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Original article 47

Effect of diaphragmatic breathing exercise on postoperative

nausea, vomiting, and retching among orthopedic surgery
patients
Hamada A.N. Ibrahim, Hanan A. Al Sebaee, Dalia S. El-Deen
Department of Medical Surgical Nursing,
Faculty of Nursing, Cairo University, Cairo,
Egypt
Correspondence to Hamada A.N. Ibrahim,
BSc, Department of Medical Surgical Nursing,
Faculty of Nursing, Cairo University, Cairo,
Egypt. Tel: +20 111 694 3201;
e-mail: hamada.9195@gmail.com
Received: 6 July 2020
Revised: 28 July 2020
Accepted: 10 August 2020
Published: 18 November 2020
Egyptian Nursing Journal 2020, 17:47–55
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
Egypt Nurs J 17:47–55
© 2020 Egyptian Nursing Journal
2090-6021

The postoperative nausea and vomiting (PONV) is

Introduction
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).
considered one of the most common causes of patient
dissatisfaction that occurs in recovery rooms or in the
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© 2020 Egyptian Nursing Journal | Published by Wolters Kluwer - Medknow DOI: 10.4103/ENJ.ENJ_19_20
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48 Egyptian Nursing Journal, Vol. 17 No. 1, January-April 2020
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
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.
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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.
Effect of diaphragmatic breathing exercise Ibrahim et al. 49
(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
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50 Egyptian Nursing Journal, Vol. 17 No. 1, January-April 2020
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
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.
Figure 1 shows that 54% of study sample live in urban
areas and 46% of them live in rural area.
Figure 2 reveals that 73 and 27% of the study
participants were nonsmoker and smoker, respectively.
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.
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Effect of diaphragmatic breathing exercise Ibrahim et al. 51

Table 1 Frequency and percentage distribution of the study Figure 1

participants regarding demographic data (N=100)
Variables n (%)
Age
<20 15 (15)
20 to <30 22 (22)
30 to <40 28 (28)
40 to <50 20 (20)
≥50 15 (15)
Mean±SD (35.2±13)
Sex
Male 55 (55)
Female 45 (45)
Marital status
Single 28 (28) Percentage distribution of the place of residence of the study par-
Married 71 (71) ticipants (N=100).
Divorced 1 (1)
Level of education
Figure 2
Cannot read and write 14 (14)
Can read and write 60 (60)
Secondary education 15 (15)
University education 11 (11)
Occupation
Working 31 (31)
Not working 69 (69)

Concerning starting oral postoperative intake, Fig. 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.

Percentage distribution of smoking status of the study participants

Section II: comparison of mean scores of nausea, (N=100).
retching, and vomiting before and after practicing
diaphragmatic breathing exercise
Table 2 shows a highly statistical significant difference Figure 3

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 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
Percentage distribution of starting oral intake of the study participants
(N=100).
nausea score after 6 h and mean nausea score after
12 h (t-test=18.686, P=0.000).
Table 4 shows that there was a highly statistically
significant difference among the study participants
after performing the diaphragmatic breathing exercise
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52 Egyptian Nursing Journal, Vol. 17 No. 1, January-April 2020

Table 2 Comparison of vomiting mean scores as reported by Table 3 Comparison of nausea mean scores as reported by
study participants before and after performing diaphragmatic study participants before and after performing diaphragmatic
breathing along the study period (N=100) breathing along the study period (N=100)
Study period Mean±SD t-test P value Study period Mean±SD t-test P value
Before intervention 4.39±2.95 7.624 0.000* Before intervention 6.59±0.88 24.149 0.000*
6 h after intervention 2.12±2.39 6 h after intervention 3.7±1.16
Before intervention 4.39±2.95 12.893 0.000* Before intervention 6.59±0.88 36.034 0.000*
12 h after intervention 0.59±1.4 12 h after intervention 1.11±1.6
6 h after intervention 2.12±2.39 7.641 0.000* 6 h after intervention 3.7±1.16 18.686 0.000*
12 h after intervention 0.59±1.4 12 h after intervention 1.11±1.6
*Significant at P≤0.000. *Significant at P≤0.000.

Table 4 Comparison of retching mean scores as reported by Table 5 Comparison of total nausea, vomiting, and retching
study participants before and after performing diaphragmatic mean scores as reported by study participants before and
breathing along the study period (N=100) after performing diaphragmatic breathing along the study
Study period Mean±SD t-test P value period (N=100)

Before intervention 4.57±0.7 24.429
6 h after intervention 2.45±0.91
Before intervention 4.57±0.7 42.371
12 h after intervention 0.60±0.93
6 h after intervention 2.45±0.91 22.53
12 h after intervention 0.60±0.93
*Significant at P≤0.05.
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 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).
Discussion
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
0.000* Study period Mean±SD t-test P value
Before intervention 15.55±3.2 20.454 0.000*
0.000* 6 h after intervention 8.27±3.57
Before intervention 15.55±3.2 34.054 0.000*
0.000* 12 h after intervention 2.3±3.36
6 h after intervention 8.27±3.57 20.533 0.000*
12 h after intervention 2.3±3.36
*Significant at P≤0.000.
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.
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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
Effect of diaphragmatic breathing exercise Ibrahim et al. 53
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
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54 Egyptian Nursing Journal, Vol. 17 No. 1, January-April 2020
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
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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