SUMMARIZING JURNAL

Oleh Klompok 4 :

1. I Gede Jaya Saputra (193213013)

2. Kadek Ayu Ulan Sudariyanthini (193213020)
3. Leila da silva Pinto (193213021)
4. Ni Nyoman Ayu Krisna Sari (193213037)
5. Ni Putu Cintya Dewi (193213038)
6. Ni Putu Eka Cintya Parwita (193213040)
7. Putu Riska Pramudita Dewi (193213049)
8. Solangia cabral da Conceicao Santos (193213052)
9. Rai Angga Putra Gunawan (193213051)

KEPERAWATAN PROGRAM SARJANA

STIKES WIRA MEDIKA BALI
DENPASAR
2021/2022
 Observational Study Medicin
e
OPEN

Effect of evidence-based nursing intervention on ®

upper limb function in postoperative radiotherapy

patients with breast cancer
Xin Wang, BSa, Qian Lai, BSb, Yuzhen Tian, BSa, Ling Zou, BSc,∗
Abstract
To investigate the effect of evidence-based nursing (EBN) intervention on upper limb function in postoperative breast cancer
patients undergoing radiotherapy.
A total of 126 breast cancer patients who had received postoperative radiotherapy in the Union Hospital affiliated with Tongji
Medical College, Huazhong University of Science and Technology from September 2017 to September 2018 were randomly
divided into 2 groups, namely, experimental and control groups, with 63 cases in each group. Both the control and
experimental groups received routine postoperative radiotherapy followed by traditional and EBN interventions, respectively.
All patients were followed up for 6 months and differences in the upper limb function after nursing intervention were compared
between the 2 groups.
The scores of self-rating anxiety scale (SAS), self-rating depression scale (SDS), and short form-36 survey (SF-36) in the 2
groups had no statistical significance before intervention. After the EBN intervention, the SAS and self-rating depression scale
scores of patients in the experimental group were lower than that of those in the control group. In the experimental group,
90.67% of the patients had an excellent score for the University of California, Los Angeles shoulder score, which was higher
than that of the control group (73.92%). The Mayo Elbow Performance Score of the experimental group (95.01) was higher
than that of the control group (91.33). The total length of the sum of arm circumference in the experimental group was (128.39
cm) lower than that of the control group (143.66 cm). The scores of SF-36 in the overall health, physical pain, mental health,
and physiological functions of the patients in the experimental group were higher than those of the control group. All of these
parameters’ differences between the 2 groups were of statistical significance (P < .05).
EBN can positively influence the negative emotional state of breast cancer patients after radiotherapy. At the same time, it is
helpful in reducing the degree of lymph node edema on the affected side of the upper limb, thereby improving the function of
the shoulder joint, which has a positive effect on the upper limb function.
Abbreviations: EBN = evidence-based nursing, SAS = self-rating anxiety scale, SDS = self-rating depression scale, SOAC =
sum of arm circumference, UCLA = University of California.
Keywords: breast cancer, evidence-based nursing, radiotherapy, upper limb function

