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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 47-55

Effect of diaphragmatic breathing exercise on postoperative nausea, vomiting, and retching among orthopedic surgery patients


Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Submission06-Jul-2020
Date of Decision28-Jul-2020
Date of Acceptance10-Aug-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Hamada A.N Ibrahim
Department of Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_19_20

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  Abstract 


Background Postoperative nausea, vomiting, and retching (PONVR) is still the most common and distressing complaint after surgery and general anesthesia. Despite the potency of pharmacological management of PONVR, patients still experience such problem. Nonpharmacological strategies such as diaphragmatic breathing exercise could be integrated with pharmacological management to minimize the possibility of PONVR.
Aim The aim was to evaluate the effect of diaphragmatic breathing exercise on selected postoperative complaints such as nausea, vomiting, and retching among postoperative orthopedic patients.
Design One-group pretest–post-test quasi-experimental design was used.
Research hypotheses H1: The mean score of nausea before will be different from the mean score of nausea after performing diaphragmatic breathing exercises among postoperative orthopedic patients. H2: The mean score of retching before will be different from the mean score of retching after performing diaphragmatic breathing exercises among postoperative orthopedic patients. H3: The mean score of vomiting before will be different from the mean score of vomiting after performing diaphragmatic breathing exercises among postoperative orthopedic patients.
Patients and methods The current study was conducted at recovery rooms and orthopedic wards at Kaser Al-Ainy Teaching Hospital, affiliated to Cairo University Hospital, under supervision of the Ministry of Higher Education. A convenient sample of 100 adult male and female conscious patients who underwent orthopedic surgery under general anesthesia were included in the study along 3 consecutive months. Three tools were utilized to collect data: Demographic and Medical Related Data Form; Glasgow Coma Scale; and Index of Nausea, Vomiting, and Retching.
Results The study results revealed that the mean total nausea, vomiting, and retching scores are statistically significantly decreased among postoperative orthopedic patients after performing diaphragmatic breathing exercise when compared with before performing.
Conclusion Diaphragmatic breathing was effective in reducing the severity and occurrence of PONVR.
Recommendations The diaphragmatic breathing exercise should be included in nursing curriculum as a new approach to treat postoperative nausea and vomiting.

Keywords: diaphragmatic breathing, postoperative nausea, postorthopedic surgery, vomiting and retching


How to cite this article:
Ibrahim HA, Al Sebaee HA, El-Deen DS. Effect of diaphragmatic breathing exercise on postoperative nausea, vomiting, and retching among orthopedic surgery patients. Egypt Nurs J 2020;17:47-55

How to cite this URL:
Ibrahim HA, Al Sebaee HA, El-Deen DS. Effect of diaphragmatic breathing exercise on postoperative nausea, vomiting, and retching among orthopedic surgery patients. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:47-55. Available from: http://www.enj.eg.net/text.asp?2020/17/1/47/300779




  Introduction Top


Postoperative complaints from general anesthesia and surgery are broad and potentially destructive and devastating. The severity of postoperative complaints ranges from benign and common such as nausea and vomiting to debilitating but rare like stroke and death. It must be managed taking into consideration an adequate perioperative anesthetic plan (Cardinale et al., 2019).

The postoperative nausea and vomiting (PONV) is considered one of the most common causes of patient dissatisfaction that occurs in recovery rooms or in the immediate 24–48 h after surgery and general anesthesia. It is reported to have an incidence of 30% in all postsurgical patients and up to 80% in high-risk patients; the highest occurrence appears in the first 6 h after surgery (Veiga et al., 2017).

Nausea is defined as an unpleasant sensation associated with an urge to vomit but absence of expulsive muscular movements. Retching is defined as the spastic contraction of the respiratory muscle without the expulsion of gastric content. Vomiting is defined as the vigorous expulsion of gastric content from the mouth. Patients rated vomiting as the most undesirable postoperative outcome and nausea as the fourth of undesirable adverse effects after surgery as reported by Moreno et al. (2013). The female sex, nonsmoking status, history of PONV or motion sickness, and use of volatile anesthesia and opioids are considered well-established risk factors for occurrence of PONV (Abired et al., 2019).

There are multimodal pharmacological strategies for managing postoperative nausea, vomiting, and retching (PONVR) like prokinetic agents, serotonin receptors blockers, dopamine receptors blockers, corticosteroids anticholinergic, antihistaminic, neurokinin 1 receptors antagonists, benzodiazepines, and octreotide, but are associated with many adverse effects, so nonpharmacological measures could be integrated with pharmacological strategies to prevent postoperative complications and minimize risk factors to improve patient outcomes (Zabirowicz and Gan, 2019).

