TELAAH JURNAL

Pengaruh Teknik Pernapasan Dalam terhadap Keparahan

Nyeri di antara Arteri Koroner Pasca Operasi Pasien Bypass
Graft

Disusun Oleh :

Ismi Nurina Sari

2011102412093

S1 KEPERAWATAN
UNIVERSITAS MUHAMMADIYAH KALIMANTAN TIMUR
2021
 TELAAH JURNAL
I. DESKRIPSI UMUM
No Item : -

1. Judul Jurnal : Pengaruh Teknik Pernapasan Dalam terhadap Keparahan

Nyeri di antara Arteri Koroner Pasca Operasi Pasien Bypass Graft
2. Penulis Jurnal : Shaimaa Mohamed Hany, Zinab Hussien Ali, Heba Abdel-
azeem Mostafa
3. Nama Jurnal/dipublikasikan oleh: www.noveltyjournals.com
4. Penelaah : Ismi Nurina Sari
5. Sistematika penulisan : Times new roman, ukuran 12, spasi 1,5. Judul penulisan,
Abstrak, Perkenalan, Tujuan Studi, Hipotesis Penelitian, Hasil, Pembahasan,
Kesimpulan, Refrensi
6. Referensi Daftar Pustaka :
1) Emmert, MY (2017): CABG di era PCI modern. European Heart Journal, 38 ( 26): 2029-2032.
2) Manzurul, AA, Ahmed, I., Ahmed, M. & Hossain, AL (2016): Hasil bypass arteri koroner di
luar pompa operasi graft (OPCAB): Analisis 129 kasus, Jurnal Jantung Bangladesh, 31 (1):
23-25.
3) Wilkins, E., Wilson, L., Wickramasinghe, K., Bhatnagar, P., Leal, J., Luengo-Fernandez, R., &
Townsend, N. (2017): Statistik penyakit kardiovaskular Eropa 2017. avb di: https: // scholar.
google.com.eg/scholar, diakses pada: 13-9-2018: 10 pagi.
4) Kang, S., & Brennan, TJ (2016): Mekanisme nyeri pasca operasi, Obat Anestesi dan Nyeri,
11 ( 3): 236- 248.
5) Solomen, S.Aaron, P. (2015): Teknik pernapasan - Ulasan, Jurnal Internasional Pendidikan
Jasmani, Olahraga Dan kesehatan 2 (2): 237-241.
6) Adelborg, K., Horváth-Puhó, E., Schmidt, M., Munch, T., Pedersen, L., Nielsen, PH, & Toft
Sørensen, H. (2017): Kematian tiga puluh tahun setelah operasi cangkok bypass arteri
koroner: studi kohort berbasis populasi nasional Denmark, Sirkulasi: Kualitas dan Hasil
Kardiovaskular, 10 (5): e002708.
7) Ajorpaz, NM, Mohammadi, A., Najaran, H., & Khazaei, S. (2014): Pengaruh musik pada nyeri
pasca operasi di pasien yang menjalani operasi jantung terbuka. Studi Keperawatan dan
Kebidanan, 3 ( 3): 2023.
8) Salama, S. , R. , (2006): efek teknik hubungan pada menghilangkan rasa sakit untuk pasien
perut pasca operasi Ain universitas shama (diterbitkan PBB).
9) Hinkle, JL, Cheever, KH, (2016): Brunner dan Suddarth's Text Book of Medical Surgical
Nursing. Philadelphia, Wolters Kluwer Health / Lippincott Williams & Wilkins, edisi ke-1318,
409-410.
10) Patra, S., Jena, M., Pande, A., Ghosh, D., & Chakraborty, RN (2017): Penilaian Bypass Arteri
Koroner Status Cangkok pada Pasien Gejala: Studi Observasional. J Bedah Toraks
Kardiovaskular, 2 (1): 1-4.
11) Ahmed, G., Mohammed, Z., & dan Ghanem, H. (2015): Pencangkokan bypass arteri koroner
'Efek berkembang dan menerapkan standar asuhan keperawatan pada hasil pasien. Jurnal
Ilmu Amerika, 11 (7): 181-188.
12) Pettersson, H., Faager, G., & Westerdahl, E. (2015): Peningkatan oksigenasi selama kinerja
berdiri dalam latihan pernapasan dengan tekanan ekspirasi positif setelah operasi jantung:
Uji coba terkontrol secara acak, Jurnal Pengobatan Rehabilitasi, 47 ( 8): 748-752.
13) Ünver, S., Kıvanç, G., & Alptekin, H. (2018): Pendidikan latihan pernapasan dalam menerima
dan melakukan status dari pasien yang menjalani operasi perut, Jurnal Internasional Ilmu
Kesehatan, 12 (4): 35-38.
14) Akca, NK, & Dogan, A. (2012): Manfaat kemampuan berolahraga rumahan pada pasien
dengan osteoartritis / Osteoartritli hastalarin evde egzersiz yapma ve yarar gorme
durumlari, Turki Jurnal Pengobatan Fisik dan Rehabilitasi, 58 ( 4) 288-294.
15) Ahmed, MA, Alaa Eldeen, SA, Youssef, HA, & Mohammed, MA (2015): Perbandingan efek
terapi konservatif dan botol tiup di antara pasien bedah jantung terbuka untuk pencegahan
komplikasi paru pasca operasi, Jurnal IOSR Ilmu Keperawatan dan Kesehatan, 4 (4): 42-55.
16) EL Mokadem, NM, & Ibraheem LM (2017): Aplikasi Dingin dan Latihan Pernapasan untuk
Mengurangi Nyeri dan Kecemasan Selama Pengangkatan Tabung Dada, Jurnal Ilmu
Keperawatan Amerika; 6 (4): 285-292.
17) Menache, CC, du Plessis, AJ, Wessel, DL, Jonas, RA, & Newburger, JW (2010): Insiden saat
ini dari komplikasi neurologis akut setelah operasi jantung terbuka pada anak-anak, The
Annals of thoracic operation, 73 ( 6): 1752- 1758.
18) Abd Elkreem, MH, Ragab, AM, & Sayed, NM, (2014): Pengaruh Latihan Pernapasan pada
Efisiensi Pernafasan dan Intensitas Nyeri pada Anak yang Menerima Kemoterapi, Jurnal
Pendidikan dan Praktek, 5 (6): 18-32.
19) Zubrzycki, M., Liebold, A., Skrabal, C., Reinelt, H., Perdas, M., & Zubrzycka, A. (2018):
Penilaian dan jalur fisiologi nyeri, Jurnal Penelitian Nyeri ( 11): 1599–1611.
20) Ghasemi, S., Darzi, H., & Ebad, A. (2017): Perbandingan Efek Aromaterapi dengan Mawar
dan Lavender tentang Parameter Fisiologis Pasien yang Menjalani Bedah Jantung Terbuka:
Uji Klinis, Crit Care Nurs J, 10 (2): e10029.
21) Stiller, K., Montarello, J., Wallace, M., Dajf, M., Grant, R., Jenkins, S., & Yates, H. (2010):
Khasiat latihan pernapasan dan batuk dalam pencegahan komplikasi paru setelah operasi
arteri koroner, Dada, 105 ( 3): 741-747.
22) Dehghani, MF, Ebadi, A., Ali, M., & Rahmani, H. (2016): Nyeri Pasca Operasi setelah Bypass
Arteri Koroner Bedah Cangkok: efek Relaksasi. AVA Kongres Bersama Kardiovaskular Iran
ke-4 di: https: // www.
researchgate.net/publication/301340543_Postoperative_Pain_after_Coronary_Artery_By
pass_Grafting_Surgery_eff ect_of_Relaxation Diakses pada: 25-10 - 2018: 12 am.
23) Maron, BA, Cockrill, BA, Waxman, AB, & Systrom, D., M. (2013): Latihan kardiopulmoner
invasif uji, Sirkulasi, 127 ( 10): 1157-1164.
24) Westerdahl, E., Lindmark, B., Eriksson, T., Hedenstierna, G., & Tenling, A. (2015): Latihan
pernapasan dalam mengurangi atelektasis dan meningkatkan fungsi paru setelah operasi
bypass arteri koroner. Dada, 128 ( 5): 3482-3488.
25) Coelho, LD, Fernando, SRC, & Hortense, P. (2014): Penilaian nyeri selama istirahat dan
selama aktivitas di periode pasca operasi bedah jantung Rev, Latino-Am. Enfermagem 22
(1): 136-43.
26) Mello, LCD, Rosatti, SFC, & Hortense, P. (2014): Penilaian nyeri selama istirahat dan selama
aktivitas di periode pasca operasi operasi jantung, Revista latino-americana de
enfermagem, 22 ( 1): 136-143.
27) Peter, M. (2011): Latihan dan anak-anak. Jurnal AORN, tersedia di: www.findarticles.com.
Diakses pada 30-8- 2018: 4pm.
28) Busch, V., Magerl, W., Kern, U., Haas, J., Hajak, G., & Eichhammer, P. (2012): Pengaruh
Dalam dan Lambat Pernapasan pada Persepsi Nyeri, Aktivitas Otonomi, dan Pemrosesan
Suasana Hati-Sebuah Studi Eksperimental, Obat Nyeri, l 13 (2): 215.
29) Lalehgani, H., Esmaili, S., Karimi, M., Moghni, M., & jivad, N. (2013): Efek sangat lambat dan
teratur bernapas pada intensitas nyeri dari balutan luka bakar, Perawatan Kritis, 6 (4): 229–
234.
30) Topcu, S., & Findik, U. (2012): Pengaruh latihan relaksasi dalam mengendalikan nyeri pasca
operasi, Manajemen Nyeri Perawatan, 13 (1): 11-7.
II. DESKRIPSI CONTENT :

No Komponen Jurnal Item Question to help “Telaah Jurnal”

1 Pendahuluan 1. Apa masalah penelitian?

 Peneliti mengemukakan bahwa teknik

relaksasi napas dalam merupakan cara non-
farmakologi seperti mengurangi rasa sakit
dan mengembalikan rasa nyaman
pengendaliaan nyeri penting untuk pemulihan
secara keseluruhan, meningkatkan kepuasan
pasien dan mengurangi biaya perawatan
kesehatan.

2. Seberapa besar masalah tersebut?

(Prevelensi/Insiden)
 Nyeri masih merupakan manifestasi utama
yang dilaporkan oleh pasien pasca operasi
jantung, kemungkinan penyebab terjadinya
yaitu kompikasi dan keterlambatan
pemulihan. Teknik pernapasan merupakan
metode yang saring digunakan sebagai
tindakan non-farmakologi untuk mengurangi
dan mengontrol rasa sakit/nyeri pasca
operasi.
3. Dampak masalah jika tidak di atasi?
 Resiko terjadinya keparahan pada nyeri
seperti nyeri kronik, komplikasi, dan
keterlambatan pemulihan.

4. Bagaimana kesenjangan yang terjadi? Bandingkan

antara masalah yang ada/kenyataan dengan
harapan/target?
 Studi menunjukkan bahwa daro 47% hingga
75% pasienmelaporkan nyeri pada priode
pasca operasi, dan insiden nyeri kronik pasca
operasi berkisaran antara 18% hingga 61%.
Sedangkan yang terjadi dilapangan
persentase pasien yang melaporkan nyeri
tajam 40%, gelisah 43,3% pasien nyeri 40%
dan meringis 40%.
 5. Berdasarkan masalah penelitian, apa tujuan dan
hipotesis yang ditetapkan oleh peneliti?
 Pada akhir penelitian ini pasien yang
menjalani CABG dan yang akan menerima
teknik pernapasan dalam akan mengalami
lebih sedikit rasa sakit setelah menerima
terknik pernapasan.

2 Metode

1. Desain penelitian apa yang digunakan?

 Desain Eksperimen

Untuk Desain Eksperimen:

a. Apakah menggunakan kelompok kontrol untuk
menentukan efektifitas suatu intervensi?
 Ya, karena untuk membandingkan
bagaimana pasien melakukan teknik
pernapasan dalam sebelum CABG dan untuk
mengevaluasi pasien melakukan teknik
pernapasan dalam setelah CABG.
b. Apakah peneliti melakukan random alokasi
(randomisasi)?
 Ya, karena penelitian ini mengambil 60
responden dari 2 jenis kelamin secara acak
dengan membagi 2 kelompok.

c. Jika peneliti melakukan randomisasi, bagaimana

prosedurnya, apakah dilakukan randomisasi
sederhana, blok, stratifikasi?
 Peneliti tidak menjelaskan

1. Desain Penelitian d. Jika ternyata pada data dasar (base line) terdapat
perbedaan karakteristik/variabel perancu pada kedua
kelompok, apakah peneliti melakukan pengendalian
pada uji statistik dengan stratifikasi atau uji
multivariate?
 Ya, menggunakan data karakteristik sosio
demografi

e. Apakah peneliti melakukan masking atau

penyamaran dalam memberikan perlakuan pada
responden (responden tidak menyadari apakah
 sedang mendapatkan intervensi yang diuji cobakan?
 Peneliti tidak menjelaskan dalam penelitian
ini

f. Untuk menjamin kualitas pengukuran, apakah

peneliti melakukan blinding saat mengukur
outcome? Blinding merupakan upaya agar sampel
atau peneliti tidak mengetahui kedalam kelompok
mana sampel dimasukkan (eksperimen atau kontrol).
Hal ini menunjukkan upaya peneliti meningkatkan
validitas informasi.
 Peneliti tidak menjelaskan dalam penelitian
ini

1. Siapa populasi target dan populasi terjangkau?

 Sample dari 60 pasien dawasa dari 2 jenis
kelamin

2. Siapa sampel penelitian? Apa kriteria inklusi dan

eksklusi sampel?
 Yang mengalami CABG
 Kriteria inklusi
a) Pasien dewasa dari kedua jenis kelamin yang
2. Populasi menjalani CABG
b) Sadar sepenuhnya.
c) Bebas dari narkotika
 Kriteria eksklusi
a) Pasien kanker.
b) Buka kembali dan Ulangi CABG.
c) Pasien mengeluh sakit kronis.
d) Pasien mengeluh sakit paru.

3. Bagaimana metode sampling yang digunakan

untuk memilih sampel dari populasi target?
 Purposif sampling

4. Berapa jumlah sampel yang digunakan dalam

penelitian? Metode atau rumus apa yang
digunakan untuk menentukan jumlah sampel?
 60 pasien dewasa dibagi menjadi 2 kelompok
 studi dan control yang sama (30 pasien untuk
setiap kelompok)

1. Variable apa saja yang diukur dalam penelitian?

 Teknik Pernapasan dalam dan nyeri

2. Metode apa yang digunakan untuk mengumpulkan

data?
 Purposif sampling

3. Alat ukur apa yang digunakan untuk mengumpulkan

data?
 Tiga alat yang di gunakan untuk
mengumpulkan data
a) Alat 1 :Wawancara lembar penilaian
pasien
b) Alat 2 : Lembar daftar periksa
pengamatan pasien
3. Pengukuran c) Alat 3 : Lembar penilaian nyeri dan ttv
atau
Pengumpulan 4. Bagaimana validitas dan rehabilitas alat
Data ukur/instrumen yang digunakan? Apakah peneliti
menguji validitas dan reliabilitas alat ukur? Jika
dilakukan apa metode yang digunakan untuk
menguji validitas dan reliabilitas alat ukur dan
bagaimana hasilnya?
 Validitas dilakukan untuk mengukur apakah
instrument yang diuji bisa digunakan, instrument
ini diuji oleh 5 orang ahli di bidangnya.
Reliabilitas studi data di periksa ulang selama
enteri untuk kelengkapan.

5. Siapa yang melakukan pengukuran atau

pengumpulan data? Apakah dilakukan pelatihan
khusus untuk observer atau yang melakukan
pengukuran?
 Sesuai dengan jurnal yang penelaah baca,
seluruh peneliti melakukan pengumulan dan
pengukuran data serta tidak ada pelatihan khusus

4. Analisis Data 1. Uji statistik apa yang digunakan untuk menguji

hipotesis atau menganalisis data?
 Analisis deskriptif
 2. Untuk penelitian eksperimen apakah peneliti
menggunakan metode intention to treat atau on
treatment analysis?
 Peneliti tidak mencantumkan dalam penelitian

a. Intention to treat adalah menganalisis semua

sampel yang megikuti penelitian, baik yang drop
out, loss follow up atau berhenti sebelum
penelitian selesai. Sampel yang drop out
dianggap hasil intervensi yang gagal.
 Peneliti tidak mencantumkan dalam
penelitian
b. On treatment analysis hanya menganalisis
sampel yang mengikuti penelitian sampai selesai
saja, sedangkan sampel drop out diannggap tidak
mengikuti penelitian dan tidak diikutkan dalam
analisis
 Peneliti tidak mencantumkan dalam
penelitian
3. Program atau software statistik apa yang digunakan
peneliti untuk menganalisis data?
 Spss software versi 18 di windows 7

3 Hasil

1 Bagaimana alur (flow) penelitian yang menggambarkan

responden yang mengikuti penelitian sampai selesai, drop
out dan loss follow up?
Alur Penelitian  Peneliti tidak mencantumkan dalam penelitian
dan Data Base
line
 2. Bagaimana karakteristik responden dan baseline data?
 Peneliti menjelaskan pasa karakteristik menggunakan
demografi untuk kelompok studi dan kontrol penilaian
praktik pasien mengenai teknik pernapasan dalam juga
dicantumkan olej peneliti dan penilaian nyeri untuk
kelompok belajar dan kelompok kontrol setelah
mempraktekkan teknik pernapasan setelah CABG.

