Effect of Giving Left Oblique Position to Changes in the Scale of Back

Pain in Post Patients Percutaneous Coronary Intervention

Arfah May Syara, Anita Srigandaria Purba, Pitriani, Samuel Ginting

Institut Kesehatan Medistra Lubuk Pakam

Keywords: Percutaneous Coronary Intervention, Pain, Oblique left

Abstract: Percutaneous Coronary Intervention is an intervention or non-surgical action to open or dilate the coronary

arteries that experience narrowing of the arteries. The impact of this action is back pain due to long bed rest

or immobilization. Back pain can be reduced by practicing a slanted sleeping position with a pillow or support

between the two legs. The purpose of this study was to determine the scale of back pain before and after

treatment of left oblique position in post PCI patients. This study uses a quasy-experimental design Pre test

and Post test. Measuring the scale of back pain in this study used the Numeric Rating Scale (NRS). The

population in this studywere post PCI patients at GrandMed Hospital. The number of respondens in this study

were 10 respondens. Data was collected using an observation sheet to measure the scale of pain, then the data

was analyzed using the Paired Sample t-test to get the value p=0,081>(α=0,05). The results showed that there

was no effect on giving the left sloping position to changes in the scale of back pain in post PCI patients.

Based on the results of the study it was concluded that the administration of the left oblique position in post

PCI patients could not reduce the scale of back pain. Recommendations for futher research can be added to

back massage interventions to reduce back muscle tension or the intensity of back pain.

1 INTRODUCTION

According to world statistics there are 9.4 million

deaths each year caused by cardiovascular disease

and 45% of these deaths are caused by coronary heart

disease (Kundasamy, 2014). Coronary arteries are

vessels blood that supplies oxygen and nurtition to the

heart muscle have metabolic needs high on both

things

While the 2014 World Health Statistics, there

were 17.5 million or 46.2% of all deaths worldwide

due to cardiovascular disease and it is estimated that

the number will increase until 2030 to 23.4 million

deaths (WHO, 2014). The World Health Organization

(WHO) defines cardiovascular disease as a disease

related to the heart and blood vessels, about 50% of

the world's population experiences death each year.

Percutaneous Coronary Intervention is an

intervention or non-surgical action to open / dilate /

dilate the coronary arteries that are narrowed so that

blood flow can return to the heart muscle and usually

often done through the femoral artery in more than

95% of cases (Chair, et al., 2007). Percutaneous

Coronary Intervention can cause some post-

complications complications because of using arterial

access (Kern, 2009). Transfemoral PCI procedures

can cause 5-10% complications, including hematoma,

infection, arterial venous fistula or retroperineal

hemorrhage. Reduction of complications after PCI

can be done with immobilization such as sleeping for

6-8 hours.

Percutaneous Coronary Intervention (PCI,

formerly known as angioplasty with stent) is a non-

surgical procedure that uses a catheter (a thin flexible

tube) to place a small structure called a stent to open

up blood vessels in the heart that have been narrowed

by plaque buildup, a condition known as

atherosclerosis. PCI improves blood flow, thus

decreasing heart-related chest pain (angina), making

you feel better and increasing your ability to be active.

PCI is usually scheduled ahead of time. A catheter is

inserted into the blood vessels either in the groin or in

the arm., Using a special type of X-ray called

fluoroscopy, the catheter is threaded through the

blood vessels into the heart where the coronary artery

is narrowed, When the tip is in place, a balloon tip

covered with a stent is inflated, The balloon tip

compresses the plaque and expands the stent, Once

the plaque is compressed and the stent is in place, the

balloon is deflated and withdrawn, The stent stays in

the artery, holding it open.

Through this process the patient feels pain and

discomfort in the back of the body due to

452

Syara, A., Purba, A., Pitriani, . and Ginting, S.

Effect of Giving Left Oblique Position to Changes in the Scale of Back Pain in Post Patients Percutaneous Coronary Intervention.

DOI: 10.5220/0009838104520458

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 452-458

ISBN: 978-989-758-460-2

immobilization (EBN, 2004 in Silber, 2006).

Changing the position of the bed using a pillow after

the post PCI action can effectively reduce back pain

and stabilize hemodynamics without increasing

vascular complications Razaei, Morteza, Ahmadi,

Mohamadi & Jafarabadi (2008). The complications

that may arise such as bleeding, hematoma coronary

artery rupture, aneurysm and arterial fistula (Hoek, et

al., 2010). According to the Heart Lung and Blood

Institute, complications include bleeding, infection

and pain, damage to blood vessels and allergies to the

contrast agents used.

According to Brunner and Suddarth (2002)

states that the factors are affect the pain as follows:

meaning of pain towards individuals (every

individual has a different meaning in looked at the

pain response, both on time different in the same

individual nor the same complaints. Some individuals

have positive responses and faster than other

individuals, pit depends on the conditions and

individual interpretation of the pain). The second

factor is individual tolerance of pain, tolerance of

someone related with the intensity of pain wherein the

individual can respond well or otherwise. The third

factor is threshold there is a limit to one's ability to

want to adapt and respond to pain which influences

behavior someone and the fourth factor is age, the age

difference someone has different influences in

looking at pain. At age adults are usually better able

to tolerate pain well, but in children the upper pain

threshold is low for distinguish pain and pressure,

while people who are elderly experience failure in

feeling tissue damage, due to changes degenerative

pain in the nerve pathway compared to young age.

Risk factors for vascular complications after

PCI action according to Lins, et al., (2006) include

old age, female sex, low body weight, concomitant

diseases such as hypertension, diabetes, kidney

failure and others, drugs used such as thrombolytic

therapy, heparin and PCI procedural actions such as

length of procedure duration and large sheats size ≥

7F. To avoid complications, patients are required to

immobilate in supine or bed rest positions for 8-12

hours (Chair, et al., 2007). This causes complaints in

patients with discomfort such as back pain (Agustin,

et al., 2010).

To reduce complaints and patient discomforts

nursing measures to improve patient comfort with

changes in left tilt position do not affect the

complications that will occur and can reduce back

pain (Mohammady, et al., 2014). Client comfort and

safety are one of the goals of post-catheterization

nursing care management.

Progressive relaxation techniques are one of the

non-pharmacological therapies to deal with pain

developed by Edmun Jacobson (1930) in Banks

(2005). In addition, the benefits of progressive

relaxation techniques for patients include reducing

tension and anxiety (Paula, 2002).

Back pain can be reduced by practicing the

sleeping position on the side with a pillow or a

support between the legs (Archard, 2007). With the

left side sleeping position using a pad can reduce the

pressure on the large veins (inferior vena cava) in the

front of the spine which returns blood from the lower

body to the heart. This position will also ensure

healthy blood circulation.

The left tilt position not only maximizes blood

flow but also improves kidney function, which means

better disposal of residual fluid products (Heidi,

2006). The role of nurses in dealing with back pain

complaints is to provide health education about non-

pharmacological therapies to reduce back pain,

especially after PCI.

The patient immobilization process will because

back pain complaints as pain receptor triggers

(nociceptor) for influences the release of bradykinin,

histamine and prostaglandins, ingredients that are is

sensitive to pain. Pain signal this will be passed on by

sensory neurons in spinal cord, triggering the release

of glutamate as a neurotransmitter that delivers pain

signals from one neuron to one neuron other. This

pain signal will be received by thalamus, then passed

on to somato sensory cortex in the cerebrum where

pain will be localized. Through this process the

patient feels pain and feels no comfortable on the

back of the body due to from immobilization (EBN,

2004 in Silber, 2006).

Based on preliminary survey results found the

number of patients post percutaneous coronary

intervention (pci) in grandmed hospital in the january

2019 period as many as 36 people. to reduce back

pain in post pci patients, many factors are needed,

including left tilting mobilization.