According to the National Center for Complementary and Integrative Health (2016), complementary therapy is the approach that can be used alongside the traditional medical treatment to control nausea and vomiting. Diaphragmatic breathing is one of the simple and cost-effective strategy; it is safe with minimal space requirements, ease of learning, and ease of practice that could be used to relieve PONV, and anxiety and has other positive effects on the patient status (Emami-Sahebi et al., 2018; Wise geek, 2019).

Nurses working in the recovery room and postsurgical department have an effective role in prevention of PONV through informing the patient about diaphragmatic breathing as a new approach in caring PONV and the other benefits of applying diaphragmatic breathing on the body (Rosenberg, 2015).

Most of the nationally and internationally performed studies regarding PONV were focused only on acupressure, aromatherapy, and pharmacological measures. However, there were no previous studies concerned with diaphragmatic breathing exercise. Therefore, the current study was conducted to assess the effect of diaphragmatic breathing exercise on postorthopedic surgeries complaints (Craven et al., 2017; HealthTimes, 2017).

Significance of the study

More than 40 million patients undergo surgery per year in the USA and more than 100 000 000 patients worldwide, with ∼30% experiencing PONV (Smith et al., 2012). Mndolo et al. (2014) found an incidence of PONV at Queen Elizabeth Central Hospital in Malawi was 29%, and the incidence of PONV among postoperative patients in South Africa was ∼27%, as reported by Rodseth et al. (2010). Moreover, there was a higher incidence of PONV in Uganda (40.7%), in Nigeria (41%), in Tanzania (41.4%), in Ghana (34%), and in South West Ethiopia (27.4%), as cited by Obsa et al. (2020). Scant research studies about PONV have been done by physicians, but there is no clear incidence about the incidence of PONV in Egypt.

Denholm and Gallagher (2018) reported that PONV is one of the most distracting adverse effects after surgery and anesthesia that occurs frequently in orthopedic patients receiving patient-controlled analgesia. PONV is considered the worst complaint than pain as reported by postoperative patients. It is associated with higher rate of complication such as dehydration, electrolyte imbalance, suture dehiscence, bleeding, hematoma, aspiration, esophageal rupture, and airway compromise. Complementary alternative measures such as diaphragmatic breathing can improve patient outcomes, quality of care, and reduce cost through decreasing recovery room stays and improving discharge. Literature has documented diaphragmatic breathing as a simple, effective, cost-effective, nonpharmacological approach that is safe with minimal space requirement, ease of learning, and ease of practice that could be used to relieve PONV, anxiety, and has other positive effects on the patient status (Phillips et al., 2015).


  Patients and methods Top


Aim

The aim of the current study was to evaluate the effect of diaphragmatic breathing exercise on nausea, vomiting, and retching among postoperative orthopedic patients.

Research hypotheses

H1: The mean score of nausea before will be different from the mean score of nausea after performing diaphragmatic breathing exercises among postoperative orthopedic patients.

H2: The mean score of retching before will be different from the mean score of retching after performing diaphragmatic breathing exercises among postoperative orthopedic patients.

H3: The mean score of vomiting before will be different from the mean score of vomiting after performing diaphragmatic breathing exercises among postoperative orthopedic patients.

Research design

One-group pretest–post-test quasi-experimental design was used to achieve the aim of this study.

Setting

The current study was conducted at recovery rooms and orthopedic wards at Kaser Al-Ainy Teaching Hospital, affiliated to Cairo University Hospital, under the supervision of the Ministry of Higher Education.

Sample

A convenient sample of 100 adult male and female conscious patients who underwent surgery under general anesthesia was included in the study along three consecutive months. The following inclusion criteria were considered: adult, postoperative patient, undergoing elective orthopedic surgeries receiving general anesthesia, with blood pressure not less than 110/65 mmHg, alert with Glasgow Coma Scale (GCS)=13–15, and complaining of one or more attacks of either nausea or vomiting. The following were the exclusion criteria: patients with disturbance in conscious level with GCS less than 13, undergoing spinal or regional anesthesia, emergent orthopedic surgeries, and past history of severe respiratory and/or cardiac problems.

