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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

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					       RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
                    BANGALORE, KARNATAKA
     PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION




1.    NAME OF THE            Ms. RUMU DUTTA CHOWDHURY
      CANDIDATE AND          GOUTHAM COLLEGE OF NURSING,
      ADDRESS                MANJUNATH NAGAR,
                             WEST OF CHORD ROAD, RAJAJINAGAR,
                             BANGALORE – 560 010.


2.    NAME OF THE            GOUTHAM COLLEGE OF NURSING ,
      INSTITUTION            MANJUNATH NAGAR,
                             WEST OF CHORD ROAD, RAJAJINAGAR,
                             BANGALORE – 560 010.


3.    COURSE OF THE STUDY    M.Sc. NURSING I YEAR
      AND SUBJECT            MEDICAL – SURGICAL NURSING


4.    DATE OF ADMISSION TO   23.06.2008
      THE COURSE
5.    TITLE OF THE TOPIC     A STUDY TO DETERMINE THE
                             EFFECTIVENESS OF STRUCTURED
                             TEACHING PROGRAM ON MANAGEMENT
                             OF PATIENTS WITH SPINAL CORD INJURY
                             AMONG SIGNIFICANT OTHERS IN
                             SELECTED HOSPITALS, BANGALORE




                                 1
6.    BRIEF RESUME OF THE INTENDED WORK:

6.1   NEED FOR THE STUDY :
                  Spinal Cord Injury (SCI) is an insult to the spinal cord resulting in a
      change, either temporary or permanent, in its motor, sensory and autonomic
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      function.       SCI can cause paralysis, sensory impairment, autonomic nervous
      system dysfunction, bowel, bladder and sexual dysfunction, leading to
      immobility and physical dependency that can alter lifestyle and self-esteem. It
      physically and psychologically affects not only the individual, but also the
      family and society. 2


                  In 2004, the National spinal cord injury statistical centre reported an
      annual incidence of 11,000 cases of new traumatic SCI’s with a prevalence of
      250,000 cases. In Australia, an incidence of 300 to 400 new cases per year and a
      prevalence of 10,000 persons with SCI. In England, 400 new cases of SCI each
      year has been recorded.3 In India, approximately 15 lakhs people live with SCI
      and 20,000 new cases of SCI are added to the list every year. In Bangalore,
      incidence of SCI is 20.9%, among which 44% central cord, 25.1% cauda equina,
      17.1% brown sequard. 4


               The segment of the population with the greatest risk of SCI has been
      found in young adult men between the ages of 16 and 30 years. Causes of SCI
      include many types of trauma which are comprising of 50% Motor vehicle
      crashes, 24% falls, 11% violence, 9% sport injuries, and 6% other miscellaneous
      causes. Other causes of SCI includes vascular disorders, tumor, infectious
      conditions, spondylosis, iatrogenic injuries. 5


               Another study on demographic characteristics of individuals with SCI
      reveals that falls from height was the leading cause 25%, followed by 17.4%
      road traffic accidents, among which 19.2% each were in the age group of 18-25
      and 40-50 years age group. The conclusion was drawn that traumatic lesion were
      common in men and non traumatic in women while lumbar level is the

                                           2
commonest level of lesion in these individuals.6


        SCI care involves the management of a large number of secondary
medical problems such as pressure sores, urinary tract infection, pain, spasticity,
bladder and bowel problems, renal calculi, respiratory complications, obesity and
diabetes. The incidence of secondary complications recorded as 15-100% people
with SCI develops deep vein thrombosis, 7.6% heterotrophic ossifications,
26.6% pneumonia, 67.1% urinary tract infection, 44.3% spasticity, 41.8%
pressure sores. Pain is voiced by 10% of the respondents each year. 7


        A related study was done to document the incidence of secondary
complications from 348 patients with post-acute SCI, more than 95% of these
patients reported at least one secondary problem, and more then half reported 3
or more. Obesity, pain, spasticity, urinary tract infection and pressure sores were
common. Issues of social integration were also identified. The results suggest
that improvement is needed in practices related to prevention and follow-up. 8


