 breathes for
five days from first post-operative day.

INCENTIVE SPIROMETRY

It is a lung exerciser used to improve lung performance as well as an instrument used to

measure the lung capacity among children aged between 6-12 years, who had undergone surgery
under general anesthesia, exclusive of thoracic, open-heart, spinal, and cranial surgeries, used
twice a day, each session involves 10 breathes for five days from first post-operative day.
RESPIRATORY EFFICIENCY

In this study it refers to the respiratory variables of pulmonary functions measured in terms
of respiratory rate, expiratory capacity, chest expansion, breath holding time and oxygen saturation
by using observer-reported respiratory efficiency scale.

POST-OPERATIVE CHILDREN

It refers to the children aged between 6-12 years, who had undergone surgery under
general anesthesia exclusive of thoracic, open-heart, spinal and cranial surgery irrespective of their
sex, and those who stays for the period of 1 week after the surgery in pediatric units of
selected hospitals of Mangalore.

6.7 ASSUMPTIONS

The study assumes that,

1. most of the children who had undergone surgery under general anesthesia may experience
respiratory distress.

2. breathing exercises are effective in promoting lung expansion which in turn leads to
reduction of unwanted secretion and also improve the strength of respiratory muscles.

3. breathing exercises are effective in reducing post-operative pain.

4. breathing exercises with pop-up toys make the session interesting to the children.

5. breathing exercise during post- operative period are effective in preventing respiratory
complications.

6.8 DELIMITATIONS

The study is delimited to,

1. children who has undergone surgery under general anesthesia, exclusive of thoracic, open-
heart, spinal, and cranial surgery in selected hospitals of Mangalore.

2. children aged between 6-12 years.

3. children those who are available during the data collection time.
 4. the effectiveness of breathing exercise is assessed only by using validated child self-reported
and observer-reported respiratory efficiency scale.

5. children those who stays for the period of one week after surgery.

6.9 HYPOTHESES

All hypotheses will be tested at 0.05 level of significance

H1: There will be a significant difference between the effectiveness of breathing exercise used by
pop-up toys and incentive spirometry among post-operative children aged between 6-12 years.

H2: There will be a significant co-relation between self-reported and observer - reported respiratory
efficiency scores of pop-up toys and incentive spirometry among post-operative children aged
between 6-12 years.

H3:There will be a significant association between respiratory efficiency scores of pop-up toys
versus incentive spirometry and selected variables of post-operative children aged between 6-12
years.

7. MATERIALS AND METHOD

7.1. Source of data

The data will be collected from the children aged between 6-12 years, who had undergone
surgery under general anesthesia exclusive of thoracic, open-heart, spinal and cranial surgery
irrespective of their sex, and those who stays for the period of 1 week after the surgery in
pediatric units of selected hospitals of Mangalore.
7.1.1. Research design

Quasi-experimental, non-equalent repeated measure with two-group design is adapted for the study.

GROUP-1 WITH POP-UP TOYS

PRE-TEST INTERVEN POST-TEST INTERVEN POST-TEST

TION TION

DAY-1 O1.1 X1.1 O1.2 X1.2 O1.3

DAY-2 - X1.3 O1.4 X1.4 O1.5

DAY-3 - X1.5 O1.6 X1.6 O1.7

DAY-4 - X1.7 O1.8 X1.8 O1.9

DAY-5 - X1.9 O1.10 X1.10 O1.11

 O1.1 _ pre-test of group-1 with pop-up toys

 X1.1 to X1.10 –intervention with pop-up toys.
 O1.2 to O1.11_post-test of group-1 following each intervention

GROUP-2 WITH INCENTIVE SPIROMETRY

PRE-TEST INTERVEN POST-TEST INTERVEN POST-TEST
TION TION
O2.2 X2.2 O2.3
DAY-1 O2.1 X2.1
- X2.3 O2.4 X2.4 O2.5
DAY-2
- X2.5 O2.6 X2.6 O2.7
DAY-3
- X2.7 O2.8 X2.8 O2.9
DAY-4
- X2.9 O2.10 X2.10 O2.11
DAY-5

 O2.1- pre-test of group-2 with incentive spirometry

 X2.1 to X2.10- intervention with incentive spirometry.
 O2.2 to O2.11- post-test of group-2 following each intervention.
 7.1.2 Setting

The study will be conducted in pediatric units of selected hospitals at Mangalore.

7.1.3 Population

In this study, population consists of children aged between 6-12 years, irrespective of their sex,
who had undergone surgery under general anesthesia exclusive of thoracic, open-heart, spinal and
cranial surgery, and those who stays for the period of 1 week after the surgery in pediatric units of
selected hospitals of Mangalore.

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling procedure

A non-probability Purposive sampling technique with random assignment will be adopted for this
study.

7.2.2 Sample size

Sample size will be 40. A random assignment of 20 subjects in each of two groups will be
done.

7.2.3Inclusion criteria for sampling

1. Children who had undergone surgery under general anesthesia exclusive of thoracic, open-
heart, spinal and cranial surgery, in pediatric units of selected hospitals of Mangalore
2. 2. Children aged between 6-12 years irrespective of their sex are included.