3. Pada penelitian eksperiment apakah variabel perancu

(counfounding variable) dalam data base line tersebar
seimbang pada setiap kelompok? Jika tidak seimbang apa
yang dilakukan peneliti untuk membuat penelitian bebas
dari pengaruh variabel perancu?
 Peneliti tidak mencantumkan dalam penampilan

Hasil Penelitian 1. Apa hasil utama dari penelitian? Jika peneliti melakukan uji
hipotesis, apakah hipotesis penelitian terbukti atau tidak
terbukti ( bermakna atau tidak secara statistik )? Apakah
hasil penelitian juga bermakna secara klinis?
 secara statistik dalam keparahan nyeri di antara pasien
yang diteliti setelah menerapkan teknik pernapasan
dalam dari (7,1menjadi 4,07) di antara kelompok studi
setelah hari pertama, dan dari (5 hingga 1,5) sebelum dan
sesudah hari ke 2 hari praktik dengan p-value <0,001
tetapi peningkatan yang signifikan dalam intensitas
nyeri di antara kelompok kontrol dari (6,9) hingga (7.4)
dalam hari pertama dan dari (0,91 hingga 1) dalam hari
ke 2 dengan p-value <0,003, Juga, ada rata-rata tingkat
keparahan nyeri rendah yang signifikan secara statistik
pada kelompok studi setelah hari pertama , dan sebelum
dan sesuda hari ke 2 latihan

2. Untuk penelitian eksperimen dengan variabel dependen

kategorik apakah peneliti menjelaskan tentang nilai
kepentingan klinis dari hasil penelitian seperti number need
to treat (NTT), relative risk reduction (RRR) atau absolute
risk reduction (ARR)
 Peneliti tidak mencantumkan dalam penampilan
4 Diskusi

1. Bagaimana interpretasi peneliti terhadap hasil

penelitian? Apakah peneliti membuat interpretasi
yang rasional dan ilmiah tentang hal-hal yang
ditemukan dalam penelitian berdasarkan teori
terkini? Catatan: meskipun hasil penelitian tidak
sesuai dengan hipotesis, namun suatu penelitian
tetap berkualitas jika peneliti mampu menjelaskan
rasional secara ilmiah mengapa hipotesisnya tidak
terbukti.
 Bagian 1 : Karakteristik sosio demografis
dan lembar data medis dari sempel peneliti.
Mayoritas dasi responden adalah laki-laki
sama seperti penelitian terdahulu oleh
Patra.S et all yang menegaskan bahwa
hampir setengah dari pasien penelitian
dominan laki-laki
 Bagian 2 : Pasien berlatih tentang teknik
pernapasan dalam.
Ada peningkatan yang signifikan secara
statistik pada sesi skor Praktis dengan tingkat
kepuasan tinggi pada sesi ketiga di antara
kelompok studi. Temuan ini konsisten
dengan ( 13) yang melakukan "pendidikan
latihan pernapasan dalam menerima dan
melakukan status pasien yang menjalani
operasi perut" di Turkya, menekankan
bahwa, salah satu temuan terpenting dari
penelitian ini adalah bahwa korelasi positif
yang kuat ditemukan antara menerima
pendidikan dan melakukan latihan.
 Bagian 3 : Penilaian nyeri sebelum dan
sesudah latihan untuk kedua kelompok
belajar dari hari pertama dan kedua
 Bagian 4: Pasien berlatih tentang teknik
pernapasan dalam setelah CABG
Tentang evaluasi skor latihan untuk teknik
nafas dalam setelah CABG di 1 st dan 2 nd
hari di antara kelompok studi penelitian ini
menggambarkan bahwa ada perbedaan yang
signifikan secara statistik antara skor praktik
dengan tingkat kepuasan tinggi skor praktik
di 2 nd hari di antara kelompok I versus di 1
st hari. Hasil ini menggambarkan tingkat
pelatihan pasien yang baik tentang teknik
 pernapasan dalam.
 Bagian 5 : Tingkat keparahan nyeri pada
kelompok studi yang berbeda
Dalam penelitian ini peneliti melaporkan
perbedaan yang signifikan antara kelompok
studi dan kontrol dalam hal tingkat
keparahan nyeri sebelum dan sesudah
prosedur di hari pertama dan hari ke dua.

2. Bagaimana peneliti membandingkan hasil

penelitiannya dengan penelitian-penelitian
terdahulu serta teori yang ada saat ini untuk
menunjukkan adanya relevansi?
 Peneliti membandingkan penelitian dengan
penelitian sebelumnya melihat hasil distribusi
frekuensi.

3. Bagaimana peneliti menjelaskan makna dan

relevansi hasil penelitiannya dengan perkembangan
ilmu keperawatan/kesehatan serta terhadap
pemecahan masalah?
 Dalam penelitiain ini perawat dapat
mengajarkan pasien untuk melakukan teknik
pernapasan dalam untuk mengurangi nyeri
pasca operasi,

4. Bagaimana nilai kepentingan (importancy) hasil

penelitian?

 Temuan dari penelitian ini menunjukan bahwa

keparahan kelompok nyeri kelompok kontrol
dalam 1 hari setelah CABG dengan presntasi
nyeri ringan yang tinggi (43,3%), Untuk
presentase nyeri berat (88,7%). setelah
menerapkan teknik pernapasan rata-rata tingkat
keparahan nyeri rendah yang signifikan secara
statistik pada kelompok studi setelah 1 hari, dan
sebelum dan sesudah 2 hari latihan

5. Bagaimana applicability hasil penelitan menurut

peneliti? Apakah hasil penelitian dapat diterapkan
pada tatanan praktik keperawatan ditinjau dari
aspek fasilitas, pembiayaan, sumber daya manusia,
dan aspek legal?
  Teknik pernapasan dalam adalah teknik
perawatan yang aman, murah, dan non-
farmakologis yang efektif untuk mengurangi
keparahan nyeri setelah CABG. DBS yang
dapat direkomendasikan sebagai teknik pereda
nyeri setelah CABG.
6. Apakah mungkin penelitian ini direplukasi pada
setting pratik klinik lainnya?

 Peneliti merekomendasikan menerapkan teknik

pernapasan dalam untuk pasien yang menjalani
CABG dengan mengajarkan teknik sebelum
operasi dan menerapkannya setelah operasi
sebagai perawatan rutin dan teratur untuk
mengurangi timbulnya nyeri yang terkait
dengan operasi.
7. Apakah peneliti menjelaskan kekuatan dan
kelemahan penelitian? Apakah kelemahan ini tidak
menurunkan validitas hasil penelitian?
 Peneliti tidak menjelaskan kelemahan dan
kekuatan dalam penelitian ini.
 ISSN 2394-7330
International Journal of Novel Research in Healthcare and Nursing
Vol. 6, Issue 2, pp: (32-46), Month: May - August 2019, Available at: www.noveltyjournals.com

Effect of Deep Breathing Technique on severity

of Pain among Postoperative Coronary Artery
Bypass Graft patients
Shaimaa Mohamed Hany, Zinab Hussien Ali *, Heba Abdel-azeem Mostafa **
Demonstrator at Critical and Emergency Nursing, Faculty of Nursing Fayoum University, Professor of Medical Surgical
Nursing, Faculty of Nursing Helwan University*, Lecturer of Medical Surgical Nursing, Faculty of Nursing Fayoum
University**

Abstract: Coronary artery bypass grafting (CABG) is the most common kind of heart surgery. Good pain control
after surgery is important to facilitate overall recovery, improve patient satisfaction, and reduce health care cost.
Deep breathing technique is a non-pharmacological way to counteract the negative effects of surgery as reducing
pain, and to refocus attention away from uncomfortable events. Aim of the study: To determine the effect of deep
breathing technique on severity of pain among postoperative coronary artery bypass graft patients. Research
design: A quasi-experimental design was utilized. Setting: The study was conducted in the cardio-thoracic intensive
care unit at Fayoum University Hospitals. Methods: A purposive sample of 60 adult patients from both genders
who were randomly and alternatively divided into two equal groups study and control (30 patients in each). Tools:
data collection tool included: Interview patient’s assessment sheet, patient observational checklist sheet, pain
assessment and vital signs. Results: The study revealed that there was a significant difference in decrease of pain
severity among study group after implementing the deep breathing technique. Conclusion: the application of deep
breathing technique for CABG patients is effective in decreasing severity of pain. Recommendations: Apply the deep
breathing technique for each patient undergoing CABG.
Keywords: Coronary artery bypasses graft, Deep breathing technique, Pain.

