“A STUDY TO EVALUATE THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON COLOSTOMY CARE OF ADULT AMONG III YEAR B.Sc NURSING STUDENTS IN SELECTED PRIVATE COLLEGES AT BANGALORE’’
M.Sc Nursing Dissertation Protocol submitted to
RajivGandhiUniversity of Health Sciences, Karnataka, Bangalore
By
MS.SWATI S. AWATHARE
M.Sc NURSING 1ST YEAR
2010-2012
Under the Guidance of
HOD, Department of Medical Surgical Nursing
Nightingale College of Nursing
Guruvanna Devara Mutt
Near Binnyston garden
Magadi Road
Bangalore –23
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE,KARNATAKA
CURRICULUM DEVELOPMENT CELL
CONFORMATION FOR REGISTRATION OF SUBJECTS FORDISSERTATION
Registration number :
Name of the candidate:Ms.Swati S. Awathare
Address : Guruvanna Devara Mutt, Near Binnyston
Garden, Magadi Road, Bangalore-23 Name of the institution : Nightingale College of Nursing
Course of study and subject:M.Sc. Nursing in Medical Surgical Nursing.
Date of admission to course:
Title of the topic : A study to evaluate the effectiveness of structured teaching programme on colostomy care of adult among III year B.Sc nursing students in selected private colleges at Bangalore.
Brief resume of the intended work : Attached
Signature of the student:
Guide NameS:
Remarks of the guide:
Signature of the guide:
Co-guide name:
Signature of co-guide:
HOD name:
Signature of HOD :
Principal Name :Mrs.Jayakadambari
Principal Mobile No:09886367287
Principal E-mail ID:
Remarks of the Principal:
Principal Signature:
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS.SWATI S. AWATHAREI YEAR M.Sc. NURSING,
NIGHTINGALECOLLEGE OF NURING
GURUVANNA DEVARA MUTT, NEAR BINNYSTONGARDEN,
MAGADI ROAD,BANGALORE-23
2 / NAME OF THE INSTITUTION / NIGHTINGALE COLLEGE OF NURING, GURUVANNA DEVARA MUTT, NEAR BINNYSTON GARDEN, MAGADI ROAD,BANGALORE-23
3 / COURSE OF STUDY AND SUBJECT / M.sc nursing IN MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO THE COURSE / 15.09.2010
5 / TITLE OF THE TOPIC:
“A STUDY TO EVALUATE THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON COLOSTOMY CARE OF ADULT AMONG III YEAR B.Sc NURSING STUDENTS IN SELECTED PRIVATE COLLEGES AT BANGALORE’’
6.7.
8. / BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
A variety of gastrointestinal/genitourinary etiologies may necessitate the creation of a fecal or urinary diversion. Teaching the patient how to carte of a new also my can be a challenging experience for the nurse. The patient with an stormy needs Encouragement, support and counseling to learn how to integrate self stormy care into daily activities.
A variety of gastrointestinal/genitourinary may necessitate the creation of a fecal or urinary diversion. These may include biventricular disease, inflammatory bowel disease, colorectal (meer, intestinal abstraction, gastrointestinal trauma and gynecological cancers (Beitz 2004).
Indication for creating a urinary stoma are bladder cancer Neurogenic bladder, interstitial cystitis & Refractory redication cystitis. The Etiology of the disease will determine if the ostomy is going to be temporary or permanent (Toma selli & McGinis,2004).
Among different types of surgically created ostomies, a colostomy is an opening constructed in the colon (large intestine) to allow for the Elimination of stool. A colostomy may be located in the ascending, transverse or sigmoid colon. The point of surgical resection will determine the consistency of the stool output. An ileostomy is surgically constructed from ileum (Small intestine) it is created high in the gastrointestinal tract, therefore, stool output is of relatively high amount and of liquid consistency (Vasilevsky & Gardon 2004).
* Patient Education :
When a patient is scheduled for ostomy surgery he or she may experience many feelings such as variety fear, loss of body image and depression especially if a diagnosis of cancer is the cause for surgery, preoperactive teaching can help relieve some of these feeling and contribute to the patient’s positive Recovery (O’shea 2001).
