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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