1. INTRODUCTION
Coronary artery bypass grafting (CABG) since its introduction in the 1960s has rapidly become the standard of care for
patients with multi vessel coronary artery disease (1). Thousands of heart surgeries are performed every day in the United
States. In recent years, surgeons performed five hundred thousand coronary bypass procedures. This is the most common
kind of heart surgery, also called coronary artery bypass graft surgery (CABG),coronary artery bypass (CAB), coronary
bypass, or bypass surgery. CABG surgery in an effective modality for the management of a subset of CAD patient (2).
The surgery involves using a healthy section of blood vessel from another part of the body to bypass a part of a diseased
or blocked coronary artery. This creates a new route for blood to flow so that the heart muscle will get the oxygen-rich
blood it needs to work properly to improve the quality of life, the pumping action of heart, and the chance of survival so
that the results of CABG are usually excellent. The surgery improves or completely relieves symptoms in most patients
(3).
Management of acute postoperative pain is an essential component of perioperative patient care. Good pain control after
surgery is important to facilitate overall recovery, improve patient satisfaction, and reduce health care cost. Effective
postoperative pain management is also likely to decrease morbidity and improve functional outcome. Moreover, severe
acute postoperative pain is a risk factor for chronic postsurgical pain, raising more awareness regarding the importance of
adequate perioperative pain management, despite heightened awareness and clinical advancements in pain management
postoperative pain continues to be a significant clinical problem (4).

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Deep breathing technique can be defined as the most frequently method used from non-pharmacological interventions
during a painful procedure and the therapeutic intervention by which purpose full alteration of a given breathing pattern is
categorized as breathing exercises. Outcomes have ranged from relaxes to calms due to influence on parasympathetic
nervous system, reduces and prevents the build-up of toxins in the lungs by encouraging the clearing of the small air sacs
(alveoli), increase lung volume, to clear secretions, to improve gas exchange, to control breathlessness, to increase
exercise capacity, to reduce blood pressure, to reduce obesity, relaxation response for stress reduction and to control pain
(5).
Significance of Study:
Pain is still the main manifestation reported by patients who undergo cardiac surgery, possibly accounting for
complications and delays in recovery. Studies show that from 47% to 75% of patients report pain in the postoperative
(PO) period of cardiac surgery. Untreated acute pain may become chronic pain. The incidence of post-sternotomy chronic
pain ranges from 18% to 61% in different samples (6).
Coronary artery bypass graft (CABG) surgery is one of the most frequently performed cardiac surgery procedures
worldwide that improves blood flow to the heart. It is used for people who have severe coronary heart disease. The
prevalence of CABG is 26.79% in North America, 0.72% in Asia, 17.94% in Western Europe and 18.14% in the rest of
the world. In Iran, 60% of all open-heart surgeries are CABGs (7 ) .
2. AIM OF THE STUDY
The aim of the present study was to determine the effect of deep breathing technique on the severity of pain among
postoperative coronary artery bypass graft patients through the following objectives:-
1. Assess patients practice regarding the deep breathing technique.
2. Implement deep breathing technique for patients undergoing CABG.
3. Evaluate the effect of implemented deep breathing technique on the severity of pain among postoperative CABG
patients.
3. THE RESEARCH HYPOTHESIS
At the end of the study patients undergoing CABG and who will receive deep breathing techniques will experience less
pain after receiving deep breathing techniques as measured by (pain scale).
Design:
A Quasi-experimental research design was utilized in this study.
Setting:
This study was carried out at the cardio-thoracic intensive care unit at Fayoum University Hospital.
Subjects:
A purposive sample of 60 adult patients from both genders undergoing CABG were involved in this study from the above
mentioned setting and divided into two equal study and control groups (30 patients for each group).
Inclusion criteria:
1. Adult patients from both gender undergoing CABG.
2. Fully conscious.
3. Extubated form mechanical ventilator (1st day after extubation).
4. Free from narcotics.
Exclusion criteria:
1. Cancer patients.
2. Re open and Redo CABG.
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3. Patients complaining from chronic pain.

4. Patients complaining from pulmonary problem.
Tools for Data Collection:
Three tools were used to collect the data according to the following:
Tool (I): Interview Patient’s assessment sheet :
It is an interview administered sheet that was adapted form (8) and the investigator makes some changes to be suitable for
the present study and consists of the following three parts that were filled by the investigator:
The socio demographic characteristic and medical data of the patient
The medical and surgical history of the patient
The life style of the patient and consists of the three parts: smoking, nutrition status and physical activity.
Tool (II): Patient Observational Checklist Sheet:
It was developed by the investigator based on literature review (9) and used to assess patient how to perform deep
breathing technique before CABG and evaluate patient practice how to perform deep breathing technique after CABG.
Tool(III) : Pain assessment and vital signs sheet :
It’s administered sheet which was adapted form (8) and consist of the following two parts:
Part A:
Pain assessment pre and post deep breathing technique : It was used two time to assess pain characteristic after 24 h from
CABG hour one before and two hour after application of deep breathing technique, including the following items
location of pain, pain severity, pain quality, pain pattern, pain expression, factor aggravated, factor alleviated, type of
analgesic, duration of last analgesic taken before practice and post application of deep breathing technique the same tool was
used to assess pain including all the previous items except Factor aggravated, Factor alleviated, type of analgesic, duration
of last analgesic taken before practice .
Part B : Vital signs sheet:
It used to assess patient vital sings two times before and after deep breathing technique to detect the effect of pain on
patient and including (temperature, pules, respiration and blood pressure).
Operational design
The operational design includes preparatory phase, content validity of the modified tool and reliability, pilot study and
fieldwork.
Validity:
Content validity was conducted to determine whether or not the instrument measures what it is designed to measure. The
tools were revised by a jury of 5 experts as the following ; Lecturer of medical surgical nursing from faculty of nursing
Fayoum University, assistant professor of cardio thoracic surgery department from faculty of medicine Fayoum
University, professor of medical surgical nursing from faculty of nursing, Ain shams University, lecturer of critical and
emergency nursing from faculty of nursing, Cairo University, and assistant professor of critical and emergency nursing
from faculty of nursing Cairo University, who reviewed the content of the tools for comprehensiveness, accuracy, clarity,
relevance and applicability. Minor modifications were done.
Reliability:
Reliability of the tool was tested to determine the consistency of the measurement instrument. The degree to which an
instrument measures the same way each time if used under the same condition with the same subjects. The Cronbach’s
alpha model, which is a model of internal consistency, was used to test tool reliability. Reliability factor of the second tool
observational checklist was 0.843 and third tool pain assessment was 0.793 Statistical equation of Cronbach’s alpha
reliability coefficient normally ranges between 0 and 1; higher values more than 0.7 denote acceptable reliability.
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Pilot study:
A Pilot study was carried out with 10% (10 patients) of the sample under study to test the applicability, clarity and
efficiency of the tools, then the tools modified according to the results of the pilot study, patients who shared in pilot
study were not included in the sample and replaced by other patients.
Administrative design:
An official permission was obtained from the director of Fayoum University Hospital and head of cardio thoracic ICU
unit, in which the study was conducted. A letter was issued to them from the faculty of nursing; Helwan University
explains the aim of the study for obtaining the permission for data collection.
Ethical consideration:
An approval was obtained from a scientific research ethics committee of the faculty of nursing at Helwan University and
oral informed consent was obtained from the study subjects individually before starting the study. The aim and objectives
of the study was clarified to the patients included in the study by the investigator. Participants were assured that
anonymity and confidentiality would guarantee. Patients were informed that they are allowed to choose to participate or
withdraw from the study at any time. Ethics, culture, values were respected.
Field work includes three phases:
I-First phase (Assessment phase):
During this stage each patient was assessed individually and data collection was filled by the investigator in the morning
and afternoon shifts one day before CABG by using tool I interview patient assessment sheet was filled for the study and
control group by the investigator before CABG. It took around 5-10 minutes for each patient.
II-Second phase (Implementation phase):
Based on the basic assessment, the deep breathing technique was implemented for each patient in 5 sessions by using tool
II: patient were observed while performing deep breathing technique using observational checklist sheet was filled for the
study group by the investigator before and after CABG as following:
A- First 24 hour before CABG:
During the day the investigator gave each patient 3 sessions, each session took 2 hours by using brochure, picture and
video and at the end of the each session was evaluated as following:
First session:
The investigator divided this session into two parts. It started by theoretical part which included (what is the deep
breathing technique, importance and uses) and take hour followed by practical part which included (teaching patient how
to performing deep breathing technique and performing it) and take hour and at the end of this session was evaluated.
Second and third session:
In this session the investigator repeated practical part which included (teaching patient how to performing deep breathing
technique and performing it) and take 2hour for each session and at the end of this sessions the patient’s was evaluated.
B- First and second day after CABG:
During this phase the investigator was provided only one session to each patient in every day, each session had taken 2
hour started by pain assessment before practice for each patient by using tool (III).
Fourth and fifth session:
To assess the effect of deep breathing technique on severity of pain after CABG by using tool (II) and tool (III) after
practice as the following technique:
1- The investigator started to assess patient's condition: the patient must be alert, fully conscious extubated from
endotracheal tube and able to communicate with investigator.
2- The investigator started to assess patient's pain level before intervention.
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3- Ask patient to start deep breathing technique after patient placed in the sitting so that chest is upright position and the
feet are on the floor, and arms are resting on over bed table or High fowler's position with head supported on pillow, with
legs slightly flexed, and relax neck and shoulder.
4- The investigator observed patient during inspiration, how to use his/ here hands, how to exhale.
5- The patient repeats the steps until evaluating the effectiveness of the breathing technique.
IV-Third phase (Evaluation phase):
According to nursing process; the evaluation occurred through two phase:
1- First phase: 24 hour before surgery at the end of each learning session.
2- Second phase: First and second day after CABG to evaluate the effectiveness of the breathing technique on severity of
Pain.
Statistical Analysis
 Data were collected and coded to facilitate data manipulation and double entered into Microsoft Access and data
analysis was performed using Statistical Package of Social Science (SPSS) software version 18 in windows 7.