One essential component of the patient’s preoperative teaching is a consultation with a wound ostomy and continence nurse (WOCN) preoperative counseling provides the apportunity to assess the patient’s knowledge of the disease, educational level, support system, Employment, involvement in physical activities such as sports or hobbies and financial concern regarding purchase of ostomy supplies in addition, assessment of any physical.
1)Majority 70% of ostomates had colostomy.
2)Majority 76% of the ostomates had 0-10 years of duration of ostomy.
3)84% of ostomates had a change in their clothing style because of ostomy.
4)Majority 66% of the ostomates had a change in their dies because of ostomy.
38% of Ostomates has problem while traveling due to Ostomy.
6.1 NEED FOR STUDY
M.Joyce Black 2005 study that in prepaparaton for discharge,client need support and knowledgeable advice as they to know the nearest location for purchase of ostomy supplies immeadiately after dissmissel,home deliveries of supplies may be necessary.
The enterostomal therapy nurse can help the client learn to manage and accept the ostomy and to achieve a smooth transition from the health care facility to the home
Some cities have established ostoy rehabilitation clinics to help clients and most largeclinic to help clients and most large communities have an ostomy association that maintains contacts with American cancer society.These supportive group are helpful because client can share their ostomy concern with other who have the similar problem.
A home health care referral can add to the client peace of mind,identify a problems that might not otherwise be know and ensure necessary follow up care.
Before disharge advice clientthat it may take several weeks for them to regain their strength after major bowel surgery further when segment have been removed from the bowel,bowel habbit may alter until body adjust to the situation.A nurse may need to teach the client because wound may not be healed totally by the time the client is discharged.
1)Majority 70% of ostomates had colostomy.
2)Majority 76% of the ostomates had 0-10 years of duration of ostomy.
3)84% of ostomates had a change in their clothing style because of ostomy.
4)Majority 66% of the ostomates had a change in their dies because of ostomy
38% of Ostomates has problem while traveling due to Ostomy(oshea 2001).
5)48% of the Ostomates were practicing irrigation to regulate their bowl.
6)40% Ostomates were using two piece pouches.
7)All 100% of Ostomates felt comfortable with their Ostomy care. (TNA JOURNAL-2010)
From the above background we need to study and to evaluate the effectiveness of structured teaching programme on colostomy care of adult among III year B.Sc nursing students in selected private colleges at Bangalore
6.2 REVIEW OF LITERATURE
A review of literature is an essential aspect of scientific research .It is a
systematic identification, location, and scrutiny summary of written material that contains information relevant to the problem under study. It helps to identify the similar studies for the investigator. It enables the researcher to focus on related studies around the world at different set up. The major goal of review of literature is to develop a strong knowledge base to carry out research a non research scholarly activity1.
Ostomy complications: Annually, nearly 120,000 people undergo ostomy surgery in the US and an estimated 800,000 individuals in the JS live with an ostomy. Despite major advances in ostomy care and designated ostomy specialist such as WOCNs, as much as two thirds of individuals who undergo ostomy surgery will experience one or more stoma complications. These complications can significantly interfere with activities of daily living, lead to psychosocial distress, and reduce quality of life.
The actual incidence of peristomal and stomal complications is difficult to ascertain because rates reported in the literature very widely from 6% to 66.8%. Differences in definitions, consensus of terms, populations, study design, and tiing of measurements make comparisons of rates across studies problematic. A review of the literature revealed numerous studies describing different complication rates, select, relevant studies are presented to illustrate the wide range of rates reported in the literature.
In a large prospective audit of 3,970 ostomy patients, Cottamet al documented 1,329 (34%) complications (including peristomal skin-related problems), within 3 weeks of surgery.
Herlufsen et al investigated the frequency, severity, and diversity of peristomal skin disorders among individuals with a permanent stoma in a community population and found that skin disorders were higher for ileostomy (57%) and urostomy patients (48%) than for colostomy partiens (35%). Only 38% of study participants with diagnosed peristomal skin complications agreed they had a problem and more than 80% of participants did not seek professional help for these problems.
Ratliff et al evaluated 220 new ostomy paritents at a 2 months follow-up visit and identified a 16% peristomal complications rate. Ratliff and Donovan studied 161 ostomy paritents seen in a 1 year period and reported complication rate of 6% with complications highest in paritents with an ideal conduit (15%) and ilcostomy (9%).
In a descriptive study, Richbourg et al, using a survey questionnaire mailed to individuals who had undergone ostomy surgey at their facility, identified 34 people (76%) who had peristomal skin irritation. Participants ratedperistomal skin irritation as one of their top five difficulties after hospital discharge. Wood et al followed partients with an ileal conduit for up to 63.4 months after surgery and reported an ovrall stoma complications rate of 34.4% in addition, re-operation was required in 24.7% of the total patient population due to parastomal hernia and stoma retraction.
Sulvadulena conducted a systematic review and identified 21 studies published between 1990 and 2007 that measure the incidence of stomal and peristomal complications. Due to differences in study design, operational definitions, and timing of measurements, Salvadalena concluded it is not possible to pool date and measure the incidence of stomal and peristomal complications, Variability in study designs and absence of operational definitions were indentified as major problems is necessary to investigate challenges encountered by ostomates postporatively.
Stomal/peristomal assessment instruments: Bosio et al conductedf a prospective, observational study between 2003 and 2006 across eight ostomy centers in Italy. Patients were divided into two groups according to onset of complications (less of greater than 1 year). Peristomal skin was assessed at 0,4,12 and 24 weeks. Peristomal skin complications were identified in 339 of 656 ostomy patient (52%, 272 men and 67 women.) From the data obtained in this study, a classification scheme based on recurrent clinical manifestations (lesions) and topographical location was created and the SACS Instrument was developed by seven enterostomal nurses and four surgeons from eight facilities in Italy. The five most common sessions (L) observed in the Bosio study and included in the instrument are hyperemic lesion (Peristomal skin reddening without loss of substance), erosive lesion with loss of substance not extending beyond the dermis, ulcerative lesion extending beyond the dermis, ulcerative fibrin us/necrotic lesion, and proliferate lesions (granulomas, oxalate depiosits, neoplasm). Skin lesion severity is assessed on a scale of 1 to X – eg. LI for less severe and LX for more severe skin complications. Five topographical (T) location quadrants are used to documents peristomal lesion location.
The criteria used in the instrument are universally familiar in that I is similar to wound depthdescription and T to thaty of the grid used to help locate lesions in breast cancer patients (See
Figure 1) The instrument reduces the subjective assessment of peristomal skin lesions and promotes a universal language for communicating peristomal skin disorder. However, the SACS instrument only addresses one component of ostomy clinical decision-making and a broader instrument, such as an algorithm, is needed to address all aspects of the management of stomal and peristomal complications.
In another effort to provide clinicians with a classification system for peristomal skin complications the Ostomy Skin Tool was developed by a group of 12 ostomy care nurses from around the world in collaboration with an ostomy products manufacturer. The Ostomy Skin Tool is comprised of two sections. Part One is used to calculate a score that describe the peristomal skin condition and incorporates both the area affected and severity of the problem. Part two is a diagnostic guide that provides classification of peristomal skin complications according to clinical assessment and standardized descriptions. Content validity of the tool, the Coloplast dialogue study, is in progress.
In an effort to establish valid, reliable definitions for stomal and peristomal complications, Colwell and Beitz surveyed 686 WOCNs to clicit their evaluation on the proposed definitions. On a scale of 1 to 4, the mean score for all definitions and interventions was 3.64 (SD=0.30) and the overall survey’s Content Validity Index (CVI) was 91, demonstrating a high consensus.
The definitions proposed by Colwell and Beitz, along with use of the SACS instrument, may offer clinicians a common language and objective way to diagnose and classify peristomal skin complications. Universal adoption of both also will allow clinicias to accurately measure the prevalence and incidence of peristomal and stomal complication; both the definitions and the SACS Instrument have been content validaterd but must be tested with real patients for kfull validity and reliability. Ultimaterly, this may help WOCN expand the integration of evidence into practice and lead to improvements in the quality of care for the individuals living with an ostomy.
Algorithms and content validation. Algorithms are graphic care maps that allow users to visualize major cognitive components and processes of a clinical problem; they enable the clinician to complete a stepwise evaluation of a specifica issue. From a metacognitive perspective, algorithms help organize thinking, make relationships more meaningful, and highlight crucial decision points.
Most algorithms and decision maps in healthcare are not research-based and lack a data-driven evidence base to support their efficacy. Typoically they only have face or preliminary content validity, the lowest level of evidence (See Table 1). Establishing content validity helps ensure the components and information included adequately reflect the domain of content critical for inclusion (eg. Ostomy care); this rigorous two-stage process is based on development and judgment quantification. Poor scrutiny and incompletion of either stage compromises validity.
The development stage consists of domain (topical area) idenfification, item generation, and instrument construction. Because of the nature of ostomy care algorithm objectives, validity depends on the adequacy with which the characteristics of a variety of ostomies are sampled and represented. This development process is based on use of content experts (ie. Clinical experts).
Selected wound care algorithm have been content validated. The Solutions Algorithms, developed bt Conva Tec Inc. (Skillman.NI) were content validated in 1999 and more recently were construct validated – ie, tested for use in the selection of correct wound care using photographs of actual wounds. To the authors’ knowledge, no evidence based, validated algorithmic approaches to ostomy care are currently available.
More people than ever before are surviving cancer. The 5-year survival rate for colorectal cancer increased from 51% in the mid-1970s to 65% in 2004 (American Cancer Society, 2008). This is changing the view of cancer as an acute incurable disease to one of a manageable chronic disease. Patients who have had surgery with an ostomy require short and long term follow up to adjust and manage complications. Educational needs idenfified by patients with an ostomy include stoma care skills, counseling, diet, obtaining supplies, and management of complications (McMullen et al, 2008; Readding, 2005).
Increasingly, there is a need for comprehensive rehabilitative colorectal cancer program to address ongoing management of symptoms and complications across the disease continuum. Establishing a comprehensive program to meet the educational and service needs of the paritent with colorectal cancer is essential to providing quality effective care. Moreover, there is a shift taking place in how involved patients want to be in making decisions and obtaining helath-released information and care. Younger patients are more Internet-savvy and more active in their health care choices, whereas older patients tend to rely on the physician or care provider for information and decision support (Al-Bharani & Plusa, 2004). Patients value the presence of the multidisciplinary care team to provide information and manage care, beginning early in the diagnosis and continuing across the disease trajectory (Board, 2007). Thus timely assessment of patient learning needs and style is critical to successful education of the patient land family.
Patient education as an expected standard of care for oncology nurses (Boyle, Bruce, Iwamoto, & Summers, 2004). Surgical oncology staff nurses play an important role in initial assessment and the provision of instrumental and educational support to the patient with colerestal cancer, both preoperatively and postoperatively, transitioning the patient to community-based care. Consequently, the knowledge base and skill level of each nurse affects the care and education of the patient. Nurses need to have core knowledge and skills in the management of colorectal cancer care, specifically ostomy care, as well as an understanding of how the care provided is linked to other care providers along the illness continuum. Basic competency for all acture care nurses providing care and educational support for the new postoperative ostomy patient should include the following stoma assessment, pouch fitting, pouch emptying, acces to resources and supplies, and basic problem-solving skills (Boarini, Mc-Nichjol, Carmel, Golberg, & Pruitt, 2004). A few studies have show the importance of nursing knowledge and confidence as it relates tonew ostomy patient satisfaction (Jackson et al.,199; Moore et al., 1998). Findings show a possible link between how nurses perceive their competence, their level of ongoing in-service education, and ostomy patient satisfaction. Nurses who perceive themselves to have high competence and a favourable perception of the ostomy patient were found to have had significantly more education (Moore et al., 1998). Ostomy patients who were cared for by a nurse who was highly confident were more satisfied with their care (Jackson et al., 1993). Thus, nurses’ perception of their level of knowledge and skill affects how the ostomy patient perceives the care experience. In another study examining the use of an educational intervention to improve nursing knowledge in caring for the patient with colorectal cancer, researchers showed significant improvement in disease-related knowledge from pre-to-positintervention (knowledge et al., 2008). Additionally, nurses attending this self-directed education intervention program showed positive attitudes toward patients with colorectal cancer 4 months postintervention and maintained knowledge gained during the program (Knowles et al., 2008).