A STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES REGARDING FIRST 24 HOURS CARE OF PATIENTS WITH MYOCARDIAL INFARCTION ADMITTED

TO ICU IN SELECTED HOSPITAL OF RAICHUR WITH A VIEW TO DEVELOP SELF INSTRUCTION MODULE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

MOHAMMED SADAMUDDIN

NAVODAYA COLLEGE OF NURSING RAICHUR

NOVEMBER - 2008

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

2. Name of the Institute

Navodaya College of Nursing M.Sc. Nursing 1st yea Medical Surgical Nursing

3. Course of study and Subject 4. Date of Admission

16/06/2008

5. Title of the topic

A STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES REGARDING FIRST 24 HOURS CARE OF PATIENTS WITH MYOCARDIAL

INFARCTION ADMITTED TO ICU IN SELECTED HOSPITAL OF RAICHUR WITH A VIEW TO DEVELOP SELF INSTRUCTION MODULE

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 Need for the study: The heart requires a balance between oxygen supply and demand in order to function properly. The integrity of the coronary artery is an important determinant of oxygen supply to the heart muscles. Any disorder that reduces the size of lumen of coronary arteries may cause a decrease in blood flow and oxygen delivery to the myocardium which is life threatening condition characterized by the formation of local necrotic areas within the myocardium. Acute Myocardial Infarction usually follows the sudden occlusion of a coronary artery and the abrupt cessation of blood and oxygen flow to the heart muscles. Because the heart muscle must function continuously, blockage of blood to the muscle leads to development of necrotic areas which can be lethal.1 Atherosclerotic plaque and subsequent thrombus formations are the most common causes. It is identified that nearly 95 per cent of the people who developed a fatal cardiovascular diseases had at least one of these major risk factors: high blood pressure, smoking, diabetes beside a poor diet and over weight.5 The clinical manifestations associated with Myocardial Infraction results from ischemia of the heart muscle and the decrease in function and acidosis associated with it. The major clinical manifestation of acute Myocardial Infarction

is chest pain which may radiate to the neck, jaw, shoulder, back, or left arm. The pain also may be present in the epigastrium, stimulating indigestion. Acute Myocardial Infarction may also be associated with less common clinical manifestations which include atypical chest pain, back ache, or abdominal pain, nausea, dizziness, unexplained anxiety, weakness or fatigue, palpitation, cold sweat, or paleness, the Blood pressure and pulse rate may be elevated, late the blood pressure may drop, urine out put may be decreased, crackles may be noted in the lungs persisting for several hours to several days.1 & 2 Almost everyday, the news media covers a story on a celebrity who has suffered from or was treated for chest pain heart attack or cardiac arrest. Even on television, it is very common scene some body seeking treatment for an episode of chest pain. 1 In the year 2003, It was estimated that heart attacks are the leading cause of death among both men and women all over the world. Cardiovascular diseases are the worlds leading killer, accounting for 16.7million or 29.2 per cent of the total global deaths. 4 In the year 2007, WHO estimated that globally 29 per cent of deaths were due to cardiovascular diseases and among them, 25-28 per cent of deaths were due to Myocardial Infarction.3 And more than one million Americans had a new or recurrent acute coronary syndrome and responsible for more than 250,000 deaths annually.1 In the developing countries like India, Myocardial Infarction is one of the leading cause of deaths. The prevalence of Myocardial Infarction has increased from 40 per 1000 in 1968 to nearly 110 per 1000 in 2001. The prevalence of