 Simple descriptive analysis in the form of numbers and percentages for qualitative data, and arithmetic means as
central tendency measurement, standard deviations as measure of dispersion for quantitative parametric data.

 Quantitative data included in the study was first tested for normality by One-Sample Kolmogorov-Smirnov test in
each study group then inferential statistic tests were selected.
- For quantitative parametric data:
 In-depended student t-Test used to compare measures of two independent groups of quantitative data
 Paired t-test in comparing two dependent quantitative data.
- For qualitative data
 Chi square test to compare two or more than two qualitative groups.
 Mc-Nemar test for paired dependent qualitative data.
- Bivariate Spearman correlation test to test association between quantitative non-parametric variables.
- General linear model to compare repeated measures

 The P-value ≤ 0.05 was considered the cut-off value for significance.

4. RESULTS
Table (1): Socio demographic characteristic for both study and control group (N=60):

Study
Socio demographic Control Group
Group t-test p-value
characteristic (N=30)
(N=30)
Age (years)
Mean ±SD 44 ± 7.2 42.4 ± 8.8 0.8 0.4
Gender X2- test p-value
Male 21 70% 18 60%
0.7 0.6
Female 9 30% 12 40%
Level of education
Illiterate 4 13.3% 3 10%
Primary 1 3.3% 7 23.3% 8.3 0.08
Preparatory 3 10% 3 10%
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Secondary 14 46.7% 15 50%

University 8 26.7% 2 6.7%
Occupation
Not working 15 50% 13 43.3%
Worker 9 30% 13 43.3% 1.3 0.5
Employer 6 20% 4 13.4%
Statistical significant p-value ≥0.05
Table (1) above illustrates that; there is no statistically significant difference with p-value >0.05 between study and
control groups as regards Socio demographic characteristic with mean age of study group (44±7.2)versus(42.4±8.8)
among control group, also majority of both groups were male. As regards level of education the majority of both groups
were secondary level and occupation level show half of study group and near half of control group not working.
Table (2): Assessment of patients practice regarding the deep breathing technique before CABG for study group (N=30):

Study Group
Practical score (N=30)
Not satisfactory Satisfactory
Session 1 21(70%) 9(15%)
Session 2 9(30%) 21(70%)
Session 3 3(10%) 27(90%)
X2-test 7.8
p-value <0.001**
*statistical significant p-value ≤0.05
Table (2) above illustrates that there is highly statistically significant difference with p-value <0.001 between practical
score sessions with high percentage of patient (90%) had satisfactory level of practical score at the third session among
study group versus (15%) in first session.
Table (3): Basic pain assessment before deep breathing technique for both study and control group in the 1 st day post CABG
(N= 60):

Study Group Control Group

Variables (N=30) (N=30) X2-test p-value
No. % No. %
Location of pain
Chest 30 100% 30 100% --- ----
Pain severity
Moderate 9 30% 11 36.7%
0.3 0.8
Sever 21 70% 19 63.3%
Pain quality
Pulling 5 16.7% 0 0%
Aching 10 33.3% 12 40%
7.6 0.05*
Burning 3 10% 8 26.7%
Sharp 12 40% 10 33.3%
Pain pattern
Constant 18 60% 13 43.3%
1.7 0.3
Intermittent 12 40% 17 56.7%
Intermittent pain
Periodic 12 100% 16 94.1%
0.73 0.9
Momentary 0 0% 1 5.9%
Pain expression
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Grimacing 3 10% 12 40%

Moaning 8 26.7% 8 26.7%
Crying 2 6.7% 3 10% 9.9 0.04*
Restlessness 13 43.3% 6 20%
Protecting 4 13.3% 1 3.3%
*statistical significant p-value ≤0.05
Table (3) illustrates that; there is no statistically significant difference with p-value >0.05 between study and control
groups as regards location of pain, pain severity, pain pattern, and its intermittency before practice, On the other hand
there is statistically significant difference as regards pain quality and expression, with high percentage of patients reported
sharp (40%) and restlessness pain (43.3%) among study group, and high percentage of patients reported aching pain
(40%) and grimacing (40%) among control group before practice with p-value <0.05, 0.04 respectively.
Table (4): Pain assessment for the study and control group after practicing deep breathing technique by the study group in the
1st day after CABG (N =60):

Study Group Control Group

Variables (N=30) (N=30) X2-test p-value
No. % No. %
Location of pain
Chest 30 100% 30 100% ----- ----
Pain quality 2hr
NO 1 3.3% 0 0%
Discomfort 13 43.3% 0 0%
Pulling 6 20% 0 0%
Aching 5 16.7% 12 40% 33.02 <0.001**
Burning 0 0% 8 26.7%
Sharp 5 16.7% 9 30%
Crushing 0 0% 1 3.3%
Pain pattern
No 1 3.3% 0 0%
Constant 10 33.3% 22 73.3% 9.9 <0.001**
Intermittent 19 63.3% 8 26.7%
Intermittent pain
Periodic 15 78.9% 8 100%
0.3 NS
Momentary 4 21.1% 0 0%
Pain expression
NO 1 3.3% 0 0%
Grimacing 6 20% 3 10%
Moaning 3 10% 9 30%
26.9 <0.001**
Crying 3 10% 8 26.7%
Restlessness 1 3.3% 9 30%
Protecting 16 53.3% 1 3.3%
*statistical significant p-value ≤0.05
Table (4) illustrates that; there is no statistically significant difference with p-value >0.05 between study and control
groups as regards location of pain and intermittence after practice, On the other hand, there is highly statistically
significant difference as regards pain quality and expression and pain pattern with high percentage of patient report
discomfort (43.3%, 40 %) respectively of quality of pain in study and control group, protecting manner expression (53.3%
) in study but moaning and restlessness (30%) in control group with p-value <0.001, 0.001 and 0.001respectively.
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Pain severity after Practical in different study

groups 86.7%
80%

60%
43.3%
40% 33.3%
20%
20% 13.3%
3.3% 0%
0%
0%
No pain Mild Moderate Sever
Study group Control group

Figure (1): Pain severity after practicing deep breathing technique by the study group after CABG in the 1 st day among study
and control group.

Figure (1) shows that percentage of pain severity after Practical in different study and control group in the 1 st day after
CABG with high percentage of mild pain (43.3%) in study group, but high percentage of severe pain (86.7%) in control
group.
Table (5): Basic pain assessment before practicing deep breathing technique for both study and control group in the 2 nd day
after CABG (N= 60):

Study Group Control Group

Variables (N=30) (N=30) X2-test p-value
No. % No. %
Location of pain
Chest 30 100% 30 100% --- ----
Pain severity
Moderate 28 93.3% 23 76.7%
3.3 0.2
Sever 2 6.7% 7 23.3%
Pain quality
Discomfort 5 16.7% 1 3.3%
Pulling 11 36.7% 6 20%
Aching 12 40% 15 50%
9.04 0.1
Burning 1 2.3% 6 20%
Sharp 1 3.3% 1 3.3%
Stapping 0 0% 1 3.3%
Pain pattern
Constant 3 10% 12 40%
9.9 0.007**
Intermittent 27 90% 18 60%
Intermittent pain
Periodic 25 92.6% 17 94.4%
4.5 0.7
Momentary 2 7.4% 1 5.6%
Pain expression
Grimacing 6 20% 3 10%
Moaning 8 26.7% 15 50%
Crying 0 0% 2 6.7% 7.9 0.09
Restlessness 9 30% 8 26.7%
Protecting 7 23.3% 2 6.7%
*Statistical significant p-value ≤0.05
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Table (5) above illustrates that there is no statistically significant difference with p-value >0.05 between study and control
groups as regards pain characters (severity, quality, intermittency and expression). But there is statistically significant
difference with p-value > 0.007 regarding pain pattern.
Table (6): Pain assessment for the study and control group after practicing deep breathing technique by the study group in 2 nd
day after CABG (N = 60):
Study Group Control Group
Variables (N=30) (N=30) X2-test p-value
No. % No. %
Location of pain
Chest 30 100% 30 100% ---- -------
Pain quality 2hr
NO 15 50.3% 0 0%
Discomfort 10 33% 1 3.3%
Pulling 2 6.7% 8 26.7%
40.2 <0.001**
Aching 2 6.7% 13 43.3%
Burning 0 0% 6 20%
Sharp 1 3.3% 2 6.7%
Pain pattern
NO 15 50% 0 0%
Constant 4 13.3% 20 66.7% 25.7 0.03*
Intermittent 11 36.7% 10 33.3%
Intermittent pain
Periodic 2 18.2% 10 100%
14.3 <0.001**
Momentary 9 81.8% 0 0%
Pain expression
NO 15 50% 0 0%
Grimacing 3 10% 3 10%
Moaning 1 3.3% 6 20%
39.1 <0.001**
Crying 1 3.3% 0 0%
Restlessness 0 0% 17 56.7%
Protecting 10 33.4% 4 13.3%
*Statistical significant p-value ≤0.05
Table (6) illustrates that there is highly statistically significant difference as regarding pain quality and expression and
pain pattern, and its intermittency with high percentage no quality of pain after second hour (50%) and aching quality
(43.3%) intermittent momentary pain in pattern( 81,8% ) . NO and protecting expression (50%, 56, 7%) respectively were
noticed among study and control group after the practice in the 2nd day with p-value <0.001, 0.03, 0.001and 0.001
respectively.

