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A STUDY TO ASSESS THE KNOWLEDGE REGARDING CONTROL OF PAIN AMONG RHEUMATOID ARTHRITIS

PATIENTS ADMITTED IN HARSHA HOSPITAL, NELAMANGALA.WITH A VIEW TO DEVELOP SELF

INSTRUCTION MODULE.

PROFORMA FOR REGISTRATION

OF

SUBJECT FOR DISSERTATION

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGLORE, KARNATAKA.

HARSHA COLEEGE OF NURSING

NELAMANGALA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

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01. NAME OF THE CANDIDATE AND : SHYNI AUGUSTINE

ADDRESS 1ST YEAR MSC NURSING

HARSHA COLLEGE OF NURSING

NELAMANGALA, BANGLORE

02. NAME OF THE INSTITUTION : HARSHA COLLEGE OF NURSING

NELAMANGALA, BANGLORE.

03.COURSE OF THE STUDY : 1ST YEAR MSC NURSING

AND SUBJECT MEDICAL SURGICAL NURSING

04. YEAR OF ADMISSION : 2010

05. TITLE OF THE TOPIC : A STUDY TO ASSESS THE KNOWLEDGE

REGARDING CONTROL OF PAIN AMONG

RHEUMATOID ARTHRITIS PATIENTS

ADMITTED IN HARSHA HOSPITAL,

NELAMANGALA, WITH A VIEW TO

DEVELOP SELF INSTRUCTION MODULE.

1. INTRODUCTION AND BACKGROUND

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Rheumatoid Arthritis is a chronic inflammatory disorder that affects joints especially synovial joints. Rheumatoid Arthritis is an autoimmune disorder whose exact cause is unknown. But it is triggered by infections like streptococci, micoplasma, rubella etc. (1)

About 1% of the population in INDIA is affected by Rheumatoid Arthritis. This condition commonly acquires between the age group of 30-50years and three times more commonly in women. There by substantially decreasing mobility of the joints and overall activity of the affected person.

Ironically, the name of the disease confuses people Since the name of the disease has the word “ARTHRITIS” in it, many assume Rheumatoid Arthritis is a disease of elderly. The people who seem least likely to be diagnosed with full blown Rheumatoid Arthritis are the elderly.

Rheumatoid Arthritis is a serious illness comparable to Diabetes or Angina. Rpatients do not tend to live as long and require lifelong treatment by a specialist. There is no cure for Rheumatoid Arthritis. It is an extremely complex disease. For one thing Rheumatoid Arthritis is “heterogeneous”, meaning it does not always behave the same way, even in a single patient.

The treatment for Rheumatoid Arthritis is yet to be discovered. But at present various treatment methods are used to alleviate symptoms and reduce pain. According to American college of Rheumatology (2008 publications) the management of Rheumatoid arthritis consist of two fold trend, that is –alleviating the current symptoms and- preventing the further progression of Rheumatoid Arthritis. (Handicap).

Need For the Study

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Rheumatoid arthritis is a progressive almost irreversible conditions in which about 40% of patients end up with being total handicap. This reflects the nature of the severity of the disease. This condition not only affects the physical comfort but also makes the patient mentally depressive by limiting his/her activities. As the Rheumatoid arthritis is an autoimmune disorder caused by infections there for it is a complex condition which may complicate into other disease like Rheumatic fever, heart disease, renal failure thereby predisposing patient to the other severe diseases. Being diagnosed with RA double the risk of developing heart disease which is a major reason for high mortality rate of Rheumatoid Arthritis .

Rheumatoid Arthritis in Elderly Patients

Majithia V, Peel C, Geraci S A, conducted an explorative research in department of medicine, division of Rheumatology, in Mississippi School of medicine (2) . According to the researchers Rheumatoid Arthritis in the geriatric population presents a unique challenge to the treating care givers.

Rheumatoid arthritis affects commonly middle aged population who are still active and still earning their livelihood especially women folks who used to carry the burden of the family and children who become highly susceptible and thereby the whole family system /activity may be affected.

Even though it is a progressive disease its symptoms especially joint pain can be reduced (severity) by adopting various modalities or minor changes in day today lives which will not only decrease the severity of symptoms but may slow down the progression of Rheumatoid Arthritis and is a key approach to Rheumatoid Arthritis in today’s highly active life style.

regarding educational intervention for implementation of Arthritis Clinical Practice Guidelines in primary care. A systematic literature was conducted to identify the relevant educational interventions that reported behavioral income that ensures actual knowledge utilization in primary care. The result of the study was, interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with Rheumatoid Arthritis. This study concluded by saying that, FUTURE STUDIES ARE NEEDED to evaluate which specific organizational, provider, patient and system level factors influence the uptake of Arthritis Clinical Practice Guidelines in primary care. A research

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conducted by Sydney C. Lineker and Janice A. Husted from arthritis society Toronto (2010)(3)

Right now arthritis is one of the major health problems of America and developing countries. Since 1985 they are close to 46 million suffers of this disease. This is an alarming increase, and in order to counteract these numbers, they (American Arthritis Foundation) moved to help more researchers and patients. The American Arthritis Foundation is in constant need of researchers and speakers who can educate arthritis patients, on how they can effectively deal with their health situations. The foremost project of the American Arthritis Foundation is to provide the patients with the adequate information about their disease. They do this by giving away free communication kits that contain a guide, or a manual about arthritis, a health assessment questionnaire a participant survey form, and other additional information that proves to be essential for Rheumatoid Arthritis patients. American Arthritis Foundation (4)

Awareness about the severity of Rheumatoid Arthritis, increased rate of incidence in our society and lack of knowledge of people to manage this disease condition, and as my mother and one of my siblings is the victim of the same disease condition , inspired me to conduct a study to assess the knowledge regarding the control of pain, and help them to lead a better life with the disease, among Rheumatoid Arthritis patients.

2. REVIEW OF LITRATURE

Arthritis and Rheumatoid arthritis

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MERCK MANUAL OF MEDICAL INFORMATION (5) (2003) Reports that

Arthritis- osteoarthritis (degenerative joint disease) is a common disorder of joint cartilage and surrounding tissue that is characterized by pain, stiffness and loss of function. It affects most people to some degree by the age of 70. Before the age of 40 men develop osteoarthritis, more often than women because of injury.

LINTON, INTRODUCTION TO MEDICAL SURGICAL NURSING (6) 2007 Concludes that Arthritis- It is the most common prevalent chronic disease in men. However, it is more severe in women and is the leading cause of disability in old age. Osteoarthritis is the most common form of arthritis, is caused damage to the inside surface of the joint. Age is the primary risk factor for arthritis, with hereditary and obesity contributing to its development. The large weight bearing joints (knee, hips, and spine) are affected.

LINTON, INTRODUCTION TO MEDICAL SURGICAL NURSING (6) 2007

Rheumatoid Arthritis is a chronic, progressive, inflammatory disease. Although it is a systemic disorder, the most notable effect of Rheumatoid arthritis is on synovial joints. The disease has a peak onset in people 30-60 years of age and is more common in females than males. It affects an estimated 1%to 3% of the population. The course of the disease is variable, ranging from minimal symptoms to severe debilitation.

There is no single known cause for Rheumatoid Arthritis, but it is considered an autoimmune disorder. Possible causes include an unknown antigen one or more viruses, genetic predisposition, and hormonal factors. While research to determine the exact cause continues, many recent discoveries have improved the lives of Rheumatoid Arthritis patients.

The most common symptom of Rheumatoid Arthritis is PAIN in the affected joints that is aggravated by movements. Morning stiffness lasting more than 1 hour is almost always a feature of RA, unlike the stiffness of osteoarthritis, which is relieved within minutes. Other symptoms include weakness, weight loss, muscle ache, tenderness, warmth, and swelling of joints. The distal interphalangeal and

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metacarpophalangeal joints are affected most often. The wrist, elbow, knee, ankle are the other possible areas affected.

MERCK MANUAL OF MEDICAL INFORMATION (5) 2003 describes that

Rheumatoid Arthritis is an inflammatory arthritis in which joints, usually including those of the hands and facets are inflamed resulting in swelling, pain and often the destruction of joints. Worldwide Rheumatoid Arthritis develops in about 1% of the population regardless of race, or country of origin affecting women 2 to 3 times more than men. Usually Rheumatoid Arthritis appears between 25 and50 years of age but it may occur in any age. People with Rheumatoid Arthritis may have mild course, occasional flare-up with long periods of remission without disease or a steady progressive disease, which may be slow or rapid. Rheumatoid Arthritis may start suddenly, with many joints becoming inflamed at the same time. More often, it starts subtly, gradually affecting different joints.

BRUNNER & SUDDARTH’S MEDICAL SURGICAL NURSING (7) 2004 Explains that RHEUMATOID ARTHRITIS is commonly used as the prototype for inflammatory arthritis. The incidence 3% with a two to three times greater incidence in women. (Ruddy et al.2001). In early stage of the disease even before bony change occur limitations in functions can occur, when there is active inflammation in the joints. Joints are hot, swollen, and painful and not easily moved. The patients tend to guard or protect these joints through immobilization. Immobilization to an extended period can leads to contractures, creating soft tissue deformity.

Control of Rheumatoid Arthritis

Motla L M, Laurindo I M, Santos Netoll (2010 May) (8)

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Faculty of medicine, university of Brasilia conducted a research regarding the treatment of patients with early Rheumatoid Arthritis. According to these researchers the main goal of treatment of patient with Rheumatoid arthritis are-to reduce the pain, swelling and constitutional symptoms like fatigue ,to improve joint function , to stop progression of bone cartilage damage ,prevent disability and reduce morbidity and mortality. In recent years therapeutic concept of early Rheumatoid arthritis (first 12 months of symptoms) has changed. Three new approaches for control of Rheumatoid arthritis are

1. Early diagnosis

2. Immediate beginning of DMARD-Disease Modifying Anti rheumatic drug therapy

3. Strict control of inflammatory activity

Keely G A, Keely K S, Hootman J M, and Hookmen (2010 sept) (9)

Of department of community medicine West Virginia University USA conducted a study regarding the effect of community deliverable exercise on pain and physical function in adults with arthritis and other Rheumatic diseases.

They used Meta analysis approach and randomized control trials for six electronic data basis (internet) of Rheumatoid arthritis adults (>18 yrs) for the study publishers between the 01/01/1980 to 01/01/2008.

In total data’s of 3180 patients with Rheumatoid arthritis are observed for pain and its control over time. After the study, it was concluded that the patients with community deliverable exercise improved over time.

Carol and Riichard Fustice conducted a research (2008-sep) (10)

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On the effect of vitamin C and Rheumatoid Arthritis. This study involved more than 23,000 participants from a cancer centre from UK. After the analysis researchers concluded that people who developed arthritis consumed fewer fruits and vegetables than those who did not develop disease.

Conclusion of this study is consuming fruits and vegetables to get daily recommended dosage of vitamin C is naturally encouraged and moderation in vitamin C intake is advised for maintaining healthy bones and joints.

Knowledge of patient regarding Rheumatoid arthritis.

Silva K N, et al (2010 May) (11) conducted a research in Brazilian Cochrane centre Sao-Paulo-Brazil to assess the effectiveness and safety of balanced training (proprioceptive training) to improve functional capacity in patient with rheumatic arthritis. 864 patients with history of rheumatoid arthritis are selected by using random selection and data was collected regarding the knowledge of exercise and balance training. And they are compared with patients who had knowledge of exercise and balance control by using randomized controlled trails. After the comparative study of muscle strength, endurance walking and swimming exercise the researchers concluded that the most of the patients are unaware of exercise and balance training method.

Udrea G, Dumitrescu B, Purcarea M, Ballen I,Rezus E Deculescu D(2009 April)(12) conducted an explorative study at the Carole Davile University of Medicine Bucharest, Rumania. The purpose the study to assess the patient’s information, motivation and perspective to participate in clinical trials of new methods of treatment for Rheumatoid arthritis .They used a structured interview schedule, with questionnaire to collect the data from 96 patients. (75%women and 30%men) in the main age group of 48 work subjected to study. Out of which 73% of the patients were unaware of new methods of treatment for rheumatoid arthritis, and among the remaining 23% were unwilling to accept to the methods of controlling Rheumatoid arthritis .4% of the patients were non responsible. The study concluded that awareness is needed to be given by giving education to Rheumatoid arthritis regarding new methods of controlling Rheumatoid arthritis.

Kaplan F, and Kozin F, (jan-feb 1981) (13) conducted a study at the university of Berlin Germany by using group counseling and self instruction program. Groups

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were divided into two, i.e. Control group and experimental group. The knowledge was assessed of both groups (200 patients with Rheumatoid arthritis) before the counseling and self instruction program. Self instruction program was given for a period of 12 weeks along with counseling, regarding knowledge of Rheumatoid Arthritis. After 12 weeks both groups were assessed by using test and interview. It was found that the experimental group (rheumatoid arthritis) patients improved their scores in areas of factual knowledge of Rheumatoid arthritis, self concept, and psychologically they were more self confident. Depression level was decreased. These results showed that formal educational session, group counseling may improve the symptoms of rheumatoid arthritis patients and helping them in managing the Rheumatoid arthritis.

3. OBJECTIVES OF THE RESEARCH

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Statement of the problem

For the present study the discussion with the experts, colleague’s et al, review of literature, personal clinical experience of the researcher gave the basis for the selection of the following research problem.

A study to assess the knowledge regarding control of pain among Rheumatoid Arthritis patients admitted in Harsha hospital Nelamanagala with a view to develop a self instruction module.

Objectives of the study

1. To assess the knowledge of Rheumatoid arthritis patients regarding the control of pain.

2. To develop and prepare self instruction module for the patient with a view to improve their knowledge regarding Rheumatoid arthritis.

3. To broadly categorize patients on the basis of knowledge scores regarding Rheumatoid Arthritis and demographic variables

Operational definitions

1. Assessment: Evaluate or estimate the ability or understanding of patients regarding control of pain in Rheumatoid arthritis.

2. Knowledge: Facts, information, and skills acquired through experience or education.

3. Patient: A person receiving or registered to receive medical treatment.

4. Arthritis: The inflammation of the joint.

5. Rheumatoid Arthritis: It is an autoimmune disease that causes chronic inflammation of joints. It can also cause the inflammation of the tissues around the joints, as well as in other organs of the body.

6. Joint: A joint is where two bones meet to allow movement of body parts.

7. Rheumatism: It is a group of autoimmune condition affecting joints and connective tissue.

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8. Self instruction module: It refers to any learning material developed for the purpose of achieving pre-specified objectives. It also refers to an independent learning material, which has organized content that enhances the knowledge of patients.

Assumptions

1. The researcher assumes on the basis of literature , previous experience that patients with Rheumatoid Arthritis lack knowledge regarding control of symptoms of Rheumatoid arthritis.

2. The knowledge can be imparted by using self instruction module.3. Rheumatoid arthritis patient’s quality of life can be improved by newer

modalities of therapy.

Hypothesis

H2 (RESEARCH ALTERNATIVE HYPOTHESIS)

According to this hypothesis, there is a significant association between demographic variable and scores of Rheumatoid arthritis patients.

De Limitations of the Study

1. Study is limited to Rheumatoid arthritis patients admitted in Harsha Hospital, Nelamangala.

2. Study is limited to the patients who are present during the research.3. The study is limited to the patients who can participate, listen and

speak(excluding non viable patients, properly )

Conceptual Frame Work

The present study is based on Health Belief Model by IRWIN,M, ROSENSTOCK (1966)

4. METHODOLOGY

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It is a systematic and coordinated approach to solve the research problems. It helps researcher to project and streamline the various stages of research undertaken.

The research methodology involves systematic procedure by the researcher that includes problem identification, description, and continuous until the result and conclusion.

Research Approach

Research approach is the basic procedure for the research of enquiry. It helps the researcher regarding what data to be collected and how to analyze it. It also suggest possible conclusion to be drawn from the data. The present research is based on the problem selected that is

A study to assess the knowledge regarding control of pain among Rheumatoid arthritis patients admitted in Harsha hospital Nelamagala with a view to develop a self instruction module.

This study is explorative/descriptive study and analyses patients score with a relation to various demographic variables.

The descriptive study is considered appropriate for the present study as there are few researchers that describe extend of information, disseminated regarding RA among RA patients. The research is to be conducted with a view to develop / create an information guide sheet that can be used as a self instruction module.

Research Design

Research design incorporate most important methodology, plan for organization for the research study. Research design for the present study is descriptive explorative study of the 50 subjects suffering from Rheumatoid arthritis and selected through purposive sampling technique.

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RESEARCH DESIGN

Research setting

It is the probable geographical area where the research/study is planning to conduct. For the present study research setting is Harsha Hospital Nelamangala, Bangalore.

Research Sample

It is the small representation of a very large group or population. For the present study a small group of sample of Rheumatoid Arthritis patients to be selected randomly from patients admitted with Rheumatoid Arthritis in Harsha hospital Bangalore.

Sampling Technique

ACCOUNTABLE POPULATION

RHEUMATOID ARTHRITIS

PATIENTS

SAMPLE GROUP

50 SAMPLES OF RHEUMATOID ARTHRITIS PATIENT SELECTED RANDOMLY.

DEVELOPMENT

OF INFORMATIONAL

GUIDE SHEET

CATAGORIZING

BASED ON

DEMOGRAPHIC VALUES

ASSESSMENT TEST

MULTIPLE CHOICE QUESTIONNAIRES

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The sample is to be collected randomly from the target population by using purposive sampling technique criteria for selecting sample. The sample is to be collected on the following criteria.

Inclusion Criteria

-Patients with RA admitted in Harsha Hospital

-Patients who are present during data collection

-Patients who are willing to participate

-Patients who are 20 years of age and above

-Patients who can understand / communicate Kannada or English

Exclusion Criteria

Patients with other types of Arthritis (Osteoarthritis etc..) Patients who are not willing to participate in this study Patients who are not present during the study Patients who are below the age of 20 Patient who cannot understand/communicate Kannada or English

Sample Size

50 representive samples with Rheumatoid Arthritis have to be selected.

Selection and Development of Tool

The tool will be selected and developed based on experience, expert’s guidance, review of literature. So the tool will be broadly divided into two parts.

1. Demographic variables2. A questionnaire

The tool will be a structured questionnaire in both English and Kannada.

Blue Print and Reliability of Tool

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The blue print of the tool prepared, will be given to experts for validation. The reliability of the tool will be examined by using KARL PEARSON co-relation based on Spearmann Brown’s prophecy formula.

Method of data collection

The data will be collected directly from the sample by using self administered / researcher’s administered questionnaire.

Review of literature for tool

The tool will be developed by thoroughly reviewing books, journals, news papers etc.

Duration of the study

The researcher is intended to complete the research within a time frame of six weeks.

Ethical clearance

The researcher is intended to obtain prior permission and ethical clearance for the present study from the

Patient’s family Nursing superintend Staff nurse/ward in charge concerned Hospital

The safety, confidentiality, self respect and liberty of the patient will be given importance during the present study.

The present study does not include any invasive scientific investigation on patients, other human being or animals.

Variables

For the present study the following variables are considered.

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1. Independent Variable Assessment of Rheumatoid Arthritis patients Questionnaire

2. Dependant VariableKnowledge of patients with Rheumatoid arthritis regarding pain management (present knowledge)

3. Demographic Variables1. Age2. Gender3. Religion4. Area of residence (urban/ rural)5. Family history of Rheumatoid Arthritis (present/ absent )6. Occupation of the patient

agricultural worker industrial worker businessman/marketing professionals executives others

7. Activity of the patient highly active moderately active sedentary

8. Body weight of the patient 40 kg and below 41-50 kg 51-60 kg 61-70 kg 71-80 kg 80 kg and above

9. Habits of the patients Smoking only Alcoholism only

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Both –smoking & alcoholism No habits

10. Dietary habits vegetarian Non vegetarian

11. Presence of other disease condition present Absent Previous history of infection

12. Monthly family income less than 1000 1001-5000 5001-10000----* 10001- above

13. Educational status

illiterate up to 10th std up to PUC up to graduation post graduation ad above

Pilot Study

It is a miniature of main study

It is a small preliminary investigation of some aspects of major study like sample characteristics, tool effectiveness etc.

5. DATA ANALYSIS

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Plan for data analysis. The data obtained from the subjects will be analyzed in terms of objectives of the study. Using descriptive and inferential statistics. The plan for data analyses as follows.

-Organize data in master sheet or computer

-To obtain percentages averages and frequencies

-To obtain mean, median, and standard deviation to determine association between knowledge levels and demographic variables.

-Represent the data in tables and graph.

Bibliography

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1. Rheumatoid Arthritis Information. http://www.pubmed.com

2. Rheumatoid Arthritis in Elderly Patients. http://www.wikipedia.com

3.SYDNEY C. LINEKER AND JANICE A.HUSTED. Educational intervention for implementation of Arthritis clinical practice guidelines in primary care, Arthritis Society, Toronto. http://www.wikipedia.com

4. American Arthritis Foundation, Education and Communication. http://www.Arthritis-Education.com/Home remedies for arthritis.

5. MERCK. Merck manual of Medical information, 2003, Home edition; v.2, p.330-333 .

6. LINTON. Introduction to Medical Surgical Nursing, 2007, 4th edition; V.4, P.135,900-901 .

7. BRUNNER & SUDDARTH’S, Text book of Medical and Surgical Nursing, Philadelphia, 2004, 10th edition; P.1621-1622.

8. MOLTA L.M, LAURINDO I.M, SANTOS NEOTLL. Association of Medical Bras, University of Brasilia, 2010, May- June, V. 56(3), P.360-362.

9. KELLY G.A., KEELY K.S., HOOTMAN J.M.AND (HOOKMAN). Arthritis Care and Research, e-publications, 2010 sept, PMID-20824798.

10. CAROL & RICHARD FUSTICE. Vitamin C and Arthritis. http://www.AlSearsMD.com

11. SILVA K N. et al. Balance Training for patients with Rheumatoid Arthritis, Cochrane Data Base System,2010 May,12,5 (data base no:CD007648).

12 UDREA G, DUMITRESCU B,PURCAREA M, BALLEN I,REZUS E, DECULESCU D. Patient’s Perspective and Motivators to participate in Clinical trials with Novel Therapies, Journal of Medicine and Life,2009 April- June, V.2(2),P.227-331.

13. KAPLAN F,KOZIN F. Controlled Study of Group Counseling in Rheumatoid Arthritis, Journal of Rheumatology, 1981Jan-Feb, V.8(1), P. 91-99.

NAME OF CANDIDATE :

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SIGNATURE OF CANDIDATE :

REMARKS OF THE GUIDE :

NAME AND DESIGNATION OF GUIDE:

SIGNATURE:

NAME OF THE CO-GUIDE & DESIGNATION(IF ANY )

SIGNATURE :

HEAD OF THE DEPARTMENT :

SIGNATURE :

REMARKS OF THE CHAIRMAN OR PRINCIPAL:

SIGNATURE :

NAME AND ADDRESS :HARSHA COLLEGE OFNURSING OF THE COLLEGE NELAMANGALA