3. Children who stays for the period of 1 week after the surgery.

7.2.4 Exclusion Criteria for Sampling

1. Children, not conscious and oriented.
2. Children whose parents are not permitting to participate in the study.
3. Children with previous history of asthma or any respiratory disorders.
4. Children, on ventilator support.
5. Children, undergone open- heart, thoracic, cranial and spinal surgeries.
6. Children those who does not complete 5 days intervention schedule.
7.2.5 Instruments

TOOL-1. Demographic proforma

TOOL-2.a) child self-reported respiratory efficiency scale

b) Observer-reported respiratory efficiency scale

7.2.6 Data collection method

Data will be collected from the children aged between 6-12 years ,irrespective of their
sex, who had undergone surgery under general anesthesia exclusive of thoracic, open-
heart, spinal and cranial surgery and those who stays 1 week in a pediatric units of
selected hospitals of Mangalore, after obtaining formal permission from the concerned
authorities. The samples of the study will be selected by using a non-probability purposive
sampling technique among 40 samples, 20 samples in each group will be randomly assigned.
Both the group will be given breathing exercise with different intervention, pop-up toys and
incentive spirometry respectively twice a day each session involves 10 breathes ,for five
days. 1st day a pre-test will be assessed and post-test will be assessed after each intervention
using observer-reported and child self-reported respiratory efficiency scale.

7.2.7 Data analysis plan

The data will be analyzed using descriptive and inferential statistics.

7.3 Does the study require any investigations or interventions to be conducted on patients, or
animals? If so please describe briefly.

Yes. Children will be given breathing exercise by using pop-up toys and incentive
Spirometry twice a day each session includes 10 breathes from first post-operative day for
five days.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Ethical clearance will be obtained from the concerned authorities.

8.LIST OF REFERENCES

1. Cavenaghi S, Moura SCG, Silva TH, Venturinelli DT, Marino CHL, Lamari MN.
Importance of pre- and post-operative physiotherapy in pediatric cardiac surgery.Revista
basilera cirurgia cardiovascular.2009; 24(7-9). Available from
URLhtt://www.scielo.php?pid=s0102-76382009000400021&script=sci-arttext&tlng…..
2. Soto T,kamoto KO, Danaga MS, Board J,McEniery J.High incidence of post-operative
pulmonary complications after orthotopic liver transplantation in children.Journal of
anesthesia.1993;8(3):274-6.
3. Gale GD, Sanders DE.The Bartlett-Edwards incentive spirometer: a preliminary assessment
of its use in the prevention of atelectasis after cardio-pulmonary bypass. Can Anaesth Soc J
1977; 24:408-416.
4. Overend JT, Anderson MC, Lucy DS, Bhatia C, Jonsson IB, Timmermans C.The effect of
incentive spirometry on post-operative pulmonary complications:A systematic
Review.Chest.2001;120;971-978.
5. Ward RJ,Danziger F, Bonica JJ,et al.An evaluation of post-operative respiratory maneuvers.
Surg Gynecol Obstet 1966; 123:51-54.

6. O’Donohue WJ Jr. National survey of the usage of lung expansion modalities for the
prevention and treatment of post-operative atelectasis following abdominal and thoracic
surgery. Chest 1985; 87:76-80.
7. Fung E.Psychosocial management of fear of needles in children.Haemophilia.2009;
15(3)635-636.URLhttp;//in.mc954.mail. Yahoo .com.
8. Hall CJ, Tarala R, Harris J, Tapper J , Christiansen K.Incentive spirometry versus routine
chest physiotherapy for prevention of pulmonary complications after abdominal surgery.The
Lancet.1991;337(4).
9. Thomas AJ, McIntosh MJ.are incentive spirometry intermittent positive pressure breathing,
and deep breathing exercises effective in the prevention of post operative
pulmonarycomplicationsAfterabdominalsurgery?URLhttp%3A%2F%2Fwww.geico.cm%2Fl
andingpage%2Fgo51.
10. Kulkarni SR, Fletcher E, McConnell AK, Poskitt KR, Whyman MR.Pre-operative
inspiratory muscle training preserves post-operative inspiratory muscle strength following
major abdominal surgery.
11. Chambers TC,Taddio A, Uman LS, et al.Psychological interventions for reducing pain and
respiratory ditress during routine childhood immunizations.Clinical
 therapeutics.2009;31(7)S77-S103.

12. Reeve JC, Nicol K, Stiller K, McPherson KM, Denehy L. Does physiotherapy reduce the
incidence of post-operative complications in patients following major abdominal surgery? A
protocol for a randomized controlled trial.J Cardiothorac Surg. 2008; 3:48.
9 SIGNATURE OF CANDIDATE

10 REMARKS OF THE GUIDE

NAME & DESIGNATION OF ( IN BLOCK LETTERS)

11

11.1 GUIDE MRS. G. CHITHRA,

PROFESSOR,
UNITY COLLEGE OF NURSING,
MANGALORE.
11.2 SIGNATURE

11.3 CO-GUIDE ( IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT MRS.G. CHITHRA,

PROFESSOR,
UNITY COLLEGE OF NURSING,
MANGALORE.
11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL

12.2 SIGNATURE