2 RESEARCH METHOD

This research was conducted at the Grandmed Poly

Physiotherapy Hospital, located at Jl Raya Medan,

No.66, Lubuk Pakam. The research was conducted in

February - July 2019. This type of research is a quasi-

experimental research design with pre-test and post-

test one group. The research sample of 10 people.

Effect of Giving Left Oblique Position to Changes in the Scale of Back Pain in Post Patients Percutaneous Coronary Intervention

453

Figure 1: Research flow.

Pain measurement is performed using Verbal

Anolog Scale (VAS). VAS has been widely used in

diverse adult populations, including those suffering

from rheumatic diseases. VAS is an instrument used

to assess pain intensity using a line 10 cm long

(Figure 1) with a scale reading of 0-10 cm with a

range of meanings: no pain (0.9 cm), mild pain (1-3

cm) moderate pain (3.1 -7 cm), and severe pain (7.1-

8.9 cm). Pain measurement can be done by the

respondent himself. Determination of VAS score is

done by measuring the distance between the end of

the line on the painless line to the point indicated by

the patient, (Gillian A., Hawker, Mian, et all, 2011).

Pain examination procedure with VAS:

1. Explain to the patient about the purpose of the

measurement carried out

2. Explain to sufferers that right angle means no

pain, middle means moderate pain and left angle

means very painful (front VAS)

3. Telling the patient to choose or move the direction

of the VAS arrow on the pain scale in accordance

with the intensity of pain felt before changing

positions. Adjust the patient's position tilted to the

left by using a pillow under the back as a support

carried out for 15 minutes.

4. Record the pain scale expressed by the patient by

using a VAS pain gauge.

Pain measurement in this study was done before

and after treatment. Measurement data will be tested

by Paired Sample t-test and independent t-test. The

flow of this research can be seen in Figure 2.

0 10 mm

No pain Several pain

Figure 2: Visual Analogue Scale.

2.1 Mobilization

Mobilization is the ability to move freely, easily,

regularly, has the goal of fulfilling the needs of a

healthy life, and is important for independence

(Koizer, 2010). Mobilization aims to improve blood

circulation, maintain muscle tone and restore certain

activities so that it can meet the needs of daily

movement (Garrison, 2004). Left tilted position is a

position given to bed rest patients to reduce the

pressure for too long and prevent pressure sores

(Effendi, 2011).

Figure 3: Draw Position.

2.2 Back Pain

Pain is a multidimensional phenomenon and it is very

difficult to interpret because pain is a subjective and

personal experience (Black & Hawks, 2009). The

McGill Pain Questionnaire (MPQ) is a

multidimensional assessment scale consisting of pain

relief, pain index (PRI), pain questions regarding past

pain and its location, and pain intensity index

experienced at this time.

Back pain is one of the most common reasons

people go to the doctor or miss work, and it is a

leading cause of disability worldwide. Most people

have back pain at least once.

Fortunately, you can take measures to prevent or

relieve most back pain episodes. If prevention fails,

simple home treatment and proper body mechanics

often will heal your back within a few weeks and keep

it functional. Surgery is rarely needed to treat back

pain.

2.3 Percutaneous Coronary

Intervention

Percutaneous Coronary Intervention is an invasive

diagnostic procedure where one or more catheters are

inserted into the heart and blood vessels to measure

the pressure of the heart's chamber to determine

oxygen saturation in the blood (Smeltzer & Bare,

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

454

2010). Angioplasty works by stretching the arteries

and pressing the plaque toward the vessel wall, away

from the lumen, widening the entire vessel. This

procedure rarely causes the embolization of

atherosclerotic material.

Figure 4: Back Pain.

3 RESULTS AND DISCUSSION

3.1 Characteristics of Respondents

Data distribution of respondents based on the age of

majority aged 50-60 years as many as 5 people (50%).