        SCI often occur in adolescence and early adulthood, survivors
frequently face decades of living with physical, emotional and financial
consequences of severe disability. The male to female ratio of SCI is 4:1. The
potential for disruption of individual growth and development, altered family
dynamics, economic loss in terms of absence from work and the high cost of
rehabilitation and long term health care make SCI a major problem. Caring for
the patients with SCI at home at first seem a daunting task to the family. They
require nursing support to gradually assume full care of the patient.9


        An experimental study was done to identify nursing problems of SCI
patients after discharge from clinical rehabilitation and to identify gaps in the
nursing care regarding the prevention of complications in these patients. The
most important nursing problems in the response group appeared to be
limitations to activities of daily living, having difficulties in asking for help,

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      pain, coping with the disability, dependency on personal help and problems with
      changed bladder regulation with conclusion that SCI patients experience serious
      problems after discharge from clinical rehabilitation.10


               During rehabilitation, patients are expected to be involved in the
      therapies and learn self-care. But as patient’s physical and psychological status
      do not allow them to do the daily activities of living. The significant others of
      people with SCI have to assume a vital caring role. Without knowing all the
      consequences of SCI and management, it becomes difficult for them to provide
      necessary quality care to the patient.


               The main aim of the investigator is to help the significant others of SCI
      patients in developing knowledge, skill and confidence by providing sufficient
      information    regarding   importance    of   physical     care,   emotional   care,
      psychological support which in turn helps the patient to free from complications
      and to improve their health and quality of life. Hence the researcher is interested
      to take up the study in this aspect with the goal to increase the efficiency of
      significant others in providing care with adequate knowledge and enabling the
      SCI patient to attain optimum quality of life enveloping all dimensions such as
      physical, medical, psychological, social, cultural and occupational.


6.2   REVIEW OF LITERATURE:
               The extensive review of literature has been done and it is organized
      according to the following headings:


      A) Studies related to incidence of SCI :


               A prospective study to assess the risk factors in traumatic SCI and to
      identify preventable risk factors was done and four hundred and eighty three new
      traumatic SCI cases reported in 2000 – 2001 where male to female ration was
      2.96:1 and the average age at injury was 35.4 years. Fall from height was the

                                          4
most common cause of trauma, followed by 34.7% motor vehicle accidents. One
hundred and sixty four patients were tetraplegic and 283 patients were
paraplegics, while 36 patients had no neurological deficit. 11


        A study was conducted among 440 patients with thoracolumbar spinal
injuries aiming to correlate the outcome of SCI with various epidemiological
factors like type of injury, mode of transport, time of reporting. The study
reveals 82.04% males and 17.95% females were affected, where 40.9% of them
were in the third decade of their life. Fall from the height remained the most
common cause. Of the total population, 38.5% patients reporting within 48 hours
developed pressure sores, while 80.28% patients reporting after 5 days
developed pressure sores. The study highlights the magnitude of the problems of
trauma care and transport system and the difference an effective system can
make in the care of SCI patients. 12


B) Studies related to problems related with SCI:


         A study was done to determine pressure ulcer risk factors correlated to
the patients with SCI, medical care management during the acute as well as in
the rehabilitation and chronic stages .regarding the rehabilitation stage, no study
was deemed relevant. The researcher came to the conclusion that additional
observational studies are needed, for both the acute and rehabilitation stages to
find out the risk factors of pressure ulcer in SCI patients.13


         A study was done to assess sexual functions after SCI in interaction
with physical, psychological and social aspects among 86 males and 14 females
with SCI. A higher incidence of complications of SCI, partner dissatisfaction,
less partner co-operation, lower self-esteem and social taboos were factors
responsible for less sexual activity in the patients. The study suggests that there
is a strong need for improved treatment of the medical complications of SCI,
sexual counseling, literature, information and peer support.14

