Cancer defines the group of diseases characterized by uncontrolled growth and abnormal proliferation of cells.1 Chemotherapy administered using antineoplastic agents aiming to completely eliminate such cells or control their growth is one of the most crucial treatment steps of cancer and different tools such as port catheter may be needed during this treatment.2 Subcutaneous venous ports are catheters that allow safe and easy venous access route for long-term medications, completely inserted subcutaneously, and are applied with small surgical method.3 Ports that can be inserted into basilar, internal jugular, and subclavian veins are produced from stainless steel, titanium, or plastic material with single or double lumen. The difference between port catheter and other catheters is that it is completely implanted subcutaneously and comprises a closed system. Chemotherapy drugs and fluids to be administered intravenously with the aid of this subcutaneously implanted system can be inserted into blood circulation directly and without continuous insertion.4,5 After determining the catheter insertion site, it is cleaned with appropriate antiseptic solution and the reservoir is placed by making a small incision on the skin. Then the central end of the catheter is moved forward to the superior vena cava and right atrium entrance via a specific needle and a guide wire. By joining and fixing the reservoir and catheter under the skin, incision site is covered completely.4
Because veins used for insertions of permanent catheters such as port catheters are very close to muscular tissues, pain is felt more in invasive interventions applied to these veins.6 Therefore, pain experienced during insertion of the catheter may lead to discomfort. This makes the patient's adherence to the procedure difficult.7 Pharmacological and nonpharmacological methods are used in controlling these problems encountered during the procedure. Among nonpharmacological methods, peripheral techniques, stimulation of skin via massage and touch, cognitive-behavioral techniques, aromatherapy, acupuncture, and placebo application are frequently preferred.8,9 Although aromatherapy, one of these methods, is a part of phytotherapy, which means “herbal medicine,” its focus is symptom control rather than treatment.10 Essential oils used in aromatherapy have been determined to have numerous effects such as relaxation, anti-inflammatory, analgesic, disinfection, and antioxidant. It is also known that essential oils ensure mood control, have anxiolytic and antidepressant effects, and have many effects such as improving memory and recovering cognitive disorder in dementia related diseases.11,12 It is also stated that inhaler aromatherapy practices are very important especially for pain control. Studies investigating control of pain experienced during port catheterization and indicating the effect of aromatherapy was not found in the literature review conducted during planning of the present study. Another consideration is that patients with cancer often use integrative methods without having received information from reliable sources. Therefore, the present study was conducted to evaluate the effect of inhaler aromatherapy on pain, procedure adherence, vital signs, and oxygen saturation during port catheterization.
Aromatherapy refers to the medicinal or therapeutic use of essential oils absorbed through the skin or olfactory system. Olfactory stimulation related to aromatherapy can result in immediate reduction in pain, as well as changing physiological parameters such as pulse, blood pressure, skin temperature, and brain activity.13 In particular, aromatherapy via inhalation of essential oils is an easy, quick, and effective treatment for some physical and physiological problems such as lower and upper respiratory infections, fever, sinusitis, fatigue, depression, insomnia, and pain.14 Essential oils can be inhaled through a humidifier or by soaking gauze and placing it near the patient. Olfactory and tactile sensory stimulation produced by these oils can enhance ordinary human activities such as eating, social interaction, and sexual contact. While more than 40 plant derivatives have been identified for therapeutic use, lavender, eucalyptus, rosemary, chamomile, orange, and peppermint are the most frequently utilized extracts.13 Lavender is one of the most widely used aromatic plants for inhaler aromatherapy. Effective ingredients involve a combination of linalool and linalyl acetate. Linalool acts as a tranquilizer by affecting aminobutyric acid receptors in the central nervous system. After inhalation of lavender, a significant decrease in cortisol release from the adrenal gland and a significant increase in secretion of serotonin from the digestive system have been determined.15 It has been documented that inhalation of the essential oil of orange can stimulate the central nervous system, enhance moods, and cause sedation and relief. It is an antispasmodic, anti-inflammatory, and antibloating food digestive and a diuretic and can lower the blood pressure.16 Chamomile is one of the most popular herbs around the world. Historically, it has been used to treat many conditions including anxiety, depression, insomnia, and pain.17 Being commonly used, aromatherapy has been applied for centuries; however, few studies have examined its effectiveness in reducing pain and other symptoms.13 The aim of this study was to evaluate the effectiveness of aromatherapy on invasive pain, the procedure adherence, vital signs, and saturation.
The study was conducted in a nonrandomized controlled trial with patients for whom a port catheter was inserted to undergo chemotherapy in cardiovascular operating rooms at Şanlıurfa Mehmet Akif İnan Training and Research Hospital between April 2015 and January 2016 and Harran University Research and Application Hospital between August 2015 and January 2016.
Setting and sample
Power analysis was used to calculate the sample size of the study. While bias level was calculated as 0.05, power of the test was found to be 0.80. As a result of this analysis, the number of patients required to be included in intervention and control groups was determined as minimum 17. The study was completed with a total of 60 patients including 30 patients for the intervention group and 30 patients for the control group. Control group assessments were conducted before the intervention group so that control group members would not be subjected to any inhaler aromatherapy residual in the port catheterization room. Once control group was completed, intervention group was included in the study and then inhaler aromatherapy was applied.
Patients, who were older than 18 years, had no communication problem, respiratory system disorder, substance addiction, and allergic disorder, and agreed to participate in the study, were included in the study. Patients, who did not speak Turkish, had allergic disease and respiratory system disorder, and rejected to participate in the study, were excluded from the study.
The data were collected by using “Questionnaire” on sociodemographic characteristics, disease-related data, and properties concerning integrative methods, “visual analog scale (VAS)” to evaluate pain experienced by patients during the procedure and their procedure adherence, and “Follow-up Form” to assess vital signs and saturation before, during, and after the procedure.
The questionnaire asked about sociodemographic characteristics (age, gender, marital status, educational background, employment status, economic status), disease-related properties (type of cancer, duration of disease), and integrative methods (the state of having information about integrative methods, information source, integrative methods used, and number of methods used). The questionnaire was applied by the researcher in a face-to-face interview, thus, avoiding problems with illiterate subjects. Therefore, no problem was experienced for illiterate ones.
Visual analog scale
Visual analog scale is a scale applied by marking a straight, millimetric horizontal or vertical line with a pen. On this line, 0-cm point signifies “no pain,” whereas 10-cm point signifies “the worst pain.” The patient then marks the pail level on the scale. Scoring is made by measuring the marked point with the help of a tape measure. In most of the studies conducted so far, it is stated that VAS is a reliable tool to be used for evaluating the pain level.18 The procedure adherence of the patients was also evaluated using this scale and while 0 signifies “there was no the procedure adherence,” 10 signifies “high procedure adherence.” This evaluation was made by the physician who was not included in the study and performed the port catheterization. Behaviors of the patient such as grimacing, making a sound, and moving his or her hands-feet during catheter insertion were observed while evaluating the procedure adherence. Adherence of the patient was enumerated over VAS at the end of procedure upon observation of these criteria by the physician.
It is a form used to record vital signs and saturation values before, during, and after the procedure.
Procedure and aromatherapy application
For inhaler aromatherapy to be applied to the intervention group, orange, chamomile, and lavender oil at the ratio of 1:1:1 were diluted in 70 mL distilled water. Three drops from this mixture were dripped on the sponge. The inhaler aromatherapy application was started by placing a sponge opposite the intervention site and onto the pillow approximately 10-CM from the patient. This application lasted on average for 15 minutes.19 The patients in the control group were not subjected to any intervention during port catheterization except for routine practices of the clinic (15 mL priloc was administered for local anesthetic). Pain levels and vital signs before, during, and after the procedure and their procedure adherence during the procedure were evaluated and recorded for patients in intervention and control groups (Figure). There was no patient, whose intervention was interrupted, who did not want to continue the study, or experienced discomfort because of inhaler aromatherapy, among the patients meeting inclusion criteria of the study. The blood pressure cuff was fastened to the patients before starting the procedure and was monitored by attaching the saturation probe. Thus, blood pressure and saturation levels of the patients were followed-up from the monitor and recorded. Before the data collection stage of the study, the researcher consulted with an expert conducting scientific studies on inhaler aromatherapy and its application. The data collection stage was also started after reviewing the literature on inhaler aromatherapy.
Ethical considerations of the study
Written approval was received from relevant ethics committees and institutions to conduct the study. Both groups were informed about the aim of the study and content of the questionnaires before applying the questionnaires to both groups and the aromatherapy to the intervention group. Written consents for participation were obtained.
The data were evaluated by using χ2 test, Student t test, and 2-factor analysis of variance with repeated measures. P value of less than .05 was accepted as statistically significant.
Results on sociodemographic characteristics of the patients
It was determined that 43.3% of patients in the intervention group over 60 years old and 53.3% of patients in the control group were between the ages of 40 and 59 years; 53.3% of the intervention and 50% of the control group were female. The rate of being illiterate was 30.0% in intervention group and 6.7% in control group, a great majority of the patients in intervention and control groups were married, and there was no difference between both groups in terms of sociodemographic characteristics (P > .05) (Table 1).
Results on disease-related properties of the patients
It was found that 53.3% of the intervention group and 30.0% of the control group had another chronic disorder. In the intervention group, 36.7% of the patients were diagnosed with breast cancer; further, 46.7% digestive system cancer in control group. Also, 50.0% of the intervention group and 53.3% of the control group had the disease at stage 2 (Table 2). It was determined that 60.0% of the patients in both groups had metastasis (P > .05).
Results on Patients' characteristics concerning integrative methods
It was determined that 63.3% of the intervention group and 46.7% of the control group had information about integrative methods (P > .05). A great majority of patients in both groups preferred “special diet” as the integrative method, 50.0% of intervention group applied integrative methods to “provide additional benefit to medical treatment,” and 50.0% of control group applied integrative methods because of “despair” (Table 3).
Results on pain levels of patients
Mean pain score of the intervention group was 6.2 ± 1.6 before the procedure, decreased to 5.0 ± 1.2 during the procedure, and increased to 5.5 ± 1.2 again after the procedure and this change was statistically significant (P < .05). In the control group, mean pain score was 6.0 ± 0.9 before the procedure, increased to 7.4 ± 1.4 during the procedure, and decreased to 6.5 ± 1.6 after the procedure (P < .05) (Table 4).
Results about the procedure adherence of the patients
Mean score of the procedure adherence was 8.1 ± 2.0 in the intervention group and 7.2 ± 1.5 in the control group; however, the difference between both groups was not statistically significant (P > .05) (Table 5).
Results on vital signs and saturation of the patients
Inhaler aromatherapy was found to decrease mean arterial pressures of patients in intervention group. Inhaler aromatherapy did not affect saturation values and respiratory rates of patients in the same group (P > .05) (Table 6).
Most of the cancer cases are reported to be involved in the group aged 40 years and older, to be married and male, to be aware of the diagnosis, and to have metastasis.20–24 Similarly, most of the patients in both groups were 40 years of age and older. In addition, the majority of participants applied integrative methods and they preferred these methods primarily to “provide additional benefit to medical treatment.” In some studies on patients with cancer in Turkey, different results have been obtained regarding the use of integrative methods. In the study conducted by Ceylan et al25 with patients with cancer, it was determined that the rate of using integrative methods was 60.1%; further, Algier et al26 determined this rate as 36%. In another study, the patients' frequency of using integrative methods was 24% to 98% and they preferred the use of vitamin/mineral.22 In another study, herbal mixtures (most commonly “stinging nettle”) were the most frequently used method; the use of integrative methods was affected by factors such as gender, duration of disease, advanced stage of cancer, socioeconomic level, and educational level. The patients stated that they generally applied these methods upon recommendation by family, friend, or patients in the clinic and most of them used them during medical treatment following the diagnosis of cancer.27
In the literature, inhaler aromatherapy seems to be an integrative method that is often used for pain control. Lavender applied particularly as inhaler was reported to be effective in decreasing pain associated with different causes (coping with cancer pain, arthritis, postcesarean delivery, dysmenorrhea, renal colic, etc).28,29 In a study conducted with patients undergoing hemodialysis, it was concluded that inhaler aromatherapy was effective in bringing invasive pain under control during insertion of fistula.30 In the present study, intensity of pain experienced by patients before, during, and after the procedure was determined to decrease significantly with inhaler aromatherapy applied during the portcatheterization process (P < .05). In addition, inhaler aromatherapy positively affected blood pressure of the patients at a minimal level even though it was not statistically significant in the present study. This change at a minimal level is thought to be associated with different factors; however, in a study supporting this result and in which inhaler aromatherapy was applied to nursing students, who were performing intravenous intervention for the first time, during the intervention, it was also concluded that inhaler aromatherapy was effective on blood pressure, saturation values, and anxiety levels of the students.19
In the present study, it was also evaluated whether or not inhaler aromatherapy applied during port catheterization procedure influenced the procedure adherence of the patients and as a result of the analysis, the patients' procedure adherence increased and they did not experience any adverse effect. Uncertainty, lack of knowledge, or misinformation may lead to anxiety and discomfort.31 Therefore, patients who experience anxiety during invasive interventions have difficulty in procedure adherence. This makes it harder for health care professionals to control the procedure and prolongs the duration of procedure. Previous studies emphasized that psychological parameters such as fear, anxiety, and stress that are controlled by the limbic system can be brought under control with the efficiency of inhaler aromatherapy.32–34 Several related studies revealed that inhaler aromatherapy had positive effects on the learning process, attention level and focusing, perception, cognitive performance, memory, and mood.32–36 In a study conducted with lemon oil, it was determined that lemon oil was effective in controlling anxiety37 and inhaler aromatherapy applied to patients undergoing colonoscopy before the procedure facilitated procedure adherence.38
As a result of this study, it was determined that inhaler aromatherapy decreased the pain experienced and positively influenced procedure adherence and blood pressure during port catheterization among patients diagnosed with cancer.
In accordance with these results, it can be recommended to regularly assess the level of pain experienced by patients during the port catheterization procedure, to include inhaler aromatherapy for controlling pain of patients who are not at risk for inhaler aromatherapy, to plan studies, which evaluate the effect of inhaler aromatherapy on pain during other invasive procedures such as port catheterization and aim to standardize the amounts, dilution rates, and durations of oils used, and to incorporate them into nursing practices.
Although the present study was conducted in 2 centers, it cannot be generalized to all patients with cancer. Limitations of the study were exclusion of those with respiratory system disease, implementation of inhaler aromatherapy only during port catheterization procedure, and use of only lavender, chamomile, and orange oils for inhaler aromatherapy. Another limitation is that study groups were not prepared via randomization.
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