coronary heart disease in urban population has increased from 3.5 per cent in 1960s to 9.5 per cent in 1990s,and in rural areas it has been increased from 2 per cent in 1970s to 4 per cent in 1990s. In the year 2005, it was estimated that 30 per cent of deaths in India were due to coronary syndrome. 3 The population based surveys conducted in India shows that there is an increase in the prevalence rate of Ischemic heart disease from 1-4 per cent to 10 per cent. According to the hospital statistics in 1980 Coronary Artery Bypass Grafting (CABG) accounted for less then 10% of all cardiac surgeries. Today, it accounts for more than 60%. Every year 25,000 coronary bypass operations and 12,000 Percutaneous coronary Angioplasties (PTCAs) are carried out. In 1999 a total of 6607 valve replacements were done mostly for RHD and 6750 surgeries for congenital cardiac defects. In the year 2002, WHO estimated that 60 per cent of the worlds Cardiac Patients will be Indians by the year 2010. The medical NGO in cordination with WHO estimated that nearly 50 per cent of Cardio vascular related diseases in India occur below the age of 70, compared with just 22 per cent in the West. This trend is alarming because of its potential on Indian Economics. 4 It is estimated that cardiovascular diseases in USA Cost $274 billion each year, including the health expenditures and productivity.6 Nursing is built on a body of knowledge discreetly synthesized from physical, biological, and social science and uniquely applied as a humanistic discipline of caring for people wherever they are recognizing the health care needs of patients. Nurses must incorporate scientific knowledge and technical advances into their practice to assist the patients in remaining well and

functioning at the maximum level. Specially in critical care units of hospitals, with the advancing science and technology on par with doctors, the nurses should upgrade their knowledge. They must be able to identify life threatening arrhythmias on the electrocardiogram and to perform emergency resuscitation measures if necessary without the aid of the doctor on standing orders. The nurses specialized in the care of the patients with Myocardial Infarction and experience in cardiac care units have truly become a significant and responsible figure in the total field of health care. She meets the demands of patients and at the same time rehabilitates in such a way that the patient fits in the society. A descriptive study was conducted to assess the knowledge of sedentary workers regarding Myocardial Infarction at Raichur. The sample size was 150 sedentary workers consisting of both males and females equally. A structured questionnaire was used for collecting the data. The results showed that one sixth of the sedentary workers had high knowledge (16%), nearly two third of the sedentary workers had average knowledge (61.33%), and more than one fifth of the sedentary workers had low knowledge (22.66%). The study concluded by saying that they is a significant relationship between the knowledge of sedentary workers on Myocardial Infarction with regard to selected variables like education, occupation and habits.8 Cardiovascular diseases exert a burden on individual and society which is the single most common cause of death. In the community setting, nurses as health workers have a major role in educating and identifying the risk groups. In ICUs, the nurses working round the clock have a major responsibility in caring the

patients with cardiac disorders in general, Myocardial Infarction in specific, and identifying the complications on monitoring the patients manually and on machines . Hence, the researcher felt the need to assess the knowledge of staff nurses regarding first 24 hours care of patients with Myocardial Infarction admitted to ICU in selected hospital of Raichur with a view to develop self instruction module 6.2. REVIEW OF LITERATURE: Review of literature is to find out the methods for research study. It helps to find out the aspects of the study that must be included to confirm or refuse earlier findings. It provides basis to locate pertinent data and new ideas that need to be included in the present study. It helps the Investigator to find the comparative data that could be used for supporting present findings and drawing conclusions. 7 An experimental study was conducted to assess the knowledge of nursing personnels on first 24 hours care of the patients with Myocardial Infarction in Osmania General Hospital, Hyderabad. 50 nursing personnels were randomly selected and structured questionnaire was used for data collection. The results of the study showed that 26 per cent of nursing personnels had below average knowledge, 44 per cent had average level of knowledge, and 30 per cent had above average knowledge. The study concluded by saying that the nurses need to be given special training in caring the cardiac patients in ordered to improve their knowledge.9 A descriptive study was done to assess the knowledge regarding ventricular

