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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKASYNOPSIS PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
1. NAME OF THE
CANDIDATE AND
ADDRESS
: Mrs. JAYALAKSHMI
I YEAR MSc NURSING,
GOVERNMENT COLLEGE OF NURSING,
FORT, BANGALORE-02
2 NAME OF THE
INSTITUTION
: GOVERNMENT COLLEGE OF NURSING,
FORT, BANGALORE-02
3 COURSE OF STUDY
AND SUBJECT
: I YEAR MSc NURSING
MEDICAL SURGICAL NURSING
4. DATE OF ADMISSION : 14-06-2010
5. TITLE OF THE TOPIC : “A STUDY TO EVALUATE THE
EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON
KNOWLEDGE REGARDING
SELECTED COMPLICATIONS OF
CIRRHOSIS OF LIVER AMONG STAFF
NURSES AT SELECTED HOSPITALS,
BANGALORE.”
INTRODUCTION:
“Is life worth living? It all depends on the liver.” William James
Age does not depend upon years, but upon temperament and health.
Some men are born old, and some never grow so, and we humans we live because we
have liver Most liver diseases, including fatty liver, cirrhosis, primary biliary cirrhosis
and primary sclerosing cholangitis, result from injury to the liver.
Cirrhosis is the seventh leading cause of death by disease, killing about
25,000 people each year globally. Also, the cost of cirrhosis of liver in terms of
human suffering, hospital costs, and lost productivity is high, majority of the patients
land up in hospitalization with one or the other complications such as oesophageal
varices, hepatic encephalopathy, portal hypertension, bleeding and kidney disorders.1
The term "cirrhosis" was first used by René Laennec in 1781–1826 to
describe the abnormal liver color of individuals with alcohol-induced liver disease.
The word cirrhosis comes from the Greek word kirrhos, the name for a yellowish-
brown color.
Cirrhosis of liver represents a late stage of progressive hepatic fibrosis
characterized by distortion of the hepatic architecture and formation of regenerative
nodules. It is generally considered to be irreversible in its advanced stages at which
point the only option may be liver transplantation. In earlier stages, specific
treatments aimed at the underlying cause of liver disease can improve or even reverse
cirrhosis. Furthermore, there has been exciting progress in understanding hepatic
fibrosis, which represents a paradigm for wound healing in other tissues, including
skin, lung, and kidney, since it involves many of the same cell types and mediators.
An understanding of these mechanisms has a number of clinical implications,
including the development of interventions designed to impede or reverse hepatic
fibrosis.
Patients with cirrhosis of liver are susceptible to a variety of complications and
their life expectancy can be markedly reduced. Cirrhosis and chronic liver disease
accounted for more than 25,000 deaths and 373,000 hospital discharges in the United
States in 1998 according to a report from The National Center for Health Statistics.2
Nursing care for individuals with acute disease is multifaceted, complex, and
dictated by the stage of the disease and presenting symptomatology. Careful
monitoring is needed to spot early signs of life-threatening complications, such as
hepatic encephalopathy or esophageal bleeding. Chronic care focuses on education.
Individuals need to understand that this disease is chronic in nature and requires
continuous care to reduce or prevent serious complications. Prompt treatment needs to
be sought at any sign of complication.3
NEED FOR THE STUDY
The key to a better life for hundreds thousands people suffering from cirrhosis
of liver depends on research globally shows estimated 25,000 individuals in the
United States died from liver disease in 1998, making liver disease the tenth leading
cause of death. For individuals between 45 and 64 years of age, chronic liver disease
had an associated mortality rate of 19.6 per 100,000 persons and was the seventh
leading cause of death.2
The following statistics relate to deaths and Cirrhosis of the liver :26,259
deaths reported in USA 1999 including 11,958 for alcoholic liver disease ,27,035
deaths from alcohol related chronic liver disease and cirrhosis each year in the US
2001 ,13.2 per 100,000 men died from chronic liver disease or cirrhosis in USA 2001
,6.2 per 100,000 women died from chronic liver disease or cirrhosis in USA
2001 ,15.8 per 100,000 Hispanic/Latino people died from chronic liver disease or
cirrhosis in USA 2001 ,16.9 per 100,000 Asian/Pacific Islander people died from
chronic liver disease or cirrhosis in USA 2001.2
The exact prevalence of cirrhosis is unknown, but it has been estimated,
through autopsies, to be between 5 and 10 percent. Incidence of cirrhosis varies by
country and region, and reflects relative contributions from different risk factors. In
countries where alcohol consumption is common, alcoholic cirrhosis is the major
contributor to the overall prevalence of cirrhosis of liver.3
The study was done to enhance the professional nurse’s recognition of the
signs, symptoms and complications of end-stage liver disease, as well as the critical
nursing assessment and intervention approaches. Prior to the development of safe
methods for liver transplant, most patients with acute or chronic liver failure died
within months to years. Despite increased technology and medical advances, end
stage liver disease remains the 12th leading cause of death in the United States.