Data collection tools

Three tools were used to collect data of the current study:
  1. Demographic and Medical Data Form: it was developed by the investigator based on extensive literature review. It is composed of two parts: the first part includes demography-related data covering questions related to age, sex, level of education, occupation, etc., and the second part elicited data related to medical history such as smoking status, type of surgery, duration of anesthesia, and starting postoperative oral intake.
  2. Index of Nausea, Vomiting, and Retching (INVR): it was developed by Rhodes to evaluate nausea, vomiting, and retching (1996). The INVR is a self-report tool that consists of eight items: a numeric value for each item ranged from 0 (the least amount of distress) to 4 (the most/worst distress). Total symptoms were calculated by summing the patient’s responses to each of the eight items on the INVR. Likert scale consisted of three subscales: nausea (range: 0–12), vomiting (range: 0–12), and retching (range: 0–8), providing a total range of 0–32. The score of 0 indicated none NVR, 1–8 indicated mild NVR, 9–16 indicated moderate NVR, 17–24 indicated severe NVR, and 25–32 indicated worst NVR. The coefficient reliability of the tool working Cronbach’s α was 0.889.
  3. Glasgow coma scale: it was developed and published by Teasdale and Jennett (1974). It is a neurological tool that aims to objectively and reliably assess the level of consciousness. It was divided into three items: best eye response, best verbal response, and best motor response. The responses are ‘scored’ from 1, for no response, up to normal values of 4 (eye-opening response), 5 (verbal response), and 6 (motor response). The total coma score thus has values between three and 15, with three being the worst and 15 being the highest. The investigator used GCS to check the eligibility of the participant to be included in the study.


Pilot study

A pilot study was performed on 10 patients of the study sample fitting the inclusion criteria to assess the feasibility of the study and to test the tools for required time of filling out and to assess their clarity and applicability. There was no required modification done in the study tools, so the pilot study was included in the study sample.

Procedure

The study was conducted in three phases:

Preparatory phase: once official permission was granted to proceed with the proposed study from authoritative personnel, the researchers started to check the GCS score of the participants included in the list to ensure eligibility. The study participants who fit the inclusion criteria were interviewed individually after recovery from anesthesia to explain the nature and purpose of the current study. Written informed consent was obtained from the participants who were willing to participate. The demographic and medical data from the patients’ file at recovery rooms and orthopedic wards was gathered, and then the researchers assessed PONVR using INVR for the participants during the attack before starting intervention as a baseline data. All study participants received preanesthetic medications like antiemetics, antiacids, antibiotics, and analgesics and received volatile anesthetic agent as isoflurane during the induction of anesthesia and during the surgery. Moreover, all study participants received neostigmine during recovery from the anesthesia.

Implementation phase: during implementation, the participants were instructed to practice diaphragmatic breathing exercise as follows: first, lay flat on the bed or in semi-setting position and then relax the shoulders; second, put one hand on the abdomen and another one on the chest; third, take breathe through the nose, with careful attention to move the hand resting on the abdomen with each breath while maintaining stillness in the hand that is on the chest; fourth, purse the lips, press gently on the stomach, and exhaled slowly for about few seconds; fifth, stay focused and attentive on the relaxing words, images, feelings and tune out any other thoughts or sounds; sixth, move the abdominal wall predominantly during inspiration and to reduce upper rib cage motion; and seventh, repeat these steps several times as needed for 10 min.

Teaching session regarding to how to perform the technique took approximately ten minutes for each participant. Moreover, participants were guided by blood pressure measurement (blood pressure measurement should not reach to less than 110/65 mmHg). The participant was instructed to stop the exercise if there is any feeling of headache or drowsiness, or if blood pressure measurement reaches to less than 110/65 mmHg.

Evaluation phase: each participant was evaluated after performing the diaphragmatic breathing exercise for two times regarding the PONV: the first time after 6 h postintervention and the second time after 12 h after intervention to evaluate the effect of diaphragmatic breathing exercise using INVR. The time spent to fill the tool ranged approximately from 15 to −20 min.

Ethical consideration

An IRB (00004025) approval to conduct the proposed study was obtained from the Research and Ethics Committee of Faculty of Nursing, Cairo University. Moreover, an official permission was obtained from hospital administrators to conduct the study. Each patient was informed about the nature and purpose of the study, and its importance. Each patient was free to either participate or not in the current study and had the right to withdraw from the study at any time without any rationale and without them being affected in the care provided. Moreover, patients were informed that data obtained would not be included in any further researches. Confidentiality and anonymity of each participant were assured through coding the data.

Statistical design

Upon completion of data collection, the collected data were coded, scored, tabulated, and analyzed using Statistical Package for the Social Sciences (version 20.0; SPSS Inc., Armonk, New York, USA). Descriptive statistics were used to present the data pertinent to the study in the form of frequency and percentage distribution, mean score, and SD. Appropriate inferential statistical tests were used to examine the research hypotheses such as t-test. The significance level of all statistical analysis was P value less than or equal to 0.05.


  Results Top


This study results were presented through two sections as follows: section I represents description of the study participants’ characteristics related to demographic and medical data, and section II covers comparison of mean scores of nausea, retching, and vomiting before and after practicing diaphragmatic breathing exercise.

Section I: characteristics of the study participants

Regarding demographic characteristics, [Table 1] reveals that 28% of the study sample had age ranged between 30 and less than 40 years. Male had the highest percentage of the study sample as it presents 55% of the patients, and 71% of study sample were married. Regarding educational level, 60% of the study sample can read and write and 69% had no work.
Table 1 Frequency and percentage distribution of the study participants regarding demographic data (N=100)

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[Figure 1] shows that 54% of study sample live in urban areas and 46% of them live in rural area.
Figure 1 Percentage distribution of the place of residence of the study participants (N=100).

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[Figure 2] reveals that 73 and 27% of the study participants were nonsmoker and smoker, respectively.
Figure 2 Percentage distribution of smoking status of the study participants (N=100).

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In relation to surgery and anesthesia-related information, 73% of the study participants underwent major surgeries, and regarding duration of anesthesia, 97% of the study sample underwent surgery under general anesthesia for more than or equal 2 h.

Concerning starting oral postoperative intake, [Figure 3] reveals that 33% had nothing per os along the 12 postoperative intervention hours, whereas 23% started after 4 h and 44% of them starting after 6 h.
Figure 3 Percentage distribution of starting oral intake of the study participants (N=100).

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Section II: comparison of mean scores of nausea, retching, and vomiting before and after practicing diaphragmatic breathing exercise

[Table 2] shows a highly statistical significant difference among the study participants regarding the mean vomiting score before and after 6 h of performing diaphragmatic breathing (t-test=7.624, P=0.000). Moreover, this table indicates that there was a highly statistically significant difference between the study participants’ mean vomiting score before and after 12 h (t-test=12.893, P=0.000). Additionally, there was a highly statistically significant difference between the study participants’ mean vomiting score after 6 h and after 12 h (t-test=7.641, P=0.000).
Table 2 Comparison of vomiting mean scores as reported by study participants before and after performing diaphragmatic breathing along the study period (N=100)

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[Table 3] shows that there was a highly statistically significant difference among the study participants’ mean nausea score before and after 6 h of performing diaphragmatic breathing (t-test=24.149, P=0.000). In addition, there was a highly statistically significant difference between the study participants’ mean nausea score before and mean nausea score after 12 h (t-test=36.034, P=0.000). Moreover, there was a highly statistically significant difference between the study participants’ mean nausea score after 6 h and mean nausea score after 12 h (t-test=18.686, P=0.000).
Table 3 Comparison of nausea mean scores as reported by study participants before and after performing diaphragmatic breathing along the study period (N=100)

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[Table 4] shows that there was a highly statistically significant difference among the study participants after performing the diaphragmatic breathing exercise along the study period, with t-test=24.429 between before intervention and six hours after intervention, t-test=42.371 between before intervention and 12 h after intervention, and t-test=22.53 between 6 h after intervention and 12 h after intervention, with P=0.000 along the three tests.
Table 4 Comparison of retching mean scores as reported by study participants before and after performing diaphragmatic breathing along the study period (N=100)

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[Table 5] shows that there was a highly statistically significant difference among the study participants’ total mean score of nausea, vomiting, and retching (TNVR) before and after 6 h of performing diaphragmatic breathing (t-test=20.454, P=0.000). There was a highly statistical significant difference between the study participants’ total mean score of TNVR before and after 12 h (t-test=34.054, P=0.000). Moreover, there is a highly statistically significant difference between the study participants’ total mean score of TNVR after six hours and after 12 h (t-test=20.533, P=0.000).
Table 5 Comparison of total nausea, vomiting, and retching mean scores as reported by study participants before and after performing diaphragmatic breathing along the study period (N=100)

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  Discussion Top


PONVR is a serious problem that occurs after surgery and general anesthesia. Postoperative nausea occurs in about half of all patient who underwent surgery, and about one-third of them complain of postoperative vomiting. The present study aimed to evaluate the effect of diaphragmatic breathing exercise on nausea, vomiting, and retching among postoperative orthopedic patients. The discussion of reported findings of the current study compared with the recent literatures and other related studies. It also explains to what extent the results of the current study supported or contradicted with the results of others. A discussion of this study findings is presented into two sections. The first section is concerned with study participants’ characteristics. The second section is concerned with comparison of mean regarding scores of nausea, retching, and vomiting before and after practicing diaphragmatic breathing exercise.

Section I: study participants’ characteristics

Demographic data

The findings of the current study showed that half of the studied sample aged between 20 and less than 40 years old, with mean±SD age of 35.2±13 years. Close results were reported by Rathna et al. (2018) in a study entitled ‘Efficacy of Single Parenteral Dose of Palonosetron Versus Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Surgeries under General Anesthesia’ that the mean age of the study sample was 34.04±9.93 years. Moreover, in the same line, Laskin et al. (2019) reported in a study entitled ‘Predicting Postoperative Nausea and Vomiting in Patients Undergoing Oral and Maxillofacial Surgery’ that slightly more than one-third of participants were more than or equal to 40 years old. In contrast, Antle et al. (2019) reported in a study entitled ‘Antiemetics for Postoperative Nausea and Vomiting in Patients Undergoing Elective Arthroplasty’ that the majority of the study sample was aged above 50 years old.

Regarding sex, more than half of them were males. The same finding was reported by Laskin et al. (2019) that more than half of participants were males. In contrast, Alli et al. (2017) showed in a study entitled ‘The Effect of Ethnicity on the Incidence of Postoperative Nausea and Vomiting in Moderate to High Risk Patients Undergoing General Anesthesia in South Africa’ that more than three-quarters of the study sample were females.

In addition, near three-quarters of the current study sample were married. This could be owing to that the majority of patients were in the adulthood and middle age stages. Furthermore, more than half of them lived in urban areas and could read and write, and additionally, more than two-thirds had no work. This could be owing to the disease nature, which restricted the patients’ ability to work.

Medical data

Furthermore, the present study delineated that approximately more than three-quarters of participants underwent major surgery for more than 2 h. The earlier finding is consistent with Moreno et al. (2013) who mentioned in a study entitled ‘Postoperative Nausea and Vomiting: Incidence, Characteristics and Risk Factors − A Prospective Cohort Study’ that more than three-quarters underwent major surgery. Moreover, the last result is in the same line with Leong et al. (2015) who mentioned in a study entitled ‘Singapore General Hospital Experience on Ethnicity and the Incidence of Postoperative Nausea and Vomiting after Elective Orthopedic Surgeries’ that more than three-quarters underwent surgery less than 3 h (the median surgical duration was 2–3 h).

Regarding anesthesia, this study depicted that the total sample underwent surgery under general anesthesia, and the majority of them persisted under its effect for more than or equal to 2 h. The same result is showed by Rathna et al. (2018), in which all participants underwent surgery under general anesthesia. Moreover, in the same context, Yeo et al. (2018) reported in a study entitled ‘Aprepitant Prophylaxis Effectively Reduces Preventing Postoperative Nausea And Vomiting In Patients Receiving Opioid Based Intravenous Patient-Controlled Analgesia’ that mean duration of anesthesia was 143.5±83.5 min, which means it was more than 2 h. In contrast, the result of Jessel and Selvaraj (2018) mentioned in a study entitled ‘PostOperative Nausea and Vomiting (PONV) Rates Following the Introduction of an Enhanced Protocol in Patients Undergoing an Elective Primary Lower Limb Arthroplasty’ that less than one-fifth of participants underwent general anesthesia. In addition, Al-ghanem et al. (2019) reported in a study entitled ‘Predictors of Nausea and Vomiting Risk Factors and its Relation to Anesthesia in a Teaching Hospital’ that mean duration of anesthesia was 82.39±53.47.

Regarding smoking, the current study demonstrated that approximately three-quarters of participants were nonsmokers. The same result was presented by Al-Ghanem et al. (2019) who reported that approximately three-quarters of the study sample were nonsmokers, whereas Kappen et al. (2015) mentioned in a study entitled ‘Impact of Adding Therapeutic Recommendations to Risk Assessments from a Prediction Model for Postoperative Nausea and Vomiting’ that slightly more than half of participants were nonsmokers. As cited by Matthews (2017), it has been found in a study entitled ‘A Review of Nausea and Vomiting in the Anaesthetic and Post Anaesthetic Environment’ that smokers are not as sensitive as nonsmokers to noxious substances, such as anesthetic gases, deeming nonsmokers more at risk of PONV. Moreover, Moreno et al. (2013) mentioned in a study entitled ‘Postoperative Nausea and Vomiting: Incidence, Characteristics and Risk Factors − A Prospective Cohort Study’ that there is no difference between smokers and nonsmokers as risk factors for PONV.

This study denoted that about one-third of the studied participants were nothing per os until 12 h postoperative, whereas most of the remaining started oral intake between 4 and 6 h postoperative. In contrast, Chalya et al. (2015) mentioned that most of the studied participants had their first oral intake after 12 h postoperatively that can influence the incidence of nausea and vomiting in the postoperative period. This is at variant with Öbrink et al. (2015) who reported that no association between timing of postoperative oral intake and PONV.

Section II: comparison of mean scores of nausea, retching, and vomiting before and after practicing diaphragmatic breathing exercise

The present study illustrated that generally, there was a highly statistically significant difference between participants’ mean scores of nausea, retching, and vomiting score before and after performing diaphragmatic breathing exercise. Additionally, there was a highly statistically significant difference between mean scores of nausea, retching, and vomiting among participants before, after 6 h, and after 12 h after performing diaphragmatic breathing exercise. This can be interpreted in the light of the fact that diaphragmatic breathing exercises reduce the incidence of nausea, vomiting, and retching because it has a relaxing and stabilizing effect on the autonomic nervous system and vagus nerve stimulation, so it regulates gastrointestinal movements, induces relaxation, and decreases anxiety. In addition, it relaxes spastic contraction of respiratory and abdominal muscles during the nausea, vomiting, and retching (Russell et al., 2014; Chen et al., 2017).

These current study findings supported the three proposed research hypotheses; it might be related to the fact that nonpharmacological strategies such as relaxation techniques (music, hypnosis, cognitive distraction, guided imagery and relaxation exercise and breathing exercise) were effective for managing common chemotherapy adverse effects like nausea and vomiting as documented by Lotfi-Jam et al. (2018), and Avalos et al. (2020) who added that distraction therapy involving diaphragmatic breathing relaxation and biofeedback were effective in management of belching and rumination syndrome which is abnormal postprandial reflex of increased gastric pressure occurring with an increase in abdominal muscle tone, simultaneous with relaxation of the esophageal sphincters, allowing retrograde flow of gastric content.

Moreover, the current result agreed with Bonthi et al. (2019), who reported in a study entitled ‘Rumination Syndrome in Essential Medical Disorders of the Stomach and Small Intestine’ that diaphragmatic breathing exercise is the best strategy to reverse the gastroesophageal pressure gradient and is easily taught and is highly effective for managing rumination syndrome. Moreover, it reduces abdominal wall tone and increases the crural component of the lower esophageal sphincter during and after eating. Moreover, Carlson et al. (2019) reported that diaphragmatic breathing and body scan exercises are highly effective in treatment of fatigue, insomnia, nausea, and vomiting.

In addition, in the same line with the reported results of this study, Larios-Jiménez et al. (2019) stated in a study entitled ‘Efficacy of relaxation techniques in the reduction of tension, anxiety and stress perceived by patients with cancer under chemotherapy treatment’ that relaxation techniques such as diaphragmatic breathing have been proven to be effective in reducing nausea, vomiting, pain, insomnia, stress, and anxiety among patients receiving chemotherapy. Additionally, the current result was supported by Stromberg et al. (2015) who reported in a study entitled ‘Diaphragmatic Breathing and its Effectiveness for the Management of Motion Sickness’ that diaphragmatic breathing exercises with audio instruction and video experiences have positive effect in reducing motion sickness and heart rate and respiratory rate.


  Conclusion Top


Based on the current study findings, it can be concluded that diaphragmatic breathing exercise could be effective in reducing the intensity and frequency of occurrence of PONVR among participants undergoing orthopedic surgeries. Moreover, this study findings supported the three research hypotheses.

Recommendations

The study suggested the following implications and recommendations;
  1. The diaphragmatic breathing exercise should be included in nursing curriculum as a new approach to treat PONV.
  2. Threads or line or way or approach in the nonpharmacological management of PONVR in protocol of care for postoperative patients as an effective strategy for such a problem.
  3. The study should be replicated using a larger probability sample selected from different geographical areas in Egypt.
[38]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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