1. Introduction primary treatment for breast cancer, but it also has some
Invasive breast cancer is the most common malignancy in women, unavoidable postoperative complications, 1 of which is the upper
accounting for 23% of all cancers in women globally, and 27% in limb dysfunction of the affected side. In addition, postoperative
affluent countries.[1] At present, surgery is still the radiotherapy can cause local tissue edema, muscle contracture,
and scar formation, aggravating upper limb dysfunction. In
Editor: Guanyi Zhang. recent years, despite the advancements in radiotherapy methods
The authors have no conflicts of interest to disclose. such as 3-dimensional conformal radiotherapy and intensity-
a
Cancer Center Union Hospital, Tongji Medical College, b Department of Obstetrics modulated radiotherapy, there are still certain minor side effects.
and Gynecology, c Department of Orthopaedics, Union Hospital, Tongji Medical Hence, studies in the field of recovery of upper limb function in
College, Huazhong University of Science and Technology, Wuhan, China. breast cancer patients after radiotherapy has important clinical
∗
Correspondence: Ling Zou, Department of Orthopaedics, Union Hospital, Tongji Medical significance. With the deepening of evidence-based nursing (EBN)
College, Huazhong University of Science and Technology, Wuhan 430022, China (e-
research, a nursing practice based on real and reliable scientific
mail: 13523560916@qq.com)
evidence from patients, the traditional narrow empiricism model of
Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc. This
is an open access article distributed under the terms of the Creative Commons
nursing is transforming into a new concept of nursing.[2] The
Attribution-Non Commercial License 4.0 (CCBY-NC), where it is purpose of this study is to explore the effect of EBN on upper
permissible to download, share, remix, transform, and buildup the work provided it is extremity function by coupling it with postoperative radiothera-
properly cited. The work cannot be used commercially without permission from the py among breast cancer patients.
journal.
How to cite this article: Wang X, Lai Q, Tian Y, Zou L. Effect of evidence-based
nursing intervention on upper limb function in postoperative radiotherapy patients with 2. Materials and methods
breast cancer. Medicine 2020;99:11(e19183).
2.1. General information
Received: 23 April 2019 / Received in final form: 9 January 2020 / Accepted: 13
January 2020 http://dx.doi.org/10.1097/MD.0000000000019183 A total of 126 patients who had received postoperative
radiotherapy for breast cancer from September 2017 to
September 2018 in the Union Hospital affiliated with Tongji
Medical College, Huazhong University of Science and Technol-
ogy were selected. The patients were all female, aged 39 to 75
years, with an average of 58.9 ± 11.4 years. Inclusion criteria:
(1) All patients diagnosed with breast cancer by and “upper limb function” were used as keywords to search the
comprehensive examination of imaging, pathology, and literature in PubMed, Web of Science, and Google Scholar, and
biology; and who underwent modified radical mastectomy high-quality literature was selected for intensive reading. The
for breast cancer;
(2) Female;
(3) Patients conforming to the standard of radiotherapy for
breast cancer.
Exclusion criteria:
(1) Postoperative recurrence of breast cancer;
(2) Primary diseases of upper limbs or limb dysfunction;
(3) Unable to cooperate with workers due to mental health
issues;
(4) Complicated with organ dysfunction.
The patients were divided into an experimental and a control
group with 63 patients in each group according to the nursing
mode they received. The experimental group patients received
EBN intervention and were 46 to 72 years old, with an average
age of 58.4 ± 12.0. The control group patients received
traditional nursing intervention and were 44 to 69 years old,
with an average age of 56.0 ± 11.3. The Ethics Society
approved this study and the patients’ informed consent was
taken. There were no significant differences in the baseline
clinical and demographic data between the 2 groups.
3. Method
Postoperative radiotherapy in both groups was performed by
the same team with professional qualifications and extensive
experience at the supraclavicular region, axillary fossa, and
chest wall according to the 2017 National Comprehensive
Cancer Network (NCCN) Breast Cancer Practice Guide. [3]
Postoperative radiotherapy mainly includes 3-dimension x-ray
beams (3-D XB) and 3-D XB with electron beams (EB). The
radiotherapy dose of 3-D XB was 6 MV x-ray 50 Gy/25 times
and the radiotherapy dose of 3-D XB with EB was 26 Gy/13
times and 244 y/12 times.
The control group received routine nursing intervention,
including health education after admission, teaching, and
training on the importance of upper limb functional exercise
after operation and during radiotherapy, and basic exercises to
help patients recover their upper limb function.
3.1. EBN
1. Questions: What are the relevant factors affecting the
upper limb function of patients undergoing postoperative
radiother- apy and the types of upper limb functional
exercises available? Studies have shown that the incidence
of upper limb lymphedema after radical mastectomy or
modified radical mastectomy is 36% to 65%. The main
manifestations are upper limb movement limitation and
muscle weakness that seriously affects the quality of life of
[4]
breast cancer patients after operation. Since there is a
self-aggravating vicious circle in the pathogenesis, the
incidence increases gradually with the passage of time. [5]
It has been reported that the incidence of mild upper
limb lymphedema after breast cancer surgery is 41% and
moderate to severe edema is about 15%, leading to upper
limb dysfunction and mental depression. [6]
2. Evidence-based support: Apply evidence-based method to
find out the cause of the problem.
"Breast cancer”, “modified radical surgery”, “radiation therapy”,
main reasons for the dysfunction are as follows:
(1) Post operation: Excision of axillary lymph nodes
leading to a blockage in the lymphatic reflux of the
upper limbs after lymphatic vessel ligation; Venous
obstruction, venous adhesions, and lymphadenitis caused
by thrombophlebitis results in protein aggregation in
tissues, which increases osmotic pressure and water
absorption capacity, leading to lymphedema of the
affected limbs; and the damage of blood vessels and
nerves during operation will affect the sensory and
motor functions of the affected upper limbs.
(2) Postoperative radiotherapy: Radiotherapy causes venous
occlusion and lymphatic vessel destruction in the
radiation field. Radiotherapy can also lead to tissue
edema, muscle contracture, and scar formation, which
can aggravate upper limb dysfunction.
3. Formulating a nursing plan and intervention with the best
evidence:
(1) Pain relief: Roses et al reported that intractable pain
and numbness in the axillary lymph node, chest wall,
and upper arm of the affected side after breast cancer
dissection were common phenomena. About 25% of
patients suffered from persistent pain after operation. [7]
Persistent pain not only affects normal activities, but
also aggravates the patient’s psychological burden,
reduces compliance for functional exercise, and prolongs
recovery. Therefore, relieving pain is an important
measure for early functional exercise and long-term
adherence to treatment.
(2) Psychological intervention and health education: The
key is to understand the patient’s psychological state
and communicate with a positive attitude to help alleviate
their negative emotions. Regular health education was
given to help them correct bad habits, to explain the
importance of upper limb functional exercise, and to
improve patients’ treatment compliance.
(3) Massage and traction of the affected limbs: Relaxing
and massaging the shoulder muscles of the affected
upper limbs; kneading of the trapezius muscle, the
muscles around the rotator cuff, the supraspinatus
muscle, and the infraspinatus muscle was carried out. At
the same time, the nurse assisted the patient to perform
passive back extension exercise of the shoulder joint.
The strength of the traction was based on the degree of
the patient’s pain sensitivity, with an average of 3 times
a day for 10 minutes each time.
(4) Upper limb rehabilitation exercise: Timely and reasonable
upper limb functional exercise can make the axillary
lymph node heal flat and fully play the compensatory
role. When performing radiotherapy, exercises to
minimize the edema caused by radioactive muscle
fibrosis cannot be relaxed. Finger exercises can be done
on the same day after operation. The wrist and hand
joints can be exercised 1 to 3 days after operation;
elbow joints after 4 to 8 days to avoid abduction of
upper arm; and shoulder joints on the 8th day.
Exercises were performed 3 to 5 times a day,
with
 Table 1
Demographic characteristics of patients.
Bridge to surgery group (n Emergency operation group (n= 63)
Characteristics = 63) Number of patients% Number of patients% P
Age, yr 58.79 ± 10.75 56.86 ± 11.28 .326
Sex .675
Male 35 (55.6) 40 (63.5)
Femal 28 (44.4) 23 (36.5)
BMI 22.53 ± 3.09 22.41 ± 2.73 .132
Pathological types .914
Nvasive ductal carcinoma 34 (54.0) 38 (60.3)
Medullary carcinoma 10 (15.9) 12 (19.1)
Invasive special type of cancer 19 (30.1) 13 (20.6)
TNM stage .936
I 5 (7.9) 7 (11.1)
II 25 (39.7) 20 (31.7)
III 33 (52.4) 36 (57.1)
Lymph node(number) 23.86 ± 10.55 19.81 ± 8.30 .349
Adjuvant radiotherapy .773
3-D XB∗ 37 (58.7) 29 (46.0)
3-D XB+EB∗ 26 (41.3) 34 (54.0)

3-D XB∗ = 3-dimension x-ray beams, BMI = body mass index, EB ∗ = electron beams.

the interval between 2 exercises being not less than 2 hours, and the
time for each exercise being not less than 15 minutes. paired t test was used in the group, and the analysis of variance
was used in the group. The count data were expressed in
3.2. Observation indicators and efficacy criteria percentage (%), and the data were processed by chi square test,
and P < .05 was considered statistically significant.
The self-rating depression scale (SDS) and self-rating anxiety scale
(SAS) were used to identify the patient’s emotional state and a lower
score indicated a better mood.[8] Sum of arm circumference (SOAC) 4. Results
is the measurement of arm circumference at 20 cm, 15 cm, and 5 cm We compared the basic characteristics of the patients (age; sex;
above and below the elbow joints, plus the total circumference of body mass index; type of breast cancer; tumor node metastasis
the wrist and metacarpophalangeal joints.[9] The Mayo Elbow stage; node dissection; and radiotherapy dosage), and the results
Performance Score (MEPS), developed by Morrey in 1992, was used showed that there was no statistical significance between the 2
to evaluate the elbow joint function. The scale has a maximum
groups (P > .05) before EBN intervention (Table 1). Similarly,
score of 100 to 45 for pain, 20 for motor function, 10 for stability,
[10] there was no significant difference in the self-rating depression
and 25 for daily activities. The shoulder scores of the patients
scale (SDS) and SAS scores between the 2 groups before EBN
were scored using the University of California, Los Angeles (UCLA)
intervention. However, after the intervention, SAS and SDS scores
scoring system. In the 1981 edition of UCLA shoulder score,
of the patients in the experimental group were lower than those in
subjective evaluation of the patient was based on their pain;
the control group (Table 2). After EBN intervention, the UCLA
objective evaluation was based on the doctor’s physical
shoulder score in the experimental group was higher than that in
examination of functional activity, shoulder mobility, and muscle
[11] the control group (91.67% vs 72.92%). The MEPS of the
strength. The total score was 35 points - a score less than 29 was
experimental group patients was higher than that of the control
rated as poor, 29 to 33 was rated as good, and 34 to 35 was rated
[12] group (94.11 vs 90.23). The total length of SOAC in the
as excellent. Short form-36 survey (SF-36) was used to assess
experimental group was lower than that of the control group
the quality of life of the patients, and those with high scores
(126.39 cm vs 145.26 cm) (Table 3). The overall health, social
indicated a high quality of life.
function, physiological function, mental health, physical pain,
physical limitations, vitality, and emotional functions of the
3.3. Statistical analysis patients in the experimental group were higher than those of the
control group (Table 4). The differences between the groups, of all
All data were analyzed using the statistical package SPSS version
the above parameters, was statistically significant (P < .05).
23.0. All measurement data were represented as (x ± s). The

Table 2
Comparison of SDS and SAS scores between the 2 groups (x ± s).
Group Time SAS SDS
Control group (n = 63) Before intervention After 61.20 ± 5.39 65.71 ± 6.52
intervention Before 44.10 ± 2.53 41.19 ± 3.37
Experimental group (n= 63) intervention After 62.27 ± 5.13 64.29 ± 6.67
intervention 31.21 ± 0.54 27.95 ± 2.69
SAS = self-rating anxiety scale, SDS = self-rating depression
scale.
Table 3 Therefore, the nurse should communicate with the patient and
Upper limb function before and after intervention in 2 groups (x ± s). his family to find out the psychological state of the patient
and give corresponding psychological care. At the same time,
when
Group UCLA Mayo SOAC
instructing patients to exercise their limbs, they should be nursed
Experimental
strictly, group (n= 63)
according to the ± 0.75 condition
33.26actual 94.11 ±of2.40 126.39 ± evidence-based
the patients, 5.72 skills, and clinical experience, and gradually carry out
Control group
functional (n = 63) to27.53
exercises help± 0.49
them recover ± 2.18 normal
90.23 their 145.26 ± 5.30
limb function.
t 44.296 41.612 52.825
SOAC = sum of arm circumference, UCLA = University of California. The recovery of upper limb function occurs due to a
P <.05 <.05 <.05
significant reduction in the degree of edema in the affected
limb that consequently improves the function of the
5. Discussion shoulder joint. There are also some limitations to our study.
First, as a retrospective study, patient inclusion biases may
The evidence-based approach stems from a new paradigm of have occurred. Second, The sample size is not large, and the
medicine, evidence-based medicine, developed as a learning reliability of the results needs to be further verified. In
method by epidemiologists at the McMaster University, Canada, conclusion, our study shows that EBN intervention in breast
[13]
It is a new nursing model based on the analysis and cancer patients undergoing postoperative radiotherapy can
processing of “big data” by setting up the problems to be solved, significantly improve the quality of life of the patients by
summarizing the literature with reference values, and enhancing their upper limb function and thereby their mental
summarizing the reports from various forms of scientific research health.
results. In the actual application process, the scientific research
basis, the nurse’s skills, and the individualized needs of patients
Acknowledgment
are combined to formulate scientific and comprehensive nursing
measures.[14] It is considered to be one of the most important The authors sincerely thank the entire staff of our
factors to improve the quality of health care and patient health department for offering their assistance with the medical
outcomes.[15–18] It not only proves the value of nurses and makes service and manuscript writing processes.
nursing activities more scientific and professional, but it also
provides opportunities for improving the authority, promoting Author contributions
the development, and independence of nursing disciplines.[13] Our
Department has established a professional EBN team, which Conceptualization: Xin Wang, Qian Lai.
encourages the members to focus on discussing patients’ Data curation: Xin Wang, Qian Lai, Ling Zou.
condition. By combining available professional literature and Formal analysis: Xin
patients’ actual condition, we can formulate appropriate EBN Wang. Investigation:
plans and administer systematic nursing for patients. This Yuzhen Tian.
evidence-based care team, a responsible group, is conducive to Methodology: Qian Lai.
the development and implementation of individualized care Project administration: Yuzhen Tian.
measures. This approach is more effective as the problems and Resources: Yuzhen Tian.
nursing measures are more closely linked and hence, the care Software: Xin Wang, Qian Lai.
received by the patients is more refined with a stronger purpose. Supervision: Yuzhen Tian.
Upper limb dysfunction is common in breast cancer patients after Validation: Qian Lai.
radiotherapy. Bosompra et al found that 63% of the patients after Writing – original draft: Xin Wang, Yuzhen Tian, Ling Zou.
surgery had upper body numbness, 35% had significant Writing – review and editing: Ling Zou.
swelling, 13% to 15% had different degrees of pain, and 1% to 4%
had shoulder joint abduction limitation and muscle weakening. [19] References
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postoperative muscle contracture, and radio- therapy damage, sentinel lymph node metastasis is a marker of poor prognosis in
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in breast-saving therapy of breast cancer][J]. Geburtshilfe
Overall health 86.52 ± 3.45 64.31 ± 2.32 47.163 .036 Frauenheilkd 1989;49:367–74.
Social function 85.69 ± 3.24 64.32 ± 2.05 41.091 .006 [5] Kwan W, Jackson J, Weir LM, et al. Chronic arm morbidity after
Physiological function 84.23 ± 3.21 60.14 ± 2.43 44.637 .003 curative breast cancer treatment: prevalence and impact on
Mental health 87.68 ± 5.15 65.96 ± 3.35 28.265 .000 quality of life [J]. J Clin Oncol 2002;20:4242–8.
Physical pain 90.14 ± 3.22 71.06 ± 2.41 32.753 .002 [6] Winkler M, Akca O, Birkenberg B, et al. Aggressive warming
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Vitality 91.37 ± 2.54 68.21 ± 3.16 34.058 .005
[7] Roses DF, Brooks AD, Harris MN, et al. Complications of level I
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[11]Amstutz HC, Sew HA, Clarke IC. UCLA anatomic total shoulder arthroplasty[J]. Clin Orthop Relat Res 1981;7–20.
[12] Ormseth SR, Wellisch DK, Arechiga AE, et al. Predicting reattendance at a high-risk breast cancer clinic[J]. Palliat
Support Care 2015;13:1441–8.
[13] Schlomer G. [Evidence-based nursing: a method for nursing practice?] [J]. Pflege 2000;13:47–52.
[14] Chen LL, Lin JD. [Acupressure and Evidence-Based Nursing] [J]. Hu Li Za Zhi 2015;62:27–34.
[15] Considine J, Mcgillivray B. An evidence-based practice approach to improving nursing care of acute stroke in an
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[16] De Pedro-Gomez J, Morales-Asencio JM, Sese-Abad A, et al. Psycho- metric testing of the Spanish version of the practice
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[17] Fineout-Overholt E, Melnyk BM, Schultz A. Transforming health care from the inside out: advancing evidence-based
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[18] Peterson ED, Bynum DZ, Roe MT. Association of evidence-based care processes and outcomes among patients with
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[19] Bosompra K, Ashikaga T, O’Brien PJ, et al. Swelling, numbness, pain, and their relationship to arm function among
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Introduction  What research question or problem was addressed?
Postoperative breast cancer treatment using radiotherapy
method which aims to explore the effect of EBN on upper
extremity function in breast cancer patients.
 Are there any hypotheses formulated?
The main treatment for breast cancer also has some
unavoidable postoperative complications, including upper
extremity dysfunction of the affected side. In addition,
postoperative radiotherapy can cause local tissue edema,
muscle contractures, and scar tissue formation, exacerbating
upper extremity dysfunction.
Methods  What type of research was done?
This type of research is carried out with evidence-based
methods (EBN), nursing practice is based on real and
reliable scientific evidence from patients, the traditional
narrow empiricism nursing model turns into a new nursing
concept.
 How was data collected and analyzed?
The patients were divided into an experimental and a
control group with 63 patients in each group according to
the nursing mode they received. The experimental group
patients received EBN intervention and were 46 to 72 years
old, with an average age of 58.4±12.0. The control group
patients received traditional nursing intervention and were
44 to 69 years old, with an average age of 56.0±11.3. The
Ethics Society approved this study and the patients’
informed consent was taken. There were no significant
differences in the baseline clinical and demographic data
between the 2 groups. The control group received routine
nursing intervention, including health education after
admission, teaching, and training on the importance of
upper limb functional exercise after operation and during
radiotherapy, and basic exercises to help patients recover
their upper limb function.
Results  What were the most imfortant findings?
Comparison the basic characteristics of the patients (age;
sex; body mass index; type of breast cancer; tumor node
metastasis stage; node dissection; and radiotherapy dosage),
and the results showed that there was no statistical
significance between the 2 groups (P>.05) before EBN
intervention. And also, there was no significant difference
in the self-rating depression scale (SDS) and SAS scores
between the 2 groups before EBN intervention. However,
after the intervention, SAS and SDS scores of the patients in
the experimental group were lower than those in the control
group.
 Were the hypotheses supported?
Results after EBN intervention, the UCLA shoulder score in
the experimental group was higher than that in the control
group (91.67% vs 72.92%). The MEPS of the experimental
group patients was higher than that of the control group
(94.11 vs 90.23). The total length of SOAC in the
experimental group was lower than that of the control group
(126.39 cm vs 145.26 cm). The overall health, social
function, physiological function, mental health, physical
pain, physical limitations, vitality, and emotional functions
of the patients in the experimental group were higher than
those of the control group. The differences between the
groups, of all the above parameters, was statistically
significant (P <.05).
Discussion /  What is the overall answer to the research question?
Conclusion The overall answer to the research question the author state
This study shows that the EBN carried out
in breast cancer patients undergoing postoperative
radiotherapy can significantly improve patients' quality of
life by improving their upper extremity function and
mental health.
 How does the author explain these results?
The author explain by establishing a professional EBN
team, which focuses on patients with the conditions
 discussed and combines available professional literacy with
the actual condition of the patient, can formulate the
appropriate EBN intervention and implementation nursing
for patients
 What are the imflications of the results?
The autor state that evidence-based approach stems from a
new paradigm of medicine, evidence-based medicine,
developed as a learning method by epidemiologists at the
McMaster University, canada, this is new nursing model
based on the analysis and processing of "big data" by setting
up the problems to be solved, summarizing the literature
with reference values, and summarizing the reports from
various forms of scientific rescarch results.
 Are there any imfortant limitations?
In the journal author's explained that upper Iimb
dysfunction often occurs in breast cancer patients after
radiotherapy. It was found that 63% of patients after surgery
experienced upper body numbness, 35% had significant
swelling, 13% to 15% have different degrees of pain, and
1% to 4% had shoulder joint abduction limitation and
muscles weakening . This may be related to various factors
such as: Surgical trauma, postoperative muscle contractures,
and radiographs therapeutic damage, which not only affects
the patient's quality of life, but also negatively affects
psychology
 Are there any key recommendations?
In the journal still needs improvement in conducting
research related to reducing the degree of edema in the
affected extremity which
consequently improves the function of the shoulder joint.
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