Pain severity after practicing in different

60%
46.7% study groups 53.3% 46.7%
40%
40%

20%
6.7% 6.7%
0% 0%
0%
No pain Mild Moderate Sever
Study group Control group

Figure (2): Pain severity after practicing deep breathing technique by the study group after CABG in the 2 nd day among study
and control group.
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Figure (2) shows that percentage of pain severity after Practical in different study and control group in the 2 nd day after
CABG with high percentage of no pain (46.7) mild pain (40%) in study group, but high percentage of moderate pain
(53.3%) and sever pain (46.7%) in control group.
Table (7): The evaluating of Practice score for deep breathing technique after CABG in 1st and 2nd day among study group (N
=30):

Study Group
Practice score (N=30)
Not satisfactory Satisfactory
Day 1 6(20%) 24(80%)
Day 2 2(6.7%) 28(93.3%)
X2-test 8.6
p-value 0.03*
*Statistical significant p-value ≤0.05
Table (7) above illustrates that there is a statistically significant difference between number of patient with Satisfactory
level of practice score at the second day among group (93.3%) versus (80%) in first day with p-value <0.03.
Table (8): Comparison between study and control regarding pain severity before and after practice in 1 st and 2nd day after
CABG (N= 60):

Pain Study Group Control Group

severity (N=30) (N=30) t-test p-value
score Mean ± SD Mean ± SD
in the 1st day
Before 7.1± 1.1 6.9 ±1.1 0.47 0.6
After 4.07 ± 2.2 7.4 ± 0.89 -7.6 <0.001**
t-test 9.6 -3.2
p-value <0.001* 0.003*
in the 2nd day
Before 5 ± 0.9 5.7 ± 0.91 -2.8 0.006**
After 1.5 ± 2.2 6.3 ± 1 -10.7 <0.001**
t-test 4.1 -3.2
p-value <0.001** 0.003**
*statistical significant p-value ≤0.05
Table (8) above illustrates that; there is no statistically significant difference with p-value >0.05 between study and
control groups as regards pain severity before the procedure.
On the other hand there is highly statistically significant decrease in pain severity among studied patient after
implementing deep breathing technique from (7.1 to 4.07) among study group after 1 st day, and from (5 to 1.5) before and
after 2nd day of practice with p-value <0.001 but significant increase in pain intensity among control group from (6.9 to
7.4) in 1st day and from (0.91 to 1) in 2 nd day with p-value <0.003, Also, there is a statistically significant low mean of
pain severity in study group after 1st day, and before and after 2nd day of practice.

5. DISCUSSION
Part 1: The socio demographic characteristic and medical data sheet of the study sample
The present study showed that less than half of studied patients study and control groups were between 42.4 and 44 years.
The majorities of them were male and completed secondary education and not work. No one of them made any types of
physical activity and not drink alcohol which indicated proper matching between two groups in these variables and the
result of the study which indicated there was no significant difference between study and control group regarding socio
demographic characteristic that indicate the only effect was detected that result the provided nursing intervention (deep
breathing technique).
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These findings were supported by (10) who conducted " Assessment of Coronary Artery Bypass Grafts Status in
Symptomatic Patients: An Observational Study" confirmed that, Almost half of the study patients belonged to age group
of 65 years or less with a male predominant population. Also (11) who conducted "Coronary artery bypass grafting, Effect
of developing and implementing nursing care standards on patient’s outcomes" in Egypt reported that, In relation to
educational level, more than half of the patients were illiterate, as regards their occupation, the current study revealed that
about one-third of patients were farmer; also reported that physical activity and loading, such as lifting heavy objects can
cause exceptional angina.
In accordance with present study (12) who conducted "improved oxygenation during standing performance of deep
breathing exercises with positive expiratory pressure after cardiac surgery" reported that, No significant differences were
found between the two groups in terms of demographic or surgical data. All patients fulfilled the protocol as planned and
were included in all statistical analyses.
Part 2: Patients practice regarding the deep breathing technique
There is statistically significant improvement in Practical score sessions with high satisfactory level at the third session
among study group. These findings were consistent with (13) who conducted "Deep breathing exercise education
receiving and performing status of patients undergoing abdominal surgery" in Turkya, emphasized that, one of the most
important findings of this study was that a strong positive correlation was found between receiving education and
performing exercises.
On the same line, (14) who conducted "Benefits of home-based exercising ability in patients with osteoarthritis/
Osteoarthritis" in Turkya, one of the reasons of not performing regular exercises was found to be the lack of information
and the possibility of performing exercises was found to be 7.96 times greater among patients who received information
about exercises than among those who did not. This means, patients’ practice was improved due to follow instruction of
investigator step by step and performing practice positively.
Part 3: Basic pain assessment before and after practice for both study group in 1st day and 2 nd day
Regarding pain assessment, the basic pain assessment before practice for both study groups in the first day showed that,
there is no statistically significant difference between study and control groups as regards location of pain, pain severity,
pain pattern, and its intermittency before practice. On the other hand there is statistically significant difference as regards
pain quality and expression, with high percentage of sharp and restlessness pain among study group, and high percentage
of aching pain and grimacing pain among control group before practice, but after implementation deep breathing
technique study group show improvement in pain severity to be mild, with discomfort quality, periodic intermittent
pattern, and protecting expression.
But as regards pain assessment in the 2nd day before practice deep breathing technique there was no statistical significance
change in pain characters in both groups. Study group show significant improvement after implementation of deep
breathing technique after CABG in 2nd day in all pain characters (severity, quality, pattern, and intermittency, and
expression), with more than have of them show no pain at all; versus higher percentage of control group complain
moderate pain, aching quality, with constant pattern, and restlessness expression .These results confirmed the positive
effect of practice deep breathing technique on pain alleviation and improving pain characters.
On the same line (15) who conducted "Comparison the effect of conservative therapy and blow bottle among open heart
surgery patients for the prevention of post-operative pulmonary complications" showed that, regarding to postoperative
pain it was noticed by using numerical scale that statistical significant difference was found between the two groups
regarding pain while coughing.
This finding was in accordance with (15) emphasized that, distribution of sample according to Postoperative pain using
numerical scale after routine deep breathing exercise and chest physiotherapy (by blow bottle) for post-operative cardiac
surgery. It was noticed that statistical significant difference was found between the two groups regarding to pain. In this
respect, (16) who conducted " Cold Application and Breathing Exercises to Reduce Pain and Anxiety during Chest Tube
Removal" in Egypt, showed that there was a high statistically significant difference in pain intensity immediately, 15 and
30 minutes after chest tube removal between studied and control groups post intervention.

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This result matched with a study conducted by (17) who conducted "Current incidence of acute neurologic complications
after open-heart operations in children" who found that, physical exercises and changing position have profound positive
effect on severity of pain, respiratory pattern, and oxygen saturation. Also in the same direction (18) who conducted
"Effect of Breathing Exercise on Respiratory Efficiency and Pain Intensity among Children Receiving Chemotherapy" in
Egypt, illustrated the positive effect of deep breathing exercise on the decrease the pain score after more breathing
exercise.
Regarding factors affecting pain before practice in the 1 st and 2nd days of both study and control groups; the present study
showed that more than half of study and control group reported that movement aggravated pain. Also there were
statistically significant relations between study and control group as regard factors alleviated pain as lower percentage of
study group depend on analgesic in comparison to control group, on 2 nd day the control group need more analgesic; study
group show longer duration of last analgesic so they need less analgesic.
In this respect (19) who conducted "Assessment and path physiology of pain" emphasized that, the most severe pain was
associated with coughing, movements, turning around, getting up from bed. Although pain scores were high immediately
after the operation, the mean pain score reported by the patients when coughing and on the sixth day after the surgery was
decreased.
Assessment of vital signs before practice for both study groups in the 1 st day, there is slight elevation of blood pressure
and normal range for temperature, pulse and respiration with no statistically significant difference between study and
control groups but after practice deep breathing technique in the 1st day all vital signs were statistically decreased but
within normal rage among study group. In 2 nd day before practice deep breathing only pulse was statistically decreased
among study group, and after practice the technique in the 2nd day all vital signs were statistically decreased among study
group. These results illustrated the positive effect of practice deep breathing technique on pain control through making
patient feel relaxed which will decrease the sympathetic effect of pain on vital signs.
In this respect (20) who conducted "Comparison of the Effects of Aromatherapy with Rose and Lavender on
Physiological Parameters of Patients Undergoing Open Heart Surgery" emphasized that, Patients undergoing coronary
artery bypass grafting (CABG) are transferred to intensive care units (ICUs) where they are normally under mechanical
ventilation during the first 6 hours following surgery. Anxiety and agitation in these patients result in sleep disorders,
increased oxygen consumption by the heart muscles, increased burden of the sympathetic nervous system, tachypnea,
increased heart rate, neural-hormonal responses, and increased blood pressure, which challenge the process of weaning
from mechanical ventilation.
This result is also supported by (15) confirmed that, Assessment of vital signs in the two groups in preoperative cardiac
surgery phase and postoperative phase after routine deep breathing exercise and chest physiotherapy (by blow bottle).
Concerning the respiratory rate and temperature a significant differences were found between the two groups during the
first assessments.
On the same line (21) who conducted "efficacy of breathing and coughing exercises in the prevention of pulmonary
complications after coronary artery surgery" reported that no significant differences between 3 groups using (routine chest
physiotherapy and prophylactic chest physiotherapy) as regard temperature at any stage of treatment during fourth
postoperative day.
Results of (22) who conducted "Postoperative Pain after Coronary Artery Bypass Grafting Surgery: effect of Relaxation"
That show similarity of present study as it illustrated that relaxation has significant effects on patients' vital sign such that
24 hours after extubation, their vital sign was not significantly different because of relaxation but with more training, it
became significant after 48 and 72 hours from extubation.
(18), results pointed out that the mean scores are positively changed in O 2 saturation, respiratory rate, heart rate and
temperature. This result matched with a study conducted by (23) "The invasive cardiopulmonary exercise test" who
indicated that deep breathing is one of the best ways to lower stress in the body, also heart rate, breathing, and blood
pressure, all decrease by breathe deeply.

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International Journal of Novel Research in Healthcare and Nursing
Vol. 6, Issue 2, pp: (32-46), Month: May - August 2019, Available at: www.noveltyjournals.com

Part 4: patients practice regarding the deep breathing technique after CABG
Concerning evaluating of Practice score for deep breathing technique after CABG in 1 st and 2nd days among study group
the present study illustrated that there is a statistically significant difference with between practice score with high
satisfaction level of practice score at the 2nd day among group I versus in 1st day. This result illustrated the good level of
patients' training on the deep breathing technique.
(18) demonstrated that, there were significance differences between pre and post breathing exercises in the 1 st and 2nd
measurements, which reflect the effectiveness of breathing exercises in the second measurement. This result supported by
(24) who conducted "Deep-Breathing Exercises Reduce Atelectasis and Improve Pulmonary Function After Coronary
Artery Bypass Surgery" in Sweden, reported that with increasing the frequency and intensity of the exercises is likely to
be more efficacious all patients found the breathing technique easy to perform, and most of the patients experienced a
subjective benefit of the exercises; this is important for completion of the treatment.
(25) who conducted "Assessment of pain during rest and during activities in the postoperative period of cardiac surgery"
was in disagreement with current study as it founded no statistical difference in the intensity of pain experienced during
deep breathing between the 1st and the 2nd days, but illustrated that pain decreased over time.
Part 5: Pain severity in different study groups
Current study found no statistically significant difference between study and control groups as regards degree of pain
severity before procedure in the 1st and 2nd days. On the other hand there is statistically significant difference between
study groups as regards degree of pain severity after procedure in the 1st and 2nd days with increase in percentage of
patients with no pain and mild pain in 1st day, and 2nd day. Also pain severity degrees show significant improvement after
practice deep breath technique from sever to mild and moderate degree in the 1 st day and to mild degree or no pain in the
2nd day among study group. But this effect of decreasing pain severity was noted among study group; this result reflects
the success of that technique in decreasing pain severity degree especially when done for a couple of days.
This finding was in accordance with (26) who conducted "Assessment of pain during rest and during activities in the
postoperative period of cardiac surgery" in Brazil, the results showed that, majority of the studied sample experienced
pain at least once. Most patients reported pain on the 1 st and 2nd days postoperative, while the highest incidence of pain
occurred on the 1st day postoperative.
According to (27) who conducted "Exercise and children "the results showed that deep breathing exercise is considered a
useful form of complementary and alternative treatment apparently, the presence and characteristics of pain as pre and
post breathing exercises, highly significance differences were detected in both presence of pain, time and severity of pain.
Also it agrees with (28) who conducted "The Effect of Deep and Slow Breathing on Pain Perception, Autonomic Activity,
and Mood Processing-An Experimental Study" who found that after breathing intervention a significant reduction of
tension, anger, and depressive feelings in patients with chronic pain.
(29) who conducted "The effect of deep-slow and regular breathing on pain intensity of burn dressing" in Iran, approved
that using deep-slow and regular breathing can be an important factor in reducing pain intensity during burn dressing.
This was in agreement with (30), who conducted "Effect of relaxation exercises on controlling postoperative pain" that
reveled effect of relaxation on pain control after upper abdominal surgery stated that pain level after relaxation was
significantly lower.

6. CONCLUSION
The deep breathing technique is a safe, inexpensive, and a non -pharmacologic nursing intervention effective technique to
reduce the severity of pain after CABG. DBS that can be recommended as a pain relief technique after CABG.
Recommendations for better patient's outcome:
- Apply the deep breathing technique for patients undergoing CABG by teaching technique before surgery and apply it
after surgery as routine and regular care to decrease the incidence of pain associated with surgery.

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Vol. 6, Issue 2, pp: (32-46), Month: May - August 2019, Available at: www.noveltyjournals.com

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[5] Solomen, S. Aaron, P. (2015): Breathing techniques - A review, International Journal of Physical Education, Sports
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[6] Adelborg, K., Horváth-Puhó, E., Schmidt, M., Munch, T., Pedersen, L., Nielsen, P.H., & Toft Sørensen, H.
(2017): Thirty-year mortality after coronary artery bypass graft surgery: a Danish nationwide population-based
cohort study, Circulation: Cardiovascular Quality and Outcomes, 10(5): e002708.
[7] Ajorpaz, N.M., Mohammadi, A., Najaran, H., & Khazaei, S. (2014): Effect of music on postoperative pain in
patients under open heart surgery. Nursing and Midwifery Studies, 3(3): 2023.
[8] Salama ,S . , R . , (2006 ): effect of relation techniques on relieving pain for abdominal postoperative patient Ain
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[9] Hinkle, J. L., Cheever, K. H., (2016): Brunner and Suddarth's Text Book of Medical Surgical Nursing.
Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 13th edition18 , 409-410.
[10] Patra, S., Jena, M., Pande, A., Ghosh, D., & Chakraborty, R.N. (2017): Assessment of Coronary Artery Bypass
Grafts Status in Symptomatic Patients: An Observational Study. J Cardiovascular Thoracic Surgery, 2(1): 1-4.
[11] Ahmed, G., Mohammed, Z., & and Ghanem, H. (2015): Coronary artery bypass grafting ’Effect of developing
and implementing nursing care standards on patient’s outcomes. Journal of American Science, 11(7): 181-188.
[12] Pettersson, H., Faager, G., & Westerdahl, E. (2015): Improved oxygenation during standing performance of deep
breathing exercises with positive expiratory pressure after cardiac surgery: A randomized controlled trial, Journal of
Rehabilitation Medicine, 47(8): 748-752.
[13] Ünver, S., Kıvanç, G., & Alptekin, H. (2018): Deep breathing exercise education receiving and performing status
of patients undergoes abdominal surgery, International Journal of Health Sciences, 12(4): 35-38.
[14] Akca, N.K., & Dogan, A. (2012): Benefits of home-based exercising ability in patients with osteoarthritis/
Osteoartritli hastalarin evde egzersiz yapma ve yarar gorme durumlari, Turkish Journal of Physical Medicine and
Rehabilitation, 58 (4) 288-294.
[15] Ahmed, M.A., Alaa Eldeen, S.A., Youssef, H.A., & Mohammed, M.A. (2015): Comparison the effect of
conservative therapy and blow bottle among open heart surgery patients for the prevention of postoperative
pulmonary complications, IOSR Journal of Nursing and Health Science, 4(4): 42-55.
[16] EL Mokadem, N.M., & Ibraheem L.M. (2017): Cold Application and Breathing Exercises to Reduce Pain and
Anxiety During Chest Tube Removal, American Journal of Nursing Science; 6(4): 285-292.
[17] Menache, C.C., du Plessis, A.J., Wessel, D.L., Jonas, R.A., & Newburger, J.W. (2010): Current incidence of
acute neurologic complications after open-heart operations in children, The Annals of thoracic surgery, 73(6): 1752-
1758.
[18] Abd Elkreem, M.H., Ragab, A.M., & Sayed, N.M., (2014): Effect of Breathing Exercise on Respiratory Efficiency
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[19] Zubrzycki, M., Liebold, A., Skrabal, C., Reinelt, H., Perdas, M., & Zubrzycka, A. (2018): Assessment and path
physiology of pain, Journal of Pain Research (11): 1599–1611.
[20] Ghasemi, S., Darzi, H., & Ebad, A. (2017): Comparison of the Effects of Aromatherapy with Rose and Lavender
on Physiological Parameters of Patients Undergoing Open Heart Surgery: A Clinical Trial, Crit Care Nurs J, 10(2):
e10029.
[21] Stiller, K., Montarello, J., Wallace, M., Dajf, M., Grant, R., Jenkins, S., & Yates, H. (2010): Efficacy of
breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery, Chest,
105(3): 741-747.
[22] Dehghani, M.F., Ebadi, A., Ali, M., & Rahmani, H. (2016): Postoperative Pain after Coronary Artery Bypass
Grafting Surgery: effect of Relaxation. 4th Iranian Cardiovascular Joint Congress AVA at: https://www.
researchgate.net/publication/301340543_Postoperative_Pain_after_Coronary_Artery_Bypass_Grafting_Surgery_eff
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[23] Maron, B.A., Cockrill, B.A., Waxman, A.B., & Systrom, D., M. (2013): The invasive cardiopulmonary exercise
test, Circulation, 127(10): 1157-1164.
[24] Westerdahl, E., Lindmark, B., Eriksson, T., Hedenstierna, G., & Tenling, A. (2015): Deep-breathing exercises
reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest, 128(5): 3482-3488.
[25] Coelho, L.D., Fernando, S.R.C., & Hortense, P. (2014): Assessment of pain during rest and during activities in the
postoperative period of cardiac surgery Rev, Latino-Am. Enfermagem 22(1):136-43.
[26] Mello, L.C.D., Rosatti, S.F.C., & Hortense, P. (2014): Assessment of pain during rest and during activities in the
postoperative period of cardiac surgery, Revista latino-americana de enfermagem, 22(1): 136-143.
[27] Peter, M. (2011): Exercise and children. AORN Journal, available at: www.findarticles.com. Accessed at 30-8-
2018:4pm.
[28] Busch, V., Magerl, W., Kern, U., Haas, J., Hajak, G., & Eichhammer, P. (2012): The Effect of Deep and Slow
Breathing on Pain Perception, Autonomic Activity, and Mood Processing-An Experimental Study, Pain Medicine, l
13 (2): 215.
[29] Lalehgani, H., Esmaili, S., Karimi, M., Moghni, M., & jivad, N. (2013): The effect of deep-slow and regular
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[30] Topcu, S., & Findik, U. (2012): Effect of relaxation exercises on controlling postoperative pain, Pain Management
Nursing, 13(1): 11-7.

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Novelty Journals
 PRESENTASI JURNAL STASE KDP

Pengaruh Teknik Pernapasan Dalam terhadap Keparahan Nyeri

di antara Arteri Koroner Pasca Operasi Pasien Bypass Graft
 TELAAH JURNAL
Judul Jurnal :
Pengaruh Teknik Pernapasan Dalam terhadap Keparahan Nyeri di antara Arteri
Koroner Pasca Operasi Pasien Bypass Graft

Penulis Jurnal :
Shaimaa Mohamed Hany, Zinab Hussien Ali , dan Heba Abdel-azeem Mostafa

Dipublikasikan oleh :
www.noveltyjournals.com

Sistematika Penulisan
Times new roman, ukuran 12, spasi 1,5.
Judul penulisan, Abstrak, Perkenalan, Tujuan Studi, Hipotesis Penelitian, Hasil,
Pembahasan, Kesimpulan, Refrensi

Referensi:
• Terdapat 30 referensi
• Teori terbaru pada tahun 2018
• Teori lama pada tahun 2010
Pendahuluan
Masalah Penelitian
Peneliti mengemukakan bahwa teknik relaksasi napas dalam
merupakan cara non-farmakologi seperti mengurangi rasa sakit
dan mengembalikan rasa nyaman pengendaliaan nyeri penting
untuk pemulihan secara keseluruhan, meningkatkan kepuasan
pasien dan mengurangi biaya perawatan kesehatan

Seberapa Besar Masalah Tersebut? (Prevelensi/Insiden)

Nyeri masih merupakan manifestasi utama yang dilaporkan oleh
pasien pasca operasi jantung, kemungkinan penyebab terjadinya
yaitu kompikasi dan keterlambatan pemulihan. Teknik pernapasan
merupakan metode yang saring digunakan sebagai tindakan
non-farmakologi untuk mengurangi dan mengontrol rasa
sakit/nyeri pasca operasi
Pendahuluan
Dampak Masalah Jika Tidak Diatasi?
Resiko terjadinya keparahan pada nyeri seperti nyeri kronik,
komplikasi, dan keterlambatan pemulihan.

Bagaimana kesenjangan yang terjadi?

Studi menunjukkan bahwa daro 47% hingga 75% pasienmelapork
an nyeri pada priode pasca operasi, dan insiden nyeri kronik pasc
a operasi berkisaran antara 18% hingga 61%. Sedangkan yang te
rjadi dilapangan persentase pasien yang melaporkan nyeri tajam
40%, gelisah 43,3% pasien nyeri 40% dan meringis 40%
 Desain Penelitian

Populasi Sampel Metode Sampling

Sample dari 60 pasien 60 pasien dewasa Purposif sampling

dawasa dari 2 jenis dibagi menjadi 2
kelamin kelompok studi
dan control yang
sama (30 pasien
untuk setiap
kelompok)
Analisa Data

Analisis deskriptif, program yang digunakan Spss software

versi 18 di windows 7

Hasil
Alur Penelitian dan Data Base line
Peneliti menjelaskan pasa karakteristik menggunakan demografi
untuk kelompok studi dan kontrol penilaian praktik pasien
mengenai teknik pernapasan dalam juga dicantumkan oleh
peneliti dan penilaian nyeri untuk kelompok belajar dan
kelompok kontrol setelah mempraktekkan teknik pernapasan
setelah CABG.
DISKUSI
Bagaimana peneliti membandingkan hasil penelitiannya
dengan penelitian-penelitian terdahulu serta teori yang
ada saat ini untuk menunjukkan adanya relevansi?
Peneliti membandingkan penelitian dengan penelitian
sebelumnya melihat hasil distribusi frekuensi

Bagaimana peneliti menjelaskan makna dan relevansi hasil pen

elitiannya dengan perkembangan ilmu keperawatan/kesehatan
serta terhadap pemecahan masalah?

Dalam penelitiain ini perawat dapat mengajarkan pasien

untuk melakukan teknik pernapasan dalam untuk
mengurangi nyeri pasca operasi
DISKUSI
Bagaimana nilai kepentingan (importancy) hasil penelitian?

Temuan dari penelitian ini menunjukan bahwa keparahan

kelompok nyeri kelompok kontrol dalam 1 hari setelah CABG
dengan presntasi nyeri ringan yang tinggi (43,3%), Untuk
presentase nyeri berat (88,7%). setelah menerapkan teknik
pernapasan rata-rata tingkat keparahan nyeri rendah yang
signifikan secara statistik pada kelompok studi setelah 1 hari,
dan sebelum dan sesudah 2 hari latihan
DISKUSI
Bagaimana applicability hasil penelitan menurut peneliti?
Apakah hasil penelitian dapat diterapkan pada tatanan
praktik keperawatan ditinjau dari aspek fasilitas,
pembiayaan, sumber daya manusia, dan aspek legal?
Teknik pernapasan dalam adalah teknik perawatan yang aman,
murah, dan non-farmakologis yang efektif untuk mengurangi
keparahan nyeri setelah CABG yang dapat direkomendasikan
sebagai teknik pereda nyeri setelah CABG
DISKUSI

Apakah mungkin penelitian ini direplukasi

pada setting pratik klinik lainnya?
Peneliti merekomendasikan menerapkan teknik pernapasan dalam
untuk pasien yang menjalani CABG dengan mengajarkan teknik s
ebelum operasi dan menerapkannya setelah operasi sebagai peraw
atan rutin dan teratur untuk mengurangi timbulnya nyeri yang terk
ait dengan operasi.

Apakah peneliti menjelaskan kekuatan dan kelemahan penelitian?

Apakah kelemahan ini tidak menurunkan validitas hasil penelitian?
Peneliti tidak menjelaskan kelemahan dan kekuatan dalam penelitian ini.