arrhythmias among the nurses working in intensive coronary care units in Twin cities, A.P. A sample of 100 nurses was selected randomly. A structure questionnaire was used for data collection, which consisted items regarding causes signs and symptoms and management of patients with ventricular arrhythmias. The results of studies showed that 70 per cent nurses had below average knowledge, 28 per cent of nurses had average knowledge & 2 per cent of nurses had above average knowledge. The study concluded by saying that the nurses needs to improve their knowledge regarding ventricular arrthythmias. 10 A descriptive study was conducted to assess the knowledge of nursing personnels regarding immediate post operative care of cardiac surgery patients on ventilator in cardio thoracic intensive care unit (CTICU) in selected hospitals of Hyderabad. 30 nurses working in CTICU with atleast 6 months experience were selected by purposive sampling method. Data was collected by observation check list and questionnaire. The study revealed that majority of nurses had below average knowledge and more than one third of nurses had above average knowledge. The study concluded that the nurses had a low knowledge regarding immediate post operative care of cardiac patients on ventilators and hence educational programmes to be organized to improve their knowledge or practices in caring the patients in ICUs. 11 An experimental study was conducted to assess the knowledge regarding 12 lead electrocardiogram and continuous cardiac monitoring procedure among cardiac nurses in India. 24 cardiac nurses were selected by simple random sampling. Data was collected by using observation checklist. Their explanatory skill, placement of leads, way of taking tracings, interpretation of

electrocardiogram; nurses responsibilities during electrocardiogram procedure were also assessed. Pretest was done and structured teaching programme was implemented, later post test was conducted. The study results reported that knowledge of nurses was increased from 23.4 per cent in pretest to 72 per cent in posttest. The study concluded by saying that structured teaching programme was effective in improving the knowledge of cardiac nurses on 12 lead electrocardiogram and continuous cardiac monitoring procedure. 12 A comparative study was conducted to assess the knowledge regarding electrocardiogram among degree and diploma staff nurses in Madurai. A Sample of 60 nurses were selected by using random sampling technique in which 30 graduate staff nurses and 30 diploma staff nurses were there. Data were collected by using structured questionners. The results showed that mean score of degree nurses in the following areas were: 38.24 in introduction, 29.73 in procedure, 33.81 in interpretation, 31.52 in identification of cardiovascular disorders. The mean score of diploma nurses were 36.93 in introduction, 41.64 in procedure, 21.76 in interpretation and 19.45 in identification of cardiovascular disorders. The study concluded that the degree staff nurses had more knowledge on electrocardiogram as compared to the diploma staff nurses. 13 A descriptive study was conducted to assess the knowledge of risk factors, life habits and personal beliefs of nurses and nursing students about cardiovascular prevention in Italy. A sample of 182 nurses were selected by using random sampling technique in which 98 students attending the last year course in School of Nursing, and 84 nurses working in a cardiovascular department were there. Data were collected by using questionnaire. The results showed that

among heritable risk factors, hypertension ranked first in the awareness of both students and nurses. The risk inherent in a family history of Myocardial Infarction was recognized only by 36 per cent of subjects, 15 per cent of staff nurses and 30 per cent of students recognized that 5 to 10 of cigarettes per day are not harmful respectively. The knowledge of upper normal limits for blood pressure, plasma cholesterol and triglycerides was often poor in both the cohorts. The study concluded by saying that majority of the staff nurses and student nurses life style was a credible model for patients. 14 A comparative study was conducted to determine the feasibility and efficiency between the nurse-led clinic and resident-led clinic for stable patient recovery from recent Myocardial Infarction in Alkmaar. Samples of 200 patients were selected and the patients were randomized on transfer from the coronarycare unit to the cardiology ward. Subsequently, these patients were treated by a registered nurse practitioner (n=97) or by a resident (n-103) both of whom were under the direct supervision of the attending cardiologist. Degree of satisfaction was scored by the patients on a 0-10 point scale. The study results reported that no significant differences were found between the groups. However, patients treated by the nurse practitioners expressed a significantly higher score in the satisfaction rates. The study concluded by saying the treatment of stable post Myocardial Infarction patient in nurse-led clinic was found to be feasible and effective with a significantly higher level of patients satisfaction. 15 A comparative study was done to know the level of assessment of ischemic chest pain by using visual analogue scale among the nurses and patients. The sample included 10 expert nurses and 100 patients admitted to coronary care

unit. The nurses underwent a short programme on pain management. They were allowed to rate the pain as assessed by them separately using the scale. The results showed a strong positive correlation between the patient and nurses rating of pain. 16 An experimental study was conducted to measure perception and behavior regarding patients involvement among physicians and nursing staff caring for patients with acute Myocardial Infarction in Sweden. A sample of cardiology staff at 12 Swedish Hospitals were selected by simple random technique. The data was collected by structured questionnaire including 6 scale measuring the staffs views and behaviors. The results of the study showed that physicians and nurses did not differ significantly in their views of patients involvement. 17 An experimental study was conducted to assess the effectiveness of structured teaching programme on electrocardiogram among the final year B.Sc Nursing students in selected Nursing Institute at Raichur. The sample size was 52 final year B.Sc Nursing students selected by simple random sampling technique. A self administered questionnaire was used for data collection. The results of pretest showed that 90.4 per cent of the students possessed low knowledge and 9.6 per cent of students possessed average knowledge, where as after implementation of structured teaching programme, the results of post test showed that 88.5 per cent of the students had high knowledge and 11.5 per cent of the students had average knowledge. The study concluded by saying that structured teaching programme was effective in improving the knowledge of B.Sc Nursing students regarding electrocardiogram.18 6.3 STATEMENT OF THE PROBLEM:

A STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES REGARDING FIRST 24 HOURS CARE OF PATIENTS WITH MYOCARDIAL INFARCTION ADMITTED TO ICU IN SELECTED HOSPITAL OF RAICHUR WITH A VIEW TO DEVELOP SELF INSTRUCTION MODULE

6.4 OBJECTIVES OF THE STUDY: 1. To assess the knowledge of staff nurses regarding first 24 hours care of patients with Myocardial Infarction admitted to ICU. 2. To analyse the relationship between knowledge of staff nurses regarding first 24 hours care of patients with Myocardial Infarction admitted to ICU with selected socio-demographic variables. 3. To develop a self instruction module regarding first 24 hours care of patients with Myocardial Infarction. 6.5 HYPOTHESIS: There will be significant association between the knowledge of staff nurses regarding first 24 hours care of patients with Myocardial Infarction admitted to ICU with selected socio-demographic variables.

6.6 OPERATIONAL DEFINITIONS: Knowledge: It refers to the level of understanding of the staff nurses regarding first 24

hours care of patients with Myocardial Infarction. Staff Nurses: The qualified nurses who have completed three years of General Nursing and Midwifery course and working at Rajiv Gandhi Super Specialty Hospital at Raichur. Myocardial Infarction: Myocardial Infarction is the necrosis of a portion of heart resulting from decreased blood supply by a partial or complete blockage of coronary artery. ICU: ICU is a specially staffed and equipped ward dedicated to the management of patients with life threatening illnesses, injuries or complications. Self Instruction Module: It refers to the systematically organised instructions designed for the staff nurses to provide information on first 24 hours care of patients with Myocardial Infarction. 7. MATERIALS AND METHODS 7.1 Source of data: Design: The research approach adopted for this study is descriptive study. Setting of Study:

Raichur is one of backward district it has an area of 60Sq mt and located in Northen Karnataka. In Raichur 4 hospitals are functioning. They are Nandi Hospital, Rajiv Gandhi Super Specialty Hospital, Navodaya Hospital and Research center and Bhandari Hospital. Among them Rajiv Gandhi Super Specialty Hospital is selected for the study. Rajiv Gandhi Super Specialty Hospital of Raichur. It is situated in Southern part of Raichur surrounded by Hyderabad Road in its front, Government Medical College and Hospital on its left, Yermarus camp on its right and behind by Chandra Banda Road. Sample: A total of 200 staff nurses are working in Rajiv Gandhi Super Specialty Hospital. All the staff nurses get equal experience in all the wards like general wards, casualties, NICU, MICU, SICU, ICU on rotation basis. Among them, sample of 100 staff nurses will be selected for the study purpose. Sampling technique: Simple random sampling technique will be used to select the subjects as the sample.

SELECTED VARIABLES: Dependent Variables: The dependent variables are causes of Myocardial Infarction, signs and symptoms of Myocardial Infarction, assessment of patients with Myocardial

Infarction, Management of patients with Myocardial Infarction and rehabilitation of patients with Myocardial Infarction. Extraneous Variables: The extraneous variables are age, gender, religion, general education, total work experience, experience of working in ICU, and present working area which could influence the knowledge of nurses regarding first 24 hours care of patients with Myocardial Infarction. 1. Age: It is categorized as a) 21-25 years b) 26-30 years c) 31-35 years d) 36-40 years 2. Gender: Gender of the sample is categorized as a) Male b) Female 3. Religion: Religion of the sample is categorized as. a) Hindu b) Muslim c) Christian

4.

General education:

It refers to previous education of the sample. It is characterized as. a) PUC b) PUC with vocational nursing c) Degree d) Others 5. Total Work Experience:

The total work experience of the sample is categorized as a) 1 -5 years b) 6-10 years c) 11-15 years d) 16-20 years 6. Experience in ICUs: The experience of the sample in ICUs is categorized as a) < 1 year b) 1-2 years c) 3-4 years d) 5-6 years e) >6 year 7. Present working area: The present working area of the sample is categorized as

a) General ward b) Causality c) ICU d) SICU e) NICU f) MICU Inclusion Criteria: The study includes the staff nurses who are: 1) working at Rajiv Gandhi Super Specialty Hospital, Raichur 2) willing to participate in the study 3) available at the time of data collection Exclusion criteria: The study excludes the staff nurses who are not: 1) working at Rajiv Gandhi Super Specialty Hospital, Raichur 2) willing to participate in the study 3) available at the time of data collection

7.2

METHODS OF COLLECTING DATA:

Data Collection Instrument: A structured questionnaire will be developed which will be used for collecting the data. It consists of 2 parts, Part I and Part II. Part I deals with socio-

demographic data and part II represents the knowledge related items on first 24 hours care of patients with Myocardial Infarction. Data Collection Method: After obtaining the permission from the significant authorities and consent from the subjects, the Investigator will assess the knowledge of staff nurses regarding the first 24 hours care of patients with Myocardial Infarction by administering the questionnaire. Data will be collected according to the availability of sample between 8 am to 5 pm within a span of 25 to 30 days. Plan for data analysis: Data from the sample will be analyzed by using descriptive and inferential statistics. Sample characteristics will be organized and summarized with the help of descriptive statistics ie percentage and frequency. Testing the level of significance of hypothesis will be done with help of inferential statistics like chisquare test. Projected out come: The results of the study will through light on the knowledge of nurses on first 24 hours care of patients with Myocardial Infarction and also help the future researchers to have indepth studies regarding the care concerned with Myocardial Infraction patients. 7.3 DOES THE STUDY REQUIRE INTERVENTION? Since it is a descriptive study, it doesnt require any interventions

7.4 HAS ETHICAL CONSIDERATION BEEN OBTAINED FROM YOUR INSTITUTE IN CASE OF 7.3? 1. Permission will be obtained from Institutional Ethical Committee, Navodaya College of Nursing, Raichur. 2. Permission will be obtained from the significant authorities of Rajiv Gandhi Super Specialty Hospital, Raichur. 3. Consent will be obtained from the sample.

8. LIST OF REFERENCE: 1. Joyce M. Black, Jane Hokanson hawks. TEXT BOOK OF MEDICAL SURGICAL NURSING, Philadelphia: Nursing Elsevier company, 7th edition, 1701 and 07, 2002. 2. Brunner and Suddarths. TEXT BOOK OF MEDICAL SURGICAL NURSING, Philadelphia Lippincott Company, 10th edition, 793, 2004. 3. 4. WHO recommended Prevention of heart diseases, Geneva, 2005. Rajesh pande. Cardio Vascular diseases in India JOURNAL OF HEALTH PROMOTION OF EDUCATION IN SOUTH EAST ASIA 21:3,1-9, 2006. 5. Padmavathi S. A concerned effort in prevention of heart diseases in India, JOURNAL OF HEALTH PROMOTION OF EDUCATION IN SOUTH EAST ASIA. 21:3, 2-3, 2006. 6. Cardio Vascular diseases in America. JOURNAL OF HEALTH PROMOTION OF EDUCATION IN SOUTH EAST ASIA. 21:3, 23, 2006. 7. Densie F. Polit, Benedeth P. Hungler. NURSING RESEARCH PRINCIPLES AND METHODS, Philadelphia: Lippincott company 6th edition, 79, 1999. 8. Vasantha Kumari K. Knowledge of sedentary workers on Myocardial Infarction in Raichur. Unpublished thesis these Rajiv Gandhi University of health sciences Bangalore, 2006. 9. Konki Jhansli laxmi bai. Knowledge of nursing personnel on first 24 hours care of patients with Myocardial infarction in Hyderabad. Unpublished thesis NTR University of health sciences Vijay Wada. September 2002.

10.

Chemukulla samyuktha Knowledge regarding ventricular arrhythmias among nurse working in intensive coronary care units at selected Hospital Twin cities, A.P. Unpublished thesis NTR University of health sciences Vijayawada. 2006.

11.

Sunita P.S. Knowledge and practices of Nursing personnels on immediate post operative care of cardiac surgery patient on ventilator in Hyderabad. 1998.

12.

Dr. Raj Sekar. Knowledge and skills on electrocardiogram. INDIAN JOURNAL OF MEDICAL SCIENCES, 58:11, 465-67, 2002.

13.

Suvitha R.A Knowledge of degree and diploma staff on electrocardiogram in Tamil Nadu. SNA Binnial. conference, 13:19-20. Sep 2002.

14.

Steffeninog. et al. Risk factors life habits and personal belief of nurses and nursing students about cardiovascular prevention in Italy. ITALY HEART GENERAL SUPPLEMENT, 6:3, 172-7, 2005.

15.

Broers C I et. al. Nursing practioner equally as good as resident in the treatment of stable patients after recent Myocardial Infarction. DUTCH JOURNAL; NED TIJDSCHR GENEESKD, 150:46, 2544-48, 2008.

16.

Thompson DR et. al. Coronary care unit patients and nurses rating intensity of ischemic chest pain in Sutton. Intensive care Nursing. 10(2):83-8, 1994.

17.

Arnetz J.E at. al. Physicians and nurses perception of patients involvement in Myocardial Infarction care. EUROPEAN JOURNAL FOR CARDIO VASCULAR NURSING, 7:2, 113-16, 2008.

18.

Sathya Rani S. Effectiveness of Structured teaching programme on electrocardiogram among the final year B.Sc Nursing students in selected

Nursing Institute in Raichur, Unpublished thesis Rajiv Gandhi University of Health Sciences, Bangalore. 2005.

9. 10. 11.

Signature of the Candidate Remarks of the guide Name of the designation of

: : : : Ms Anna poorna . S M.Sc (Nursing) Asso Professor and

11.1 Guide

Navodaya College of Nursing, Raichur. 11.2 Signature :

11.3 Co guide (If any)

11.4 Signature

11.5 Head of the Dept

Ms Anna poorna . S M.Sc (Nursing)

Navodaya College of Nursing, Raichur 11.6 Signature :

12.1 Remark of the Chairman & Principal :

12.2 Signature