Almost 16,000 individuals are currently waiting for a liver transplant. With the
average national waiting time being slightly more than one year before receiving a
liver transplant, individuals with end-stage liver disease will continue to be
hospitalized for acute illness related to their disease (Scientific Registry of Transplant
Recipients, 2009).The most common admissions are related to ascitis, hepatic
encephalopathy, and variceal bleeding. Each of these conditions requires accurate
identification and treatment for successful outcomes.3
The major physiologic changes that occur as a result of cirrhosis of liver
include loss of hepato cellular synthetic and metabolic functions and the development
of portal hypertension as a result of increased resistance to flow through the liver
secondary to fibrous tissue and regenerative nodules. There is also active intrahepatic
vasoconstriction that accounts for 20-30% of the increased intrahepatic resistance.
Altered liver function can affect the heart and circulatory system, the brain, the lungs,
the immune system, and the kidneys.2
Nursing care of the patient with chronic liver disease is becoming increasingly
complex. The nursing challenges include close monitoring of coagulopathy,
intravascular volume, renal function, electrolyte balance, cardiovascular status, and
nutrition. The focus of assessment and physical examination will be on detection of
signs and symptoms of altered liver function.2
Ascitis is the most common of the three major complications of cirrhosis and
results from portal hypertension, hypoalbuminemia, splanchnic vasodilation, and
increased secretion coupled with impaired liver inactivation of aldosterone.
Approximately 50% of patients with compensated cirrhosis develop ascitis within ten
years. Approximately 50% of patients with ascitis die within two years Patients with
ascitis are at significant risk for developing spontaneous bacterial peritonitis
Symptoms are typically mild and include abdominal pain, worsening ascitis, fever,
and progressive encephalopathy.3
Hepatic encephalopathy results from nitrogenous substances from the gut
adversely affecting brain function by producing alterations of neurotransmission that
affect consciousness and behaviour resulting in a mild confusional state and
progressing to coma.
Hepatic encephalopathy is frequently precipitated by infection, diuretic use,
metabolic alkalosis, constipation, CNS depressant usage, hypoxia, sepsis, azotemia,
electrolyte abnormalities, gastrointestinal bleeding, and acute deterioration of liver
function. Treatment of hepatic encephalopathy must include identification and
eradication of the precipitating cause.3
Gastroesophageal varices are present in approximately 50% of patients with
cirrhosis, with haemorrhage occurring at a yearly rate of 5-15%. . Bleeding from
oesophageal varices ceases spontaneously in up to 40% of patients but is associated
with 20% mortality at six weeks .
Patients who survive acute variceal haemorrhage have a high risk of re-
bleeding and death. The median re-bleeding rate in untreated individuals is 60%
within 1-2 years with a mortality rate of 33%.1
The frequency with which patients with end-stage liver disease will be
admitted to the acute care setting will increase as medical advances continue and
patients continue to wait for liver transplantation. The challenges of caring for these
patients are complex and require that nurses recognize the key complications and
associated diagnoses, including ascitis,
Hepatic encephalopathy, and gastroesophageal variceal bleeding. All of these
patients will require astute nursing assessment, emotional support and encouragement,
and multiple interventions to prevent or reduce morbidity and mortality. As the above
article and clinical experience of the investigator, feel to take up this study and
enhance the knowledge of staff nurse and extend the service as their best in caring and
monitoring of complications and appropriate intervention in decline mortality and
morbidity rates .2
Nurses are the primary care givers for patients, they play a major role. The
researcher working in various clinical setting came across patients with cirrhosis of
liver and related complications and the investigator also observed that many nurses
did not have adequate knowledge regarding complications of cirrhosis of liver.
Further reviewing the literature in this area it was found that only few Indian nursing
researchers have done a systematic and scientific study to explore the knowledge level
of nurses. Hence it was felt that there is a need for a scientific study related to this
aspect. So the investigator has taken the study to evaluate the effectiveness of
structured teaching programme on knowledge selected complications of cirrhosis of
liver among staff nurses at selected hospitals Bangalore.
REVIEW OF LITERATURE
Review of literature is an important source for development of a research
project, it helps to gain an insight into the research problem, and provides information
of what has been done previously. It provides for helpful suggestions for significant
investigation as it is the basis for future investigations. The review of literature for the
present study has been taken up from different sources like text books, journals,
articles and publishes and unpublished research studies.
A study was conducted on world wide mortality from cirrhosis of liver .Age-
standard cirrhosis mortality rates per 100,000 were computed for 41 countries world
wide over the period 1980-2002 using data from the WHO mortality database. Result
showed that in the early 1980’s the height rates were in Mexico, chile(around
55/100,000 men and over 14/100,000) France, Italy, Portugal, Austria, Hungary and
Romania (around 30-35/100,000 men and 10-15/100,000 women) in the southern
Europe, rates in the early 2000’s were less than halved compared to earlier decades in
contrast, rates have been raising in eastern European countries to reach extremely
high values in the mid 1990’s and declined only their after. In the UK rates were still
steadly raising. Study concluded as mortality from cirrhosis of liver shows favourable
trends in most countries of the world, following the reduction in alcohol consumption
and Hepatitis B and C virus infection.4
A study was conducted on cirrhosis of liver in Italy; regarding
epidemiological aspects in Italy in order to improve knowledge of the incidence of
liver cirrhosis, they conducted two epidemiological studies the first study showed
that about 15% of asymptomatic subjects with persistent increase in alanine amino
transferase had historical evidence of cirrhosis, cirrhosis of liver associated with viral
etiology was 91.4% of cases in the second study, which enrolled cirrhosis patients
from 13 centres from all regions of the country viral infections were detected in
82.6% of patients, the large majority of whom ,71.2% were positive for hepatitis c
virus, alcohol abuse was present in 88.7% of cases as exclusive aetiological factor the
age distribution showed that about 55% of cirrhosis patients were less than 60 years of
age these data show that hepatitis c viral infection represents the predominant
aetiological factor of cirrhosis in Italy.5
A study was conducted on alcohol consumption and the risk of chronic liver
disease by department of internal medicine and public health, university of L’Aquila,
Italy. 655 patients with chronic liver disease were involved in the study in order to
estimate the dose-response relationship between alcohol consumption and the
occurrence of chronic liver disease. They found an experimental positive association
A cross sectional study was conducted in northern Taiwan .the purpose of the
study was to examine the level of awareness on portal hypertension guidelines and
associated factors among nurses in Taiwan. A total of 1418 nurses were included in
the analysis among 10 hospitals in Taiwan . Portal hypertension management
questionnaire was developed based on the Taiwan hypertension guidelines and the 7th
report of the joint national committee on prevention, detection ,evaluation and
treatment of high blood pressure . Results suggested that a large proportions of the
nurses in northern Taiwan had insufficient knowledge on hypertension guidelines.6
A study was conducted on critical care nurses revealed that there were
recognised knowledge deficits of Abdominal compartment syndrome amongst
surveyed nurses. The incidence of abdominal compartment syndrome is reported to be
up to 35% in the intensive care population with reduced survival when compared to
other intensive care patients. Physiological changes that occur with Abdominal
compartment syndrome include compromise to the cardiovascular, respiratory, renal
and neurological systems and development of metabolic acidosis. Management may
incorporate percutaneous drainage of ascitic fluid, use of muscle relaxants, prone
positioning and surgical intervention to open, decompress and gradually close the
abdomen. Throughout this care the critical care nurse should ensure accurate
monitoring of organ function, assessment for recurrence of Abdominal compartment
syndrome as well as the amount and type of drainage, appropriate wound
management and provision of physical and psychosocial support of the patient. These
aspects of care have the potential to impact significantly on patient outcome.7
A study was conducted on nurses knowledge regarding cirrhosis and its
prevention in St. joseph Hospital, Phio. 71 nurses were selected for the study.
Questionnaire was used for quality of life and to identify the knowledge level of
nurses regarding cirrhosis and its prevention. Study showed inadequate knowledge
(22%) about cirrhosis, 28% about prevention. The problems faced because of
cirrhosis by the patient further reduce the quality of life.8
Another study was conducted to assess the effectiveness of planned teaching
programme on nurses regarding cirrhosis of liver and its prevention. 75 nurses were
selected by purposive sampling. The pre test and post test design was used for the
study. The findings of the study indicated that the planned teaching programme
enhanced the knowledge of nurses regarding cirrhosis of liver and its prevention as
the post test score (76%) was more than the pre test score (32%).9
STATEMENT OF THE PROBLEM:
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON KNOWLEDGE REGARDING SELECTED
COMPLICATIONS OF CIRRHOSIS OF LIVER AMONG STAFF NURSES
AT SELECTED HOSPITALS, BANGALORE.”
6.3 OBJECTIVES OF THE STUDY:
1. To assess the existing knowledge among staff nurses regarding selected
complications of cirrhosis of liver at selected hospitals Bangalore
2. To develop and conduct structured teaching programme regarding selected
complications of cirrhosis of liver among staff nurses at selected hospitals
Bangalore.
3. To evaluate the effectiveness of structured teaching programme on knowledge
of staff nurses regarding selected complications of cirrhosis of liver at selected
hospitals Bangalore.
4. To find the associations between the post test knowledge scores of staff nurses
regarding selected complications of cirrhosis of liver with selected socio-
demographic variables.
6.3.1 HYPOTHESIS
H1- There will be a significant difference between mean pretest and post test
knowledge scores of staff nurses regarding selected complications of liver
cirrhosis.
H2- There will be a significant association between post test knowledge scores
regarding selected complications of liver cirrhosis among staff nurse with
selected socio demographic variables.
6.3.2 VARIABLES:
* Independent variable: Structured teaching programme regarding selected
complications of cirrhosis of liver.
*Dependent variable : Post test knowledge scores of staff nurses on knowledge
of Selected complications of cirrhosis of liver.
* Attribute variable : Age, sex, family income, type of family, general
Qualification, Professional qualification, years of
experience, marital status, exposure to in-service training.
6.3.3 OPERATIONAL DEFINITIONS:
Effectiveness: In this study effectiveness refers to the difference in the percentage
of correct response and mean knowledge scores of pre test and post test conducted
for staff nurses.
Structured teaching programme: It refers to a systematically organized
teaching plan on selected complications cirrhosis of liver.
Knowledge: It refers to correct responses of staff nurses to the structured
questionnaire regarding selected complications of cirrhosis of liver.
Complications of cirrhosis of liver: It refers to complications of liver cirrhosis
such as ascitis, portal hypertension, esophageal varices and hepatic
encephalopathy.
Staff nurse: refers to registered nurses working in selected hospitals.
7. MATERIALS AND METHODS
7.1 Source of data : Data will be colleted from staff nurses working
at selected Hospitals, Bangalore.
7.2Method of data collection : Structured knowledge questionnaire
7.2.1Definition of the study subject : Staff nurses who are registered in state nursing
Council and working in selected Hospitals,
Bangalore.
7.2.2 Inclusion and Exclusion criteria:
a)Inclusion criteria : 1.Staff nurses who are present at the
time of data collection.
2. Staff nurses who are willing to
participate in the study.
3. Staff nurses who are working at
Selected Hospitals, Bangalore
b)Exclusion critetria : 1.Staff nurses who are sick or leave on the day
of data collection
7.2.3Research approach : Experimental Approach.
7.2.4Research design : One group pre test post test pre experimental
design
7.2.5Setting : Selected hospitals Bangalore.
7.2.6Sampling technique : Purposive sampling will be adapted to draw
sample
7.2.7 a) Sample size : 30 staff nurses.
b)Duration of study : 4 weeks.
7.2.8 Tools of research : Self administered Structured knowledge questionnaire will be used to Collect data .The tool consists of two parts.
Part I- Socio demographic data.
Part II-Investigator will develop structured
Knowledge questionnaire for assessing the
knowledge regarding selected complications of
cirrhosis of liver
7.2.9 Collection of data : After getting written consent from the authority
and staff nurses investigator will administer
structured knowledge questionnaire and
conducts structured teaching programme on the
same day then after 7 days post test will be
conducted with the same structured knowledge
questionnaire.
7.2.10 Method of Data Analysis : The investigator uses descriptive inferential
statistical technique.
: 1) Percentage distribution, mean percentage and
standard deviation.
2) Paired “t” test will be used to compare the
pre-test and post test knowledge score.
3) Chi-square will be used to determine the
association between level of knowledge and
selected variables.
4) The analysed data will presented in the form
of table, graphs and diagrams.
7.3 Does the study require any investigation to be conducted on patients or other
human or animals? If so describe briefly?
Yes with prior consent study will be conducted on staff nurses at selected
hospitals regarding selected Complications of cirrhosis of liver.
7.4 Has ethical clearance has been obtained from your institution in case of 7.3?
Yes informed consent will be obtained from concerned subjects and authority of
institution before the study.
Privacy, confidentiality and anonymity will be guarded.
Scientific objectivity of the study will be maintained with honesty and
impartiality.
8. List of references:
1. Lipen cott manual of nursing practise. 8th ed. :Lippincottwillams&wilkins;
Pp.698-699.
2. Joyce M B. Medical surgical nursing.5th ed.583 orchard road Singapore:Harcourt
brace company Asia pvt ltd; Pp. 1335 – 1336.
3. Lewis heitke mper dirksen medical surgical nursing assessment and management
of clinical practice. 7th ed. Mosbypublication ELSEVER Pp. 1101-1102.
4. Marioni CF , Rapisarda L, Lussetti M, Perseghin P. Prevalence of liver damage in
alcoholics and drug addicts. Recenti Prog Med. 2007 Nov;08(11):577-80. [cited
1st Dec 2010]; available from: http://www.google .co.in/information/.htm.
5. De Bac C, Clementi C, Duca F, Livoli D, Poliandri G, Bozza A, a study onliver
cirrhosis: epidemiological aspects in Italy. Res Virol. 2007 Mar-Apr; 148(2):139-
42 available from http://www.google .co.in/information.
6. Chen HL, Liu PF, Liu PW, Tsai PS. Awareness of Hypertension Guidelines in
Taiwanese Nurses: A Questionnaire Survey. 2010 Nov 10. [Epub ahead of print]
available from http://www.pub med .co.in.
7. Spencer P, Kinsman L, Fuzzard K.ANUM Critical Care Unit, Bendigo Health,
P.O. Box 126, Bendigo, Vic 3552, 1850189. Australia. Available from
http://www.pub med .co.in.
8. Niederau C, Benmba G. Kautz A. quality of life and knowledge of cirrhosis of
liver among nurses . Z Gastroenterol. 2008 Jan; 46(1):22-33. . Available from
http://www.pub med .co.in.
9. Chatterjee P. A study to assess the effectiveness of structured teaching programme
on knowledge of nurses regarding hepatitis and its prevention. Nursing journal of
India 2002;81(8):41-43. [cited 1st Dec 2010] available from
http://www.pubmed.co.in/information
10. Verma H. Cirrhosis has many causes; chronic alcholholism and hepatitis C.
{online}. 2004 [cited 1st Dec 2010]; available from:
http://www.pubmed.co.in/information
9. SIGNATURE OF THE
CANDIDATE:
:
10. REMARKS OF THE GUIDE : The present study helps the staff nurses to
improve their knowledge on selected
complications of cirrhosis of liver and
thereby help nurses to provide quality
nursing care.11. NAME AND DESIGNATION OF
11.1 GUIDE : Mrs Shantakka N Chougale. M.Sc.(N)
P G guide and Lecturer
Medical surgical nursing.
G C N B -2
11.2 SIGNATURE :
11.3 CO-GUIDE (if any) :
11.4 HEAD OF THE DEPARTMENT : Mr .G Basavaraju. M.Sc. (N)
HOD& P G guide
Medical surgical nursing
G C N B-2
11.5 SIGNATURE :
12.
12.1 REMARKS OF THE PRINCIPAL : Topic selected for the study is relevant and
forwarded for needful
12.2 SIGNATURE :
ETHICAL COMMITTEE CLEARANCE
1. TITLE OF THE DISSERTATION : “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SELECTED COMPLICATIONS OF CIRRHOSIS OF LIVER AMONG STAFF NURSES AT SELECTED HOSPITALS BANGALORE”
NAME OF THE CANDIDATE AND ADDRESS
: Mrs Jayalakshmi MI st. Year M.Sc. Nursing. G C N B-2.
3. SUBJECT : Medical Surgical Nursing
4. NAME OF THE GUIDE : Mrs Shantakka M Chowgale. M.Sc. (N)P G Guide.& Lecturer Department of Medical surgical nursing G C N B-2
APPROVED/NOT APPROVED(If not approved, suggestion)
:
Prof. H.H. DASEGOWDA M.Sc (N)Head of the Department,Psychatric NursingGovernment College of Nursing,Fort, Bangalore-02
Dr. SUVARNA B. TALWARHead of the Department,Obestrics and Gynecological NursingGovernment College of Nursing,Fort, Bangalore-02
Smt. N. RENUKA MSc (N)Head of the Department of Pediatric Nursing,Government College of NursingFort, Bangalore-02
Sri. H.B. PRAKASHHead of the DepartmentCommunity Health Nursing,Government College of Nursing,Fort, Bangalore-02
Sri. G.BASAVARAJU, H.O.D.Medical Surgical Nursing,Government College of NursingFort, Bangalore-02
Smt. S. HEMAVATHY MSc (N)Principal,
Government College of Nursing,Bangalore-02
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