                                       5
        A descriptive co-relation survey on emotional problems of patients with
SCI was conducted to identify emotional problems and to develop and validate
guidelines for providing emotional support to SCI patient. The study revealed
that majority of SCI patients were in the age group of 17-30 years mainly
married male and from nuclear family and having 71% moderate state anxiety.
12.9% of respondents were severely anxious whereas 16.1% had mild anxiety.
The researcher came to the conclusion to participate in providing holistic health
care and in rehabilitation of SCI patients by early detection of emotional
problems and by taking individual need based timely intervention to reduce these
problems.15


C) Studies related to management of SCI:


        A study on Chronic Neuropathic Pain (CNP) in the SCI’s was done with
purpose to explore the experience of CNP in SCI patients in relation with
physical, emotional, psychosocial, environmental, informational, practical and
spiritual domains and identified effective and ineffective pain coping strategies.
Medication failure in pain management was identified as a common outcome,
while strategies including use of warm water, swimming, increased activity and
distraction provided temporary pain relief. Learning to live with the pain
appeared to be related to acceptance of pain, which in turn seemed to facilitate
adjustment.16


        A study was conducted on influence of urinary management on urologic
complications in a cohort of SCI patient. The study was conducted in a
rehabilitation centre with 182 patients. The most common complication was
urinary infection. Trauma related to catheterization was the main problem with
intermittent catheterization. Percussion and crede maneuver appeared to be
acceptable techniques of bladder management if the patient is closely monitored.
17




                                   6
      D) Studies related to the role of significant family member in management
      of SCI:


                A description of care and perception of service need of SCI patients and
      family member revealed that SCI has profound personal, social and economic
      consequences for the injured person, their family and extended social networks.
      The survey collected social and demographic information and details of the type
      of care provided by family caregivers. The most frequently reported service
      types required by family caregivers included respite, personal support,
      information services and health professional services.18


                An experimental study on efficacy of support groups for spouses of
      patients with SCI and its impact on their quality of life were conducted and the
      study results bring to light the definite impact of SCI on spouse’s well being.
      The research demonstrates the unquestionable positive effect of group therapy on
      the impact of well-being of spouses of SCI survivors.19


      E) Study related to follow-up program:


                A follow-up program for patients with SCI was done to evaluate and
      improve the status of rehabilitation of community-dwelling SCI patients in their
      home and attempted to decrease the rate of re-admission. The researcher felt that
      an attempt to visit the patient’s residence to conduct a follow-up would be of
      great help.20


6.3   STATEMENT OF THE PROBLEM:


                A study to determine the effectiveness of structured teaching program
      on management of patients with spinal cord injury among significant others in
      selected hospitals, Bangalore.



                                          7
6.4   OBJECTIVES OF THE STUDY:
        1. Assess the knowledge of significant others on management of patient
           with SCI in the pretest.
        2. Assess the effectiveness of structured teaching program among
           significant others with pre and post test scores.
        3. Explore the association between knowledge scores on management of
           SCI with selected demographic variables.


6.5   OPERATIONAL DEFINITIONS:


        1. Effectiveness: Refers to the differences of scores obtained by the
           subjects between pre and post test knowledge on management of patient
           with SCI.
        2. Structured Teaching Program: Refers to systematically organized
           teaching strategy for significant others of patient with SCI which
           provided    information     regarding   etiology,   clinical   manifestation,
           management, prevention of complications, knowledge on taking care in
           their daily life, other support systems available and follow-up care which
           will help the significant others for providing quality care to the patient
           with SCI. The teaching will be involved with variety of audiovisual aids
           for duration of one hour.
        3. Management: Refers to the nutritional care, skin care, bowel and bladder
           care, pain management, exercise and psychological support to the patient
           with SCI.
        4. Spinal cord injury: SCI refers to an insult to the spinal cord resulting in
           a change, either temporary or permanent, in its motor, sensory or
           autonomic function causing paralysis, sensory impairment, bowel,
           bladder, sexual dysfunction and emotional disturbances.
        5. Significant others: Refers to the family member e.g. spouses, parents,
           siblings and who are staying and providing care to the patient with SCI.



                                        8
6.6     HYPOTHESIS:
        H1: The mean post test knowledge scores on management of patient with SCI
        will be significantly higher than their mean pre test knowledge scores among
        significant others of patients with SCI.
        H2: There will be significant association between post test knowledge scores
        with selected demographic variables.


6.7     DELIMITATIONS:
           1. The study is delimited to the knowledge of significant others of patients
                with SCI.


6.8     PROJECTED OUTCOMES:
           1.   The study would motivate and guide significant others of patient with
                SCI in its management.
           2.   The knowledge when provided to family members of patients with SCI
                with regard to holistic care would enable them to equip with necessary
                skills to manage at home thereby preventing frequency of visits to
                hospital or by reducing the length of stay in hospital.


6.9     MATERIAL AND METHODS:

7.1     SOURCE OF DATA:            Significant others who are present with the patients in
                                   the neurological ward of selected hospital.


7.2     METHOD OF COLLECTION OF DATA:

7.2.1   SAMPLING
        CRITERIA :


        INCLUSION                      1. Significant others of patient with SCI admitted
        CRITERIA                           in neurological ward of selected hospitals,
                                           Bangalore.


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                                2. Significant others of patient with SCI who can
                                    understand and speak either English or Hindi.
                                3. Significant       others   who   are   willing   to
                                    participate in the study.
        EXCLUSION               1. Significant others who are not present with the
        CREITERIA                   patient in the selected hospital.
                                2. Significant others of patient with SCI who do
                                    not understand Hindi and English.
                                3. Significant others who are not willing to
                                    participate in the study.


7.2.2   RESEARCH             The research design adopted for the study is pre
        DESIGN:              experimental, one group pre test – post test design.

7.2.3   VARIABLES:


        INDEPENDENT           Structured teaching program.
        VARIABLES:
        DEPENDENT             Knowledge
        VARIABLES:
7.2.3   SETTING OF           The study will be conducted in neurology ward of
        STUDY:               selected hospitals, Bangalore.
7.2.4   SAMPLING             The investigator will        use purposive sampling
        TECHNIQUE.:          technique
7.2.5   SAMPLE SIZE:         The sample size for the study is 40 significant others
                             of patients with SCI.
7.2.6   TOOL FOR             Structured knowledge questionnaire will be formed
        RESEARCH:            with the help of literature review and expert’s opinion
7.2.7   DATA COLLECTION After getting prior permission from the respective
                             authorities, the researcher will conduct a pretest
                             session with the help of definite, concrete and


                                    10
                                    predetermined questionnaire. Then the structured
                                    teaching program will be delivered on the same day.
                                    The post test knowledge score will be assessed after 7
                                    days with the same questionnaire. The proposed
                                    duration of study is 30 days.
7.2.8   METHOD OF DATA              The data will be analyzed in terms of the objectives of
        ANALYSIS AND                the     study   using    both   descriptive   (frequency,
        PRESENTATION:               percentage, mean and standard            deviation) and
                                    inferential statistics (Chi square & coefficient of
                                    correlation)
                                     The data obtained will be plotted in the master
                                          sheet.
                                     Demographic variables will be described in terms
                                          of frequency and percentage.
                                     The pre – test, post – test knowledge scores will
                                          be expressed on mean + or – standard deviation
                                          by using tables.
                                     A paired ‘t’ test will be computed to determine the
                                          significant difference between mean post – test
                                          and mean pre – test knowledge scores of the
                                          significant family members of the patient with
                                          SCI.
                                     Association between demographic variables and
                                          knowledge regarding management of patient with
                                          SCI.


7.3     DOES      THE     STUDY       REQUIRE          ANY      INVESTIGATIONS           OR
        INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
        HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.
        Yes, the study require administration of structured teaching program to the
        significant others of patient’s with SCI.

                                              11
7.4   HAS     ETHICAL       CLEARANCE            BEEN     OBTAINED       FROM    THE
      HOSPITAL AUTHORITY OF THE PARTICULAR INSTITUTION AND
      PATIENT?
      Yes, informed consent will be obtained from the hospital authorities from the
      selected hospitals. Consent will be obtained from the subject. Confidentiality
      will be maintained.
8     LIST OF REFERENCES
         1. Spinal cord injury: Definition, epidemiology, pathophysiology.available
              at http://www.emedicine.com/pmr/topic182.htm.
         2.    Balazy Thomas E. Management of chronic pain in spinal cord injury,
              CNJ review medical journal. available at
              http://www.thecni.org/reviews/09-1-p20-balazy.htm.
         3. Lim Peter AC, Tow Adela M. Recovery and Regeneration after spinal
              cord injury: A review and summary of recent literature. 2007. 36:49 – 57.
         4. IndMedica.com/journal.php.
         5.   Lewis, Heitkemper, Dirksen, O’ Breien, Bucher. Medical Surgical
              Nursing: Assessment and Management of Clinical Problem. 7th edition,
              India, Mosby Elsevier, 2007, p1589 – 1609.
         6.    Gupta Nalina, M. John Solomon, Raja Kavitha. Demographic
              characteristics of individual with paraplegia in India – A survey. Indian
              Journal of physiotherapy and occupational therapy. 2008. Vol – 2(3).
         7. Hoey Stephen. Spinal Cord Injury-A review of literature.3852 40006.p1-
              15
         8. Anson CA, Shepherd C. Incidence of secondary complications in spinal
              cord injury. Klemm Analysis group, Atlanta, Georgia 30345, USA.
         9. International    Campaign      for    Cures    of   Spinal   Cord    Injury
              Paralysis(ICCP).Global summary of spinal cord injury, Incidence and
              Economic Impact. Written and compiled for the ICCP. March 2007.
         10. Bloemen-Vrencken JH, de Witte LP. Post-discharge nursing problems of
              spinal cord injured patients: on which fields can nurses contribute to
              rehabilitation?Hoensbroeck, Dec 2003.17(8):890-8.

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11. Singh     Roop,    Sharma     Sansar   Chand,    Mittal    Rajeev,   Sharma
      Ashwini.Traumatic Spinal Cord injuries in Haryana: An epidemiological
      study. Indian Journal of Community Medicine. 2003-10-2003-12. Vol.28,
      No.4.
12. Upendra B, Mahesh B, Sharma L et al. A correlation of outcome
      measures with epidemiological factors in thoracolumbar spinal trauma.
      Indian J Orthop.2007;41:290-4
13. Gelis A, Duperyron A et al. Pressure ulcer risk factors in persons with
      SCI: part I: acute and rehabilitation stages. France. Spinal cord advance
      online publication.September2008
14. Sharma SC, Singh R, Dogra R, Gupta SS. Assessment of sexual
      functions after spinal cord injury in Indian patients. India. Int J Rehabil
      Res. March 2006;29(1)
15. Sharma Veena. Spinal cord injury and emotional problems. The Nursing
      Journal of India. January 2005.Vol XCVI No.1
16. Henwood P, Ellis JA. Chronic neuropathic pain in spinal cord injury: the
      patient’s perspective, Canada.
17. Gallien P, Nicolas B, Robineau S, Le Bot MP, Durufle A, Brissot R.
      Influences of urinary management of urologic complications in a cohort
      of spinal cord injury patients. France. PMID: 9779672.
18.    Michele Foster. Delena Amsters. Glenys Carlson. Spinal cord injury
      and family care givers: A description of care and description of service
      need. Australian Journal of Primary Health – Vol. 11. No. 1. 2005.
19. Sheiza A, Manigandan C. Effecacy of support groups for spouses of
      patients with spinal cord injury and its impact on their quality of
      life.International Journal of Rehabilitation Research. December 2005.
      Vol.28(4).
20. Prabhaka MM, Thakker. A follow-up program in India for patients With
      spinal cord injury:Paraplegia safari. J spinal Cord Med.2004;27(3):260-2



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