MR MAHANTESH MIRJI
I YEAR M.Sc. NURSING
MEDICAL SURGICAL NURSING
2012-14
SHREE SIDDAGANGA INSTITUTE OF
NURSING SCIENCES AND RESEARCH
CENTRE B.H. ROAD TUMKUR -02
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / MR.MAHANTESH MIRJIIYEAR M.Sc. NURSING
SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE B.H.ROAD, TUMKUR-572102.
2. / NAME OF THE INSTITUTION / SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE B.H.ROAD, TUMKUR-572102.
3. / COURSE OF STUDY AND SUBJECT / MASTER OF SCIENCE IN NURSING MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO THE COURSE / 10-07-2012
5. / STATEMENT OF THE PROBLEM / A STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDE REGARDING STROKE AND ITS PREVENTION AMONG HYPERTENSIVE PATIENTS IN SELECTED HOSPITALS AT TUMKUR WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.
6.0 BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
The context in which an individual lives is of great importance for his health status and quality of life. It is increasingly recognized that health is maintained and improved not only through the advancement and application ofhealth science, but also through the efforts and intelligentlifestylechoices of the individual and society. According to theWorld Health Organization, the main determinants of health include the social and economic environment, the physical environment, and the person's individual characteristics and behaviors. The lifestyle changes in the present world leads to the many diseases such as hypertension, diabetes mellitus, cardiac diseases, renal diseases and brain diseases can leads to stroke and its incidence rate is increase from 10,81,480 in 2000 to 16,67,372 in 2015.
Astroke, orcerebrovascular accident(CVA), is the rapid loss ofbrainfunctions due to disturbance in theblood supplyto the brain. This can be due toischemiacaused by thrombosis,arterial embolism, or ahemorrhage.As a result, the affected area of the brain cannot function, which might result in aninability to moveone or more limbs on one side of the body, inability tounderstandorformulatespeech, or an inabilityone side of the visual field.1
Stroke is the third most common cause of death in the world after heart diseases and cancers. Annually, 15 million people worldwide suffer from a stroke. Out of these, 5 million attain optimal recovery, 5 million die, and 5 million suffer from a long lasting disability, placing a huge burden on families and communities. Those who develop a stroke are more in Sub-Saharan Africa than in developed countries. Tanzania, a Sub-Saharan African country found in East Africa, faces challenges relating to the outcomes of stroke, similar to other Sub-Saharan countries. According to the Ministry of Health of Tanzania, the burden share of conditions requiring long-term rehabilitation, including cardiovascular disorders, cancer, and anemia, account for 25% of the disease burden. Out of these, cardiovascular disorders alone account for 11.9%Morbidity and Mortality associated with Stroke. Morbidity and Mortality rate in India during 2007 is 90-222 per 100,000 population aged <40 years and in the year 2012
India 0.1 to 0.3 per 100 population aged <45 years and in the year 2012 0.1 to 0.3 per 100 population aged < 45 years.2
The risk factors for stroke are out of our control, several can be kept in line through proper nutrition and medical care. Risk factors for stroke include the following over age 55, African American, Hispanic or Asian/Pacific Islander, family history of stroke, High blood pressure, High cholesterol, Smoking cigarettes,obesity and overweight, cardiovascular disease, previous stroke or transient ischemic attack (TIA), High levels of homocysteine (an amino acid in blood), Birth control use or other hormone therapy, cocaine use etc
Much of stroke prevention is based on living a healthy lifestyle. This includes: knowing and controlling blood pressure,finding out if you have atrial fibrillation,non smoking,lowering cholesterol, sodium, and fat intake,following a healthy diet. If you eat plenty of tomatoes, your risk of developing stroke could be reduced significantly. Tomatoes are rich in lycopene, a powerful antioxidant. In a study published in Neurology, October 2012, researchers found that people with high blood concentrations of lycopene had a 59% lower risk of stroke compared to those with the lowest concentrations, drinking alcohol only in moderation,treating diabetes properly, exercising regularly. Moderate aerobic fitness can reduce stroke risk, a study found., managing stress, not using drug, drinking three cups of tea per day reduces the risk of stroke A study found that taking preventive medications such as anti-platelet and anticoagulant drugs to prevent stroke.
Most population-based studies indicate that a considerable proportion of hypertensive subjects are undertreated and that undertreatment is more prevalent among hypertensive men than hypertensive women. The study aim was to investigate the consequences of undertreatment of hypertension for women and men in terms of stroke occurrence. Approximately 45 000 men and women aged ≥20 years were examined in 2 population-based studies in the Netherlands. A cohort of 2616 hypertensive subjects (pharmacologically treated hypertensive’s and untreated hypertensive’s were participated. The findings shown that compared with treated and controlled hypertensive’s, the relative risks of stroke for treated and uncontrolled hypertensive’s and for untreated hypertensive’s who needed treatment were 1.30 and 1.76, respectively. These relative risks and the prevalence of (undertreated) hypertension in the total population of 45 000 subjects were used to estimate the number of strokes in the Netherlands attributable to undertreatment. Among hypertensive men and women aged ≥20 years in the Netherlands, the proportions of strokes attributable to treated but uncontrolled blood pressure were 3.1% and 4.1%, respectively. For untreated hypertensive men and women who should have been treated, these proportions were 22.8% and 25.4%, respectively.3
Data from the third National Health and Nutrition Examination Survey -III suggest that only approximately half of those taking antihypertensive drugs achieve blood pressure levels at or below the treatment goal of 140/90 mm Hg. Studies in the United Kingdomand the Netherlands have demonstrated that the quality of control of hypertension is strongly related to the occurrence of stroke in the population. Using data from a population-based case-control study, the researcher estimated the proportion of incident strokes occurring among treated hypertensive patients that may be attributable to uncontrolled BP in the United States.4
The education on hypertension and improving adherence to current guidelines might prevent a considerable proportion of the incident strokes among hypertensives. The potential impact of achieving control of blood pressure in patients already being treated on the reduction of strokes requires further investigation.
6.2 NEED FOR THE STUDY
High blood pressure is one of the most common causes of stroke because it puts unnecessary strain on blood vessel walls, causing them to thicken and deteriorate. Traditional risk factors of ischemic stroke in young adults include smoking, diabetes mellitus and hypertension. Studies from Asia showed ischemic and hemorrhagic strokes had the same risk factors, especially a history of hypertension. Other risk factors included a low high density lipoprotein level, the presence of three or more components of metabolic syndrome. In Bangkok, Thailand in 2007, morbidity of essential hypertension was 6.4% for inpatients for all age groups.5
The incidence of stroke among adults was less than 2% in some developing countries in 1990. Where there has been an increase in incidence of stroke in developing countries, the incidence of stroke among adults has also increased. Strokes occur in 5% of western European adults, 8% of Americans, and 13% of Saudi Arabians. In Thailand, stroke is fourth leading cause of death at 28.96 per 100,000 in 2009. In 2008, the death rate from stroke in 15 to 59 years old was 16.3 per 100,000 in males, and 7.8 per 100,000 in females,India of stroke for the year 1998–1999 was 36/100,000 (age- adjusted annual incidence rate 105 . Women outnumbered men regardingstroke prevalence in all age groups except in the 50- to 69. 6
A study was conducted on number of incident strokes attributable to under treatment of hypertension. The incidence rates of stroke after stratification for age, sex, and categories of hypertension treated and controlled, treated but uncontrolled, untreated but should be treated as derived from the 2 population studies. In both genders the incidence rates increased with age. Furthermore, rates were highest in the untreated hypertensive’s who should be treated. The respective age-adjusted prevalence of hypertensive’s per 100 population, treated and controlled hypertension, treated but uncontrolled hypertension, and untreated hypertension that should be treated were 11.2, 28.2, 15.5, and 39.7 for men, whereas for women these prevalence’s were 12.9, 39.4, 18.8, and 32.1 respectively. Age and sex-specific prevalence’s were used to calculate the number of subjects in each of the categories of hypertension for the whole Dutch population.7
A study was conducted on knowledge of stroke among hypertensive patients in selected hospitals. The mean age of the sample was 50.77 years. Most of the participants were females 61.3%. The findings indicated that a large percentage of the participants 52.1% define stroke as paralysis of the whole body and 19.4% as due to local beliefs. Further the findings revealed that 47.7% were not able to differentiate between stroke and heart attack. The overall level of knowledge of stroke among the participants which included their general knowledge of stroke, knowledge of the risk factors, signs, and symptoms of stroke was low. The participant’s age, education level and employment were found to be positively associated with participant’s level of knowledge of stroke.8
In Sub-Saharan African countries, there is extensive lack of knowledge pertaining to stroke within the population in general, and among the medical staff, especially on how to rehabilitate people affected by a stroke. In the Tanga region most of the people live in the village since they are heavily dependent on farming. A large proportion of them are poor local peasants and they are therefore not exposed to health educational campaigns happening in cities. Additionally most of these people firstly consult traditional healers who would not provide correct knowledge about stroke. Poor knowledge leads to low compliance in making use of prevention programmes, thus, patients are less likely to attend stroke management programmes. The main complication of stroke is mood disorder, brain abscesses, paralysis or loss of muscle movement, difficulty talking or swallowing, changes in behavior and self-care, memory loss or thinking difficulties, emotional problems.9
These findings point to the need for the implementation of appropriate health education and health promotion programmes providing information about stroke in target populations. Therefore, health professionals will have to be more involved in not only treating the patients symptoms, but also educating patients, caregivers as well as the general public on the consequences of stroke.
The researcher during his clinical practice found that most of the patients are diagnosed with stroke had the past history of hypertension. The reason behind is the patients were not knowing about the complication of hypertension and how to prevent the complication. Keeping it in mind the researcher decided to assess the knowledge and attitude of hypertensive patients regarding stroke and its prevention. Based on the knowledge and attitude of hypertensive patients the information booklet will be prepared to improve the knowledge and attitude of the patient.
6.3 REVIEW OF LITERATURE
A cohort study was conducted on estimating the probability of stroke in Korean hypertensive patients visiting tertiