A STUDY TO DETERMINE THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON ASPIRATION PNEUMONIA

AMONG MOTHERS OF INFANTS IN A

SELECTED PEDIATRIC HOSPITAL AT BANGALORE.

M.Sc. Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By

Mr. NEENACELIN CHERIAN

M.Sc NURSING 1ST YEAR

2010-2012

Under the Guidance of

HOD, Department of Pediatric Nursing sri lakshmi college of nursing no: 127/1, sri gandadakaval, magadi main road, vishwaneedam post, sunkadakatte, bangalore-91.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

Ms. NEENACELIN CHERIANSRI LAKSHMI COLLEGE OF NURSINGNo: 127/1, SRI GANDADAKAVAL, MAGADI MAIN ROAD, VISHWANEEDAM POST, SUNKADAKATTE, BANGALORE-91.

2 NAME OF THE INSTITUTION

SRI LAKSHMI COLLEGE OF NURSINGNo: 127/1, SRI GANDADAKAVAL, MAGADI MAIN ROAD, VISHWANEEDAM POST, SUNKADAKATTE, BANGALORE-91.

3 COURSE OF STUDY AND SUBJECT

M. Sc. NURSING 1st YEARPAEDIATRIC NURSING

4 DATE OF ADMISSION TO COURSE

15/05/2010

5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTERED TEACHING PROGRAMME ON ASPIRATION PNEUMONIA AMONG MOTHERS OF INFANTS IN A SELECTED PEDIATRIC HOSPITAL AT BANGALORE

6 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION

Aspiration pneumonia is bronchopneumonia that develops due to the

entrance of foreign materials that enter the bronchial tree, usually oral or gastric contents

(including food, saliva, or nasal secretions). Depending on the acidity of the aspirate, a

chemical pneumonitis can develop, and bacterial pathogens (particularly anaerobic

bacteria) may add to the inflammation. Aspiration pneumonia is often caused by an

incompetent swallowing mechanism, such as occurs in some forms of neurological

disease (a common cause being strokes) or while a person is intoxicated. An iatrogenic

cause is during general anesthesia for an operation and patients are therefore instructed to

be nil per os (NPO) for at least four hours before surgery Whether aspiration pneumonia

represents a true bacterial infection or a chemical inflammatory process remains the

subject of significant controversy. Both causes may present with similar symptoms. Initial

bacteriologic studies into the causative organisms revealed the anaerobic species to be the

predominant pathogens in community-acquired aspiration pneumonia. 1

However, subsequent studies revealed that Streptococcus

pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae are

the most common organisms. Hospital-acquired aspiration pneumonia, on the other hand,

is often caused by gram-negative organisms including Pseudomonas aeruginosa,

particularly in intubated patients.

This syndrome most commonly occurs in individuals with chronically

impaired airway defense mechanisms. This includes gag reflex, coughing, ciliary

movement, and immune mechanisms, all of which aid in removing infectious material

6.1

from the lower airways. Other risk factors include poor dentition and poor oral care,

which both increase the bacterial burden of oropharyngeal secretions. Clinicians must thus

surmise this diagnosis when a patient presents with risk factors and radiographic evidence

of an infiltrate suggestive of aspiration pneumonia. The location of the infiltrate on chest

radiograph depends on the position of the patient when the aspiration occurred.2

NEED FOR STUDY Aspiration pneumonia is defined as the development of an infiltrate in a

patient at increased risk of oropharyngeal aspiration. It occurs when a patient inhales

material from the oropharynx that is colonized by upper airway flora.. It affects

individuals of all ages, but occurs most frequently in children. Among children pneumonia

is the most common cause of death world wide. In developing world today many deaths

from bronco pneumonia are also preventable by immunization or access to simple,

effective treatments.1 Aspiration pneumonia is more common in males than in females.

Any condition that reduces a patient's gag reflex, ability to maintain an airway, orboth

increases the risk of aspiration pneumonia or pneumonitis.CVAIntracranial mass lesion

Head traumaAlcohol abuseDrug overdoseIsolated alteration of the swallowing reflex

associated with pharyngeal disease.1

The mortality associated with aspiration pneumonia mimics that of

community-acquired pneumonia: approximately 1% in the outpatient setting and up to

25% in those requiring hospitalization. This mortality range depends on complications of

the disease.The mortality rate for severe chemical pneumonitis (Mendelson syndrome) can

be up to 70%.Without treatment, aspiration pneumonia is associated with a high

incidence of cavitation and abscess formation in comparison to community-acquired

pneumonia. Other complications of both aspiration pneumonia and pneumonitis include

empyema, acute respiratory distress syndrome, and respiratory failure. Aspiration

pneumonitis can rapidly progress to respiratory failure. 3

Few studies have been designed that

distinguish between aspiration pneumonia and aspiration pneumonitis. Several studies

suggest that 5-15% of the 4.5 million cases of community-acquired pneumonia result from

aspiration pneumonia.2 Approximately 10% of patients who are hospitalized after drug

overdoses will have an aspiration pneumonitis.

