The Effect of Intervention on Semi Fowler and Fowler Positions on Increasing Oxygen Saturation in Heart Failure Patients

Introduction: In Indonesia, data from the 2013 Basic Health Study showed the prevalence of heart failure was 0.3%, an estimated 530,068 people based on a doctor's diagnosis. Cardiovascular disease is a disease that interferes with the function of the heart and blood vessels, clinical symptoms in patients with congestive heart failure (CHF) include dyspnea, orthopnea, dyspnea and paroxysmal nocturnal dyspnea (PND), pulmonary edema, ascites, pitting edema, weight gain and even shock. cardiogenic. Method: The method used in this research is an experimental research method. The type of research used is quasi-experimental (quasi-experimental). Objective: The purpose of this study was to determine the effect of semi-Fowler and Fowler positions on increasing oxygen saturation in heart failure patients at Sumedang Hospital. Results and Discussion: The first output shows the difference in oxygen saturation of the rear half-fowler of 45 and 90, on the rear half-fowler an average of 94.25, the minimum and maximum values of 90-97, Then to catch the rear bird of 90 the average is 96.50 and min and max are 93-99. Conclusion: The effect of half fowler and fowler positions given by Sumedang Hospital to increase blood oxygen saturation in heart failure patients with a value of 90.50. For the second half of Fowler's 45˚, get the values, min 90 and max 97 and mean 94.25.


Introduction
increase oxygenation at the time of inspiration or inhalation of the patient. With the increase in oxygen in the body, the oxygen carried by red blood cells and hemoglobin also increases, so that oxygen saturation also increases (Muttaqin, 2009) In patients with Congestive Heart Failure on a change in position, with the results showing that from the head up position to the semi-Fowler and Fowler positions, the average oxygen saturation value tends to increase (Khasanah, 2019). The results show that there is a difference in oxygen saturation between these positions. In addition, Safitri and Andryani's research (Safitri & Andriyani, 2011) on the effectiveness of giving the semi-fowler position to asthma patients in class III inpatients at Moewardi Hospital, Surakarta, showed that there was a difference in shortness between before and after being given the semi-fowler position. Another study conducted by Wahyuningsih, Khasanah, & Susanti (2017), in CHF patients treated at the ICCU, the results showed that there were differences between respiratory rate, oxygen saturation and complaints of shortness of breath in the initial position by giving the semi-Fowler position 45˚ and Fowler 90˚.
Data from Sumedang Hospital with cases of heart disease (CHF) in inpatient installations in January -April 2019 there were as many as 132 patients. This number is the third highest number of patients diagnosed with CHF heart failure. In addition, data on the mortality rate of CHF heart failure patients in January -April 2019 contained 10 patients. This number is the highest number of deaths from heart disease. From the results of a preliminary study conducted by researchers by observing patients diagnosed with CHF who were treated in the HCU room, it was found that 5 of 8 patients were more comfortable when resting in a sitting position, and 3 of 8 patients stated that they were more comfortable at rest in a half position. sit. The average oxygen saturation in these 8 patients ranged from 92 -98%. Meanwhile, based on the research journal Bernardi et al (2008) "effect of breathing rate on oxygen saturation and exercise performance in chronic heart failure" said that the value of oxygen saturation in CHF patients ranged from 91 -95%.
Based on the description above, the researcher is interested in examining the effect of the intervention of semi-Fowler and Fowler positions on increasing oxygen saturation in heart failure patients.
This study aims to determine the effect of semi-Fowler's and Fowler's positions on increasing oxygen saturation in heart failure patients at Sumedang Hospital. The location of the research is in the HCU room of the Sumedang General Hospital. The time used to conduct research is on July 22 -August 05, 2019.

Methods
The method used in this study is the experimental research method. The type of research used is quasi-experimental (quasi-experimental) with a pre-test-post-test one group design experimental group was given Fowler and semi-Fowler positions and then measured the value of oxygen saturation before and after the intervention. (Jaedun, 2011)  Description: X : before giving the position (pre-test) Y1 : after giving the semi fowler position 45 Y2 : after giving Fowler position 90˚ The population in this study was CHF heart failure patients in the HCU room at Sumedang Hospital with a population of 42 people or respondents, based on data taken from the hospital (researcher's place) in January to April 2019.
The sampling technique used in this study used Non-probability sampling with the Consecutive sampling , namely the selection of samples by determining subjects who meet the research criteria to be included in the study for a certain period of time, so that the required number of clients is met (Nursalam, 2019)

Results
Results of this study aimed to assess the effect of the semi-Fowler and Fowler position intervention on increasing oxygen saturation in heart failure patients at Sumedang Hospital in 2019. The data was generated from an observation sheet consisting of CHF class/stage, pre-test SaO2 value, semi-SaO2 value. Fowler 45˚, and SaO2 Fowler value 90˚. Data collection was carried out on 22 July -05 August 2019 obtained 16 respondents who met the inclusion criteria

1.
Univariate analysis Characteristic description of oxygen saturation values before positional intervention (pre-test). Description of oxygen saturation values before position intervention (Pre-test) in heart failure patients. The results of these calculations can be seen in the following table: Table 2 Frequency distribution of SaO2 values before positional action (pre-test) in heart failure patients Source: The results of primary data processing 2019 In table 2, it can be seen that the value of oxygen saturation before the position intervention (pre-test), obtained results 14 (87.5%) respondents had oxygen saturation values were not normal (<95%) and 2 (12.5%) respondents had normal oxygen saturation values (>95%).
Characteristic description of oxygen saturation value after intervention in 45˚ semi-Fowler position (post-test 1). Description of oxygen saturation value after intervention in 45˚ semi-Fowler position (post-test 1), in heart failure patients. The results of these calculations can be seen in the following  In table 3, it can be seen that the oxygen saturation value after the intervention semi-Fowler position 45˚ (post-test 1), the results obtained 9 (56.2%) respondents had abnormal oxygen saturation values (<95%) and 7 (43.8%) respondents had normal oxygen saturation values (>95 %).
Characteristic description of oxygen saturation value after intervention in Fowler's position 90˚ (post-test 2). Description of oxygen saturation value after intervention in Fowler's position 90˚ (post-test 2), in heart failure patients. The results of these calculations can be seen in the following table: In table 4 it can be seen that the oxygen saturation value after the intervention Fowler's position 90˚ (post-test 2), it was found that 1 (6.2%) respondent's had abnormal oxygen saturation values (<95%) and 15 (93.8%) respondents had normal oxygen saturation values (>95%) Characteristic description of oxygen saturation values based on delta increase. Description of oxygen saturation values before and after positional intervention (pretestposttest) in heart failure patients. The results of these calculations can be seen in the following table: Nandar Wirawan, Nandi Periadi, M Iqbal Kusuma/KESANS The Effect of Intervention on Semi Fowler and Fowler Positions on Increasing Oxygen Saturation in Heart Failure Patients   Overview of oxygen saturation values based on CHF grade. Description of oxygen saturation values before and after positional intervention (pretest-posttest) in heart failure patients. The results of these calculations can be seen in the following table:

Source: Results of data processing 2019
In table 6 it can be seen that the value of Oxygen Saturation before and after position intervention (pre-post) based on CHF class/stage. The results of the Oxygen Saturation value before giving the position (pre-test) to CHF respondents, obtained 9 respondents (56.2%), were in CHF class/grade II with Oxygen saturation <95% (abnormal). In the post semi-Fowler oxygen saturation value of 45˚, 6 respondents (37.5%), were in class/grade II with oxygen saturation <95% (abnormal). Then for the post-Fowler oxygen Nandar Wirawan, Nandi Periadi, M Iqbal Kusuma/KESANS The Effect of Intervention on Semi Fowler and Fowler Positions on Increasing Oxygen Saturation in Heart Failure Patients saturation value of 90˚, 9 respondents (56.2%), were in class/grade CHF II with an oxygen saturation value of 95% (normal).

Bivariate Analysis
The right statistical test to see the effect of the semi-Fowler and Fowler position intervention on increasing oxygen saturation in heart failure patients at Sumedang Hospital in 2019 used the Wilcoxon test bivariate analysis (Nursalam, 2015) to see the closeness of the effect with the quasitest results experiment because the results of the normality test of the percent data were not normally distributed and the following results were obtained: Source: Results of primary data processing 2019

Interpretation of results:
The first output section shows the difference between Saturation pre-test oxygen with post-semi-Fowler oxygen saturation 45˚, in the pre-test the Mean value was 90.50 with a value of 85-95 for the minimum and maximum, then for the results after being given a 45 semi-Fowler position, the Mean value was 94.25 with a value of 90-97 for the minimum and maximum. The test statistics shows the results of the Wilcoxon test, obtained a significant value of p = 0.025 < (0.05) thus it is concluded that there is a significant difference between before the pre-test and after giving the semi-Fowler position 45˚. The first output section shows the difference between oxygen saturation post semi fowler 45 with post fowler 90, in post semi fowler obtained a Mean value of 94.25 with a value of 90-97 for the minimum and maximum, then for the post fowler 90 obtained a Mean value of 96.50 with a value of 93-99 for the minimum and maximum. The test statistics shows the results of the Wilcoxon test, obtained a significant value of p= 0.005 < (0.05) thus it is concluded that there is a significant difference between (post 1) semi-Fowler position 45˚ and (post 2) fowler position 90˚.

Univariate results of oxygen saturation values before position intervention (Pretest).
Based on table 3, it can be seen that the oxygen saturation value before the position intervention (pre-test), obtained the results that 14 (87.5%) respondents had abnormal oxygen saturation values (<95%) and 2 (12.5%) respondents have normal oxygen saturation values (> 95%). Then it can be seen in table (4.1.5) that almost most of the oxygen saturation values are in CHF class/grade II respondents with the results of 9 respondents (56.2%), with Oxygen saturation <95% (abnormal). These results are in accordance with the theory quoted from (Yanci, et al 2013) said the American Heart Association in grade II patients found structural heart damage but without showing signs and symptoms of heart failure, usually in patients with myocardial infarction, coronary arteries that can trigger an increase in heart failure. preload and may exacerbate pulmonary congestion. The average value of oxygen saturation in CHF class II patients is in the range of 84-88%. (New York Association NYHA).
Univariate results of Oxygen Saturation value after intervention in the 45˚ semi-Fowler position (Posttest 1). In table 3 it can be seen that the oxygen saturation value after the intervention of the semi-Fowler position was 45˚ (post-test 1), it was found that 9 (56.2%) respondents had abnormal oxygen saturation values (<95%) and 7 (43, 8%) respondents had normal oxygen saturation values (>95%). Then it can be seen in table (6) In the post semi-Fowler oxygen saturation value of 45˚, 6 respondents (37.5%) were in class/grade II with oxygen saturation <95% (abnormal). These results are in line with the results of research conducted by Sudoyo, Setiyohadi, and Alwi, (2009) which stated that at the semi-Fowler position the gravitational force of blood circulation is lower because the direction of circulation is horizontal so it is not too against gravity and does not pump too much. Slow backflow makes the increase in the amount of fluid that enters the lungs decrease, so that the air in the alveoli is able to absorb oxygenated air.

Univariate results of Oxygen Saturation value after intervention in Fowler's position 90˚ (post 2).
In table 4 it can be seen that the oxygen saturation value after the intervention in the Fowler's position was 90˚ (post-test 2), it was found that 1 (6.2%) respondent's had abnormal oxygen saturation values (<95%) and 15 (93.8) %) respondents had normal oxygen saturation values (>95%). It can be seen in table (6)  oxygen saturation values of 90˚ were obtained by 9 respondents (56.2%), being in CHF II class with an oxygen saturation value of 95% (normal). These results are in accordance with the theory put forward by Cheever & Hinkle, (2014) that in CHF patients with pulmonary edema, the recommended position is the 90˚ Fowler position because it allows the chest cavity to expand widely and lung expansion increases. This condition can cause oxygen intake to improve so that the respiratory process returns to normal. And in line with the research of Wahyuningsih, Khasanah, and Susanti (2017) which shows that changes in respiratory status are better in Fowler's position.

Bivariate results pretest post test
The results of Bivariate analysis using the Wilcoxon test showed that there was a difference in the results of SaO2 pretest, to semi-Fowler's 45˚, to Fowler's 90˚. The difference in the value of oxygen saturation (SaO2) was seen between before the intervention (pre-test) to the post Semi-Fowler 45˚ with the results (p value 0.025) and the results from post semi fowler 45 to post fowler 90 with the result (p value 0.005). Surtiningsih (2019) regarding the study of oxygen saturation and respiration of patients with congestive heart failure in changing positions. Yudono in differences , repertoire results shows that there is a difference in SaO2 between these positions (p value 0.002), the difference in SaO2 value is seen between the head-up position and the fowler position (p value 0.033).difference in the SaO2 value of CHF patients between the head-up, semifowler, and fowler a statistically significantAnd contrary to the results of research conducted by Anisa, Utomo, Utami (2018) regarding his research on the effect of changing position on breathing patterns in patients with respiratory disorders, the results of this study obtained normal oxygen saturation values >95% in the low fowler position as many as 11 respondents, there are 14 respondents in the semi-Fowler position, and 13 respondents in the standard Fowler position, so it can be concluded that there is a normal saturation change >95% at the low fowler position to the semi-Fowler position and the semi-Fowler position to the standard fowler position with p value 0.311>α(0, 05) it can be concluded that there is no significant effect between the low fowler's position, the semi-fowler's position, and the standard fowler's position.

Conclusion
Based  2), the minimum value is 93, the maximum is 99, and the mean is 96.50 and the delta value increases from post 1 (post semi fowler 45˚) to post 2 (post fowler 90˚) the minimum value is 0, Maximum 4 and Mean 2.25, so it can be concluded that there is a significant effect after the 45˚ semi-Fowler intervention (post 1) to 90 Fowler intervention (post2).
The value of oxygen saturation shows that there is a significant difference between the results of the pre-test SaO2 to semi-Fowler's 45˚, and from semi-Fowler's 45˚ to Fowler's 90˚. The difference in the value of oxygen saturation (SaO2) was seen between before the intervention (pre-test) to the post Semi-Fowler 45˚ with the results (p value 0.025) and the results from post semi fowler 45 to post fowler 90 with the result (p value 0.005) Nandar Wirawan, Nandi Periadi, M Iqbal Kusuma/KESANS The Effect of Intervention on Semi Fowler and Fowler Positions on Increasing Oxygen Saturation in Heart Failure Patients