Based on gender, there were 7 male respondents

(70%). In Table 1. This is consistent with the theory

that the average age of back pain post Percutaneous

Coronary Intervention is between 57 to 60 years

(Mohammady et al, 2013). Price and Wilson (2006);

Woods, et al., (2005), which states that men have a

higher risk factor suffering from CAD associated with

patterns / lifestyles such as smoking and eating habits,

and activities / breaks that are less regular.

Table 1: Characteristics Table of Respondents.

Age Frequency (f)

Percentage

(%)

40-50

4 40,0

50-60

5 50,0

60-70

1 10,0

Total

10 100

Gender Frequency (f)

Percentage

(%)

Male 7 70,0

Female 3 30,0

Total 10 100

3.2 Mean before and after

Administration of Left Tilt Position

to the Scale of Back Pain in Post

Percutaneous Coronary

Intervention Patients

The results of back pain scale analysis in post

Percutaneous Coronary Intervention patients before

being given a left tilt position treatment were 1.90

with a standard deviation (large difference from the

sample value to the average) 0.994 and the average

after being given a left tilt position treatment were

1.30 with a standard deviation of 0.483

Table 2: Pain Measurement Scale Results.

Respondent

Code

Pain Scale

Pre Test Post Test

1 R1 6 3

2 R2 6 2

3 R3 5 3

4 R4 5 3

5 R5 7 3

6 R6 6 3

7 R7 5 2

8 R8 6 3

9 R9 6 3

10 R10 5 2

Table 3: Mean Pain Scale Table Before and After Left

Tilting Position Intervention.

Mean n

Std.

Deviation

Std. Error

Mean

Before 1.90 10 0.994 0.314

After 1.30 10 0.483 0.153

Back pain is a problem that often occurs in

patients with Percutaneous Coronary Intervention

related to immobilization and limited position.

Prolonged bed rest causes muscle weakness due to

continuous pressure being applied to the same

muscle, while muscle weakness is what causes back

pain. Given the left tilt position, it is expected to

relieve muscle tension, and most of all is able to

overcome back pain (Razaei et al, 2008).

Mobilization in bed includes changes in position

(tilted to the left and right, sitting in bed), passive and

active movements (Suardika, 2005). Mobilization

should be done in stages to help the patient cure.

Psychologically mobilization can increase confidence

in patients to feel better. This change in movement

and position must be explained to the patient and

family to find out the benefits of mobilization, so as

to participate in the implementation of mobilization.

Effect of Giving Left Oblique Position to Changes in the Scale of Back Pain in Post Patients Percutaneous Coronary Intervention

455

The addition of progressive relaxation

techniques, optimizing stimulation in muscle spindles

and organ tendon golgi is maximal because there is an

authogenic inhibition response arising from the

presence of isometric principles that provide a relaxed

response through tension in the muscles then assisted

with expiration at the end of isometric

implementation. This will cause optimal release of

adhesion to the connective tissue of the muscles

(fasciadan tendons), so that optimal relaxation of the

muscles occurs then pain decreases (Silbernagl,

2014).

Active movement can cause contractions in

large skeletal muscle fibers which involve the

influence of where the function of the muscle spindle

is to control any changes in muscle length and the

tendon of the organ functions to inhibit muscle

contraction. Both of these components will work

consciously and then there is an adaptation response

to the muscles with a reduction in tension in the

muscles, repairing ischemia in the tissue so that it will

eventually cause a decrease in pain (Guyton, 2006).

Progressive relaxation is a skill that can be learned

and used to reduce or eliminate tension and

experience comfort without relying on things /

subjects outside of him. According to Jacobson,

tension has to do with shrinking muscle fibers, while

the opposite of tension is the absence of contractions

(Soesmalijah Soewondo, 2016). This progressive

relaxation is a method of relaxation technique that

combines deep breathing exercises and a series of

series of contractions and certain muscle relaxation

(Kustanti & Widodo, 2008 in Setyoadi &

Kushariyadi, 20

3.3 Effect of Giving Left Slanted

Position on Changes in Back Pain

Scale in Post Percutaneous

Coronary Intervention Patients

The results of data processing using paired t-test,

before and after the administration of the intervention

in the experimental group got p = 0.081> (α = 0.05),

it can be concluded that the hypothesis in the study

was rejected, ie there was no effect of giving a left tilt

to changes in the scale of back pain in Post

Percutaneous Coronary Intervention (PCI) patients at

GrandMed Lubuk Pakam Hospital in 2019.

In addition, muscle relaxation movements

progressives can stimulate spending endorphin

hormone which gives comfort on the body. This

hormone can function as a natural sedative which is

produced in the brain and structure spinal cord.

Endorphin works by binding to existing opiate

receptors in the limbic system, midbrain, medulla

spinal cord and intestine. Opiate and opiate receptors

This endogenous then forms a intrinsic pain

suppression system. Bond between opiates and these

receptors will be able to reduce pain with prevent his

release as pain-producing neirotransmitters (Price &

Wilson, 2006).

Table 4: Effect of Giving Left Tilting Position on Changes

in Back Pain Scale in Post Percutaneous Coronary Patients.

Changes

in back

pain

scale

Paired Sample t - Test

Valu

Mean

Std.

Deviasi

95% Interval

Confidence

Pre Test

– Post

Test

0.600 0.966

0.09

1.291

0.08

According to the researchers' assumptions, it

was concluded that the treatment of the left sloping

position could not provide a response to a significant

decrease in back pain in post Percutaneous Coronary

Intervention (PCI) patients and increased comfort for

patients by reducing pressure on the back and long

bed rest in bed without increasing the incidence of

complications such as bleeding in the area of cardiac

catheterization.

According to Setyoadi & Kushariyadi, (2011)

progressive muscle relaxation is one of the

complementary therapies that can be given by nurses

or midwives in the process of providing care can be

given to clients who experience sleep disorders

(insomnia), stress, anxiety, neck muscle pain and

upper back and down, and depression so that it can

provide a relaxing effect to smooth the blood flow,

reduce muscle tension.

The principle that underlies muscle relaxation in

the body's mind approach is anything that relaxes our

muscles and mind. Stretching and relaxing each

muscle group at a time will result in progressive

relaxation of the entire body, as well as calming the

mind by stretching each muscle group for five

seconds and focusing. This is followed by breathing

deeply then releasing tension so that the muscles

become completely limp, (Bruce Goldberg, 2007).

Exercise therapy is body movement, physical

activity carried out systematically with the aim of: 1)

correcting or avoiding complaints, 2) improving or

increasing functional activity 3) avoiding or

preventing preventive measures from decreasing the

health status of risk factors 4) optimizing healthy

status, fitness or good condition (Kisner, 2007).

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

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Provision of tilted position left with post PCI is

a combination of changes in position during

immobilization in patients with tilt and helps reduce

complaints back pain and help fulfill patient needs

such as eating, drinking and patient elimination needs

(Benson in Bigatello, 2006).

Provision of tilted position left and head elevation

given to Post PCI patients with vascular closure

device affects the reduction in pain (back pain). In

patients who are immobilized then the patient must

lie on the bed, gravity pressure will increased, the

burden is on the back so the microcirculation is

disrupted, the patient's pain response will appear

(EBN, 2004).

4 CONCLUSION

a. Based on the results of the statistical tests and the

discussion above, it can be concluded that the

administration of the left tilt position has no effect

on the change in the scale of back pain in post

percutaneous coronary intervention patients at

Grandmed Lubuk Pakam Hospital in 2019.

b. Progressive muscle relaxation has so far been one

of the cheapest methods of relaxation, requires no

imagination, has no side effects, and is easy to do.

Relaxation therapy with tightening and relaxing

muscles at a time to give a feeling of physical

relaxation.

5 SUGGESTIONS

Do not apply the left sloping position as a nursing care

to get a decrease in the scale of back pain in post

percutaneous coronary intervention patients and look

for other interventions related to the reduction in back

pain scale in post percutaneous coronary intervention

patients.

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