Every year 0.9 million infants die from

aspiration pneumonia.Indeed,it is the leading cause of child death in the world. The

millennium development goal target of reducing the infant mortality rate by two-third by

2015 has renewed interest in accurate assessment of the number of children affected and

underlying causes.. A paper in the world health organization (WHO) bulletin reviews the

history and current status of knowledge on pneumonia in infants. The 1993 world

development report estimated the proportion of childhood deaths caused by acute

respiratory infections at around 30%.4 WHO established child health epidemiology

reference group (CHERG) in2001 to review epidemiological data on the main causes of

death for the year 2000.Globally there were 88 million new episodes of childhood

aspiration pneumonia, occur 95% in developing countries. The incidence of clinical

aspiration pneumonia –the risk of developing it with in a specified period of time –in

infants in developing countries is almost 29%.In developing countries 8.7% of childhood

aspiration pneumonia cases (13.1 million0 are life threatening and requires

hospitalization. Around 1 million children under five years die from aspiration

pneumonia each year, mostly in the African and South East Asia regions.Over half of the

new pneumonia cases occur in 6 countries – India (43 million),China (21

million),Pakisthan (10 million).Bangladesh,Indonesia and Nigeria (6 million each).

In Karnataka, age distribution of prevalence rate of major killer

disease like aspiration pneumonia is 5 % among infants . Pneumonia ranks first among

health problems requiring attention in the health centers. The most vulnerable members of

the population are infants who live in developing countries. On average 2-3% of children

each year have pneumonia severe enough to require hospitalization and many of these

disease episodes are potentially fate. This suggest that of every thousand children’s born

alive 12-20 die from pneumonia before their fifth birthday.5

Recently WHO has decided to launch an annual

“World pneumonia day” on November 2nd,2009.This day will mobilize effects to fight

pneumonia tightly called a ‘neglected’ or ‘forgotten’ disease, that kills more than 2

million children under the age of five each year world wide. World over pneumonia kills

more than any other illness – AIDS, Malaria and Measles. About 156 million new

episodes occur each year world wide, of which 151 million episodes are in the developing

countries. Of all community cases,7-13% are severe enough to be life threatening and

requires hospitalization. In India also 25,000 infants die of aspiration pneumonia each

year. “Millennium development goals (MDG)”- to reduce under five mortality by two-

third by 2015 are to be achieved.4

The recent studies and statistics throws the light that aspiration

pneumonia is an important problem in this contemporary epoch and more infants are

affected with aspiration pneumonia. This is mainly due to unhealthy environment and

poor knowledge among the parents regarding the disease condition. So it is evident that

children’s especially under fives are vulnerable to this disease condition and through

teaching programme the mortality and morbidity rate can be controlled and prevented to a

great extent. So the investigator is very much interested in doing this topic.

6.2 REVIEW OF LITERATURE

INTRODUCTION

Review of literature is a key step in the research process. The typical purpose

of analyzing a review of existing literature is to generate questions and to identify what is

known and what is unknown about the topic. The major goals of review of literature are

to develop a strong knowledge base to carry out research and non research scholalarly

activity.

The review has been divided under the following headings:

a)Studies related to incidence,riskfactors,etiology of aspiration pneumonia. (b) Studies related to mortality of aspiration pneumonia. (c) Studies related to assess knowledge of mothers regarding aspiration pneumonia

STUDIES RELATED TO INCIDENCE, ETIOLOGY,RISKFACTORS OF

ASPIRATION PNEUMONIA.

A study was conducted in unites state of America

in2010 to show the relation between Seizures and aspiration pneumonia The resuls were

33 seizures (5.6%) occurred while patients were eating or drinking, 14 with food in the

mouth at onset. 4 (0.6%) were followed by post-ictal emesis. Supplemental oxygen was

provided in 93% of GTC seizures, and oral suctioning in 85%. such as oral suctioning 6

A study was conducted to identify the causes and contributing

factors of persistent aspiration pneumonia in under five children comprising of 41 cases

out of 41 cases, 8 had pulmonary tuberculosis and 12 had Gram negative bacterial

infections, 12 had aspiration due to gastro esophageal reflux disease or oil instillation, 3

had immunodeficiency due to HIV infection, 2 had congenital lung malformation, 2 had

cardiac disorders and one had foreign body aspiration as causes of persistent aspiration

pneumonia. The most common underlying cause of persistent pneumonia were persistent

infection followed by aspiration and acquired immunodeficies.7

STUDIES RELATED TO MORTALITY OF ASPIRATION PNEUMONIA.

A study Was conducted to study the changing pattern of infant mortality

rate in china .The infant mortality rate in China dropped to, 20.6 per 1000 live

births in 2006, respectively, comparing to 39.7 per 1000 live births in 2000. In urban

areas, Infant Mortality Rate (IMR) dropped to 9.6 per 1000 live births in 2006,

respectively while they were and 13.8 per 1000 live births respectively in 2000. In rural

areas, infant mortality rate dropped to and 23.6 per 1000 live births in 2006, respectively

but they were 45.7 per 1000 live births respectively in 2000. During this period, the

mortality rates due to aspiration pneumonia had dropped sharply. The proportion of

deaths due to pneumonia, dropped from 19.5%, in 2000 to 15.6%, in 2006, respectively.

In urban areas, the proportion of deaths due to pneumonia dropped from 9.9% in 2000 to

9.8% in 2006, In rural areas, the proportion of d deaths due to aspiration pneumonia

dropped from 20.1% to 16.2%.8

A retrospective survey was conducted of all

patients with severe aspiration pneumonitis requiring artificial ventilation in our Intensive

Care Unit from 2002-2006 inclusive. Of 38 infants , 8 (21%) died. Five of these deaths

were due to severe primary intracranial pathology, and occurred after complete or almost

complete resolution of the pneumonitis. One death (2.5%) due to myocardial infarction

was possibly related to aspiration, and 2 deaths (5%) were definitely related to aspiration.

The 7.5% mortality related to aspiration is considerably lower than in previous clinical

studies of severe aspiration pneumonia..9

A study Was conducted Over a 9-yr period, among

505 patients exhibiting severe community-acquired pneumonia and admitted into a total of

six medical ICUs in the north of France. During the 9-yr period study, 505 patients were

retrospectively (n = 337) and prospectively (n = 168) collected. Among them,

116 patients (23%) were retrospectively (n = 73) and prospectively (n = 43) defined as

exhibiting an aspiration pneumonia. For them, main medical grounds of ICU admission

were respiratory distress in 54 patients (Group 1) and neurological disturbances in

62 patients (Group 2). For the remaining 389 patients (Group 3) no criteria for aspiration

was present. Using monovariate analysis, comparison between Group 1 and Group

2 revealed some significant differences: In Group 1, patients were older (5year versus 1 yr,

p < 0.0001), had a more severe underlying diseases (anticipated death within 5 yr, 50%

versus 16%, p = 0.001), suffered more frequently from chronic respiratory insufficiency

(30% versus 8%, p = 0.003) and exhibited, at presentation, a lower PaO2/ FIO2 (223 versus

280 mm Hg, p = 0.01). Respectively, in Group 1 and 2, underlying immunosuppression

(2 patients versus 1 patient) (15% versus 8%), mean SAPS and OSF score, presence of

initial shock, chest X-ray involvement, and biological data such as mean PaCO2

(35.9 versus 36.6 mm Hg), mean serum creatinine (17.4 versus 13.7 mg/l), mean total

serum protein (60.4 versus 64.7 g/l), mean platelets count (258,000versus 208,000/mm3)

and mean leukocytes count (15,000 versus 12,400/mm3) were not significantly different.

Significant differences in comparing characteristics of patients with(Groups 1 and 2) and

without (Group 3) aspiration pneumonia were as followed: In patients with aspiration

pneumonia mean age was lower (4 versus 1 year, p = 0.00001), underlying diseases were

less severe (anticipated death within 5 yr were, respectively, 32% versus 48%; p = 0.004),

chronic respiratory insufficiency was less frequent (18% versus 49%, p = 0.001), = 0.04)

and, on admission, mean PaCO2 (36.3 versus 43.7 mm Hg, p = 0.001) was lower.10

STUDIES RELATED TO ASSESS KNOWLEDGE OF MOTHERS REGARDING

ASPIRATION PNEUMONIA.

A study was conducted to assess the Mothers' knowledge, attitudes and

practices regarding acute respiratory infections in children in Baringo District, Kenya.

A total of 309 mothers were interviewed. Their mean age was 31.5 years (range 16-51)

and 34% had no formal education. Only 18% of mothers described pneumonia

satisfactorily. 60.2% knew that measles is preventable by immunization. 87.1% of the

mothers said they would seek health center services for severe ARI. Formal education

had a positive influence on the KAP of the mothers: The study reveals that the mothers

had good knowledge of mild forms of ARI but not the severe forms like aspiration

pneumonia 11

6.3

A study was conducted to determine Maternal perception of pneumonia in

in Enugu, eastern Nigeria. 400 women were interviewed using a pre-

tested structured questionnaire. Sixty-one per cent of them would recognize pneumonia

by difficult breathing, 42% by fast breathing and 26.5% by severe cough. Few of the

mothers mentioned signs suggestive of 'chest in drawing' (8.5%) and 'central cyanosis'

(1%). The maternal knowledge score on pneumonia signs increased significantly with

educational status and social class (p < 0.05). 12

A study was conducted among mothers to assess the knowledge and

recognition of aspiration pneumonia. The study population consists of 501 mothers. The

findings show that about 84% of the mothers said that they knew what aspiration

pneumonia is.68.7% said that pneumonia is caused by lack of parenteral care.28.9%

believed that virus causes the disease. More than 80% correctly picked rapid breathing

and chest retractions from a list of possible signs and symptoms of pneumonia..13

STATEMENT OF PROBLEM:

“A study to determine the effectiveness of Structured teaching

programme on Aspiration Pneumonia among mothers of infants in a selected

pediatric hospital at Bangalore”.

6.4

6.5

6.6

OBJECTIVES OF THE STUDY

The objectives of the study are:

To assess the existing knowledge of mothers of infants on aspiration pneumonia.

To study the effectiveness of knowledge of mothers of infants after Structured

teaching programme on aspiration pneumonia.

To associate the knowledge with selected demographic variables such as

age,religion,education of the parents, type of family, number of children, area of

residence, income.

To develop a Structured teaching programme on aspiration pneumonia.

HYPOTHESIS

The hypothesis will be tested at 0.05 level of significance.

H 1: There will be significant difference in the pre test and post test knowledge

scores of mothers. of infants on aspiration pneumonia

H 2: There will be significant association between knowledge of Mothers of infant

and selected demographic variables such as age,religion,education.of the parents,

type of family, number of children, area of residence, income.

OPERATIONAL DEFINITIONS:

DETERMINE In this study it refers to firmly decide on the effect of Structured teaching

programme on aspiration pneumonia as measured by the semi -structured questionnaire

and expressed as the post test scores of the experimental group.

EFFECTIVENESS

In this study it refers to producing the desired or intended result of structured

teaching programme on aspiration pneumonia as measured by the instrument and shown

by the post test scores of the experimental group.

STRUCTURED TEACHING PROGRAMME

It is a formal and specific teaching developed for mothers of infants

regarding meaning, causes,transmission,clinical manifestation,prevention and

management of aspiration pneumonia

KNOWLEDGE

In this study it refers to the correct responses of the mothers to the knowledge

part of the questionnaire of the interview schedule and expressed as knowledge scores

ASPIRATION PNEUMONIA

It is a type of pneumonia that develops due to the entrance of foreign materials

that enter the bronchial tree, usually oral or gastric contents (including food, saliva, or

nasal secretions). Depending on the acidity of the aspirate, a chemical pneumonitis can

develop, and bacterial pathogens (particularly anaerobic bacteria) may add to the

inflammation.

6.7

6.8

MOTHERS In this study the word refers to the mothers with infants suffering from aspiration

Pneumonia.

INFANTS

In this study the term refers to the children between the age group one month to

one years of age.

ASSUMPTIONS

Mothers will improve the knowledge regarding causes, prevention and

management of aspiration pneumonia

Structured teaching programme on aspiration pneumonia to mothers of infant

children will promote health of a children and better prevention.

Mothers are best conveyors of health information to other mothers and to family.

DELIMITATIONS:

The study is delimited to :

mothers who are having children between the age group one month to one years

of age.

who knows kannada or English

Study period is 4 weeks.

6.9

7.0

PROJECTED OUTCOME:

The present study will help the mothers of infant to understand about the

causes, prevention and management of aspiration pneumonia and hence it will help to

bring mortality.

MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from mothers of infants who are

Admitted in the hospital.

7.1.1 RESEARCH DESIGN

The research design adopted for this study is quasi experimental study. One group

post test control group design

RESEARCH APPROACH

The research approach is evaluative.

7.1.2 SETTING:

The study will be conducted in K C G hospital. at Bangalore. It is 15 km away

from the College.

7.1.3 POPULATION

The population selected are mothers of infants who are admitted in the hospital.

7.2 METHOD OF DATA COLLECTION

7.2.1 SAMPLING PROCEDURE

The Sampling Technique adopted for this study is purposive.

7.2.2 SAMPLE SIZE

The sample size is 60.

7.2.3 INCLUSION CRITERIA

The criteria for sample selection are mothers of under five who

Have children aged less than 1 year

willing to participate in the study

know kannada or English language

7.2.4 EXCLUSION CRITERIA

Children above 1yearsof age

Infants who are affected with diseases other than aspiration pneumonia

7.2.5 INSTRUMENT INTENDED TO BE USED

SELECTION OF TOOL

This consist of three parts :

PART 1 :consist of demographic variables such as age,religion,education of the parents,

type of family, number of children, area of residence, income

PART 2:Questionnaire will be used to assess the knowledge.25 Questions will be used.

PART 3:Structured teaching programme regarding meaning, causes, transmission,

clinical manifestation, prevention and management of aspiration pneumonia will also be

used.

SCORING PROCEDURE

For knowledge assessment

For Answers. If answer is yes 1

If answer is no 0

SCORING INTERPRETATION Good :- 75-100%

Average :- 50-75%

Poor :- Below 50%

7.2.6 DATA COLLECTION METHOD

Prior permission will be obtained from the Nursing

Superintendent and Ward In- charge before conducting the study. Interview will be

conducted between 10 am to 3 pm. Data will be collected from 5 samples per day. The

duration will be 4 weeks. The duration of study will be 30 minutes will be spent per each

subject.

7.2.7 PILOT STUDY

6 samples will be selected and study will be conducted to find out the

feasibility.

7.2.8 DATA ANALYSIS PLAN

The data obtained will be analyzed in view of the objectives of the study

using descriptive and inferential statistics.

The plan for data analysis was as follows: -

Frequencies and percentage of distribution will be used to analyze

the demographic data.

Mean, Median and Mode, Standard deviation is used for accessing

the knowledge scores.

Chi-square test to find out the association between knowledge

with selected demographic variables. The significant findings will

be experienced in tables, figures and graph.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER

HUMANS OR ANIMALS?

7.4

- No-

HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?

YES, Ethical clearance will be been obtained from the research committee

of sree Lakshmi college of nursing.

Consent will be taken from the hospital and permission will be taken from

the study subjects before the collection of data.

8.0 LIST OF REFERENCES

1.A.Parthasarathy ,P.S.N Menon ,Piyush Gupta, M.K.C Nayar .”Text book of Pediatrics”

4th edition.New Delhi:Jaypee brother’s Publishers;2009;pno 578.

2. Cotran, Ramzi S,Kumar, Vinay, Nelso Fausto, Robbins.” Pathologic basis of disease”

6th edition . St. Louis: Elsevier Saunders; (2005) ; pno 749.

3.International child disease and developmental research.” Health and Science Bulletin”;

4(2); June 2006.

4 WHO Bulletin”Global estimate of clinical incidence of clinical pneumonia among

children under five years of age”;2004.

5.Agnihotrao, V.Ramana kumar, etal.”Respiratory disease burden in rural India”:2005.

6. Noe KH, Tapsell LM, Drazkowski JF,”Epilepsy and Pneumonia “The American

Journal on Pediatrics 2010 Nov 29 11;4(11):pg 77-76.

7. Kumar M, Biswal N, Bhuvaneswari V, Srinivasan S. “Persistent pneumonia:

Underlying cause and outcome”.Indian Journal of Pediatrics: 2009 Nov 26.

8. Wang YP, Zhu J, Et al. “Analysis on under-5 mortality rate and the leading kinds of

diseases”. 2009 May;30(5):466-70.

9. Hickling KG, Howard R, “Aspiration pneumonia Mortality”. Intensive Care Medical journal . 2008;june 14(6):617-22.

10. Ye Y,Zulu E,et al.” pattern of pneumonia mortality among infants

”.Journal on tropical medicine and hygiene:Nov;81(5):770-5.

11 .Simyu D.E,Wafula E.M,Nduati R.W.”Mothers knowledge,attitudes and practices

regarding acute respiratory infections in children”.East African medical

journal:2003;June;80(6):303-7.

12 .Uwaezuoke SN, Emodi IJ, Ibe BC.” Maternal perception of pneumonia in children”.

Annals of Tropical Paediatrics:2002 Sep;22(3):281-5.

13 .S.fuchg, etal.”The burden of pneumonia in children in Latin America”. Paediatric

respiratory review: vol 6; 2000.

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3CO-GUIDE

11.4SIGNATURE

11.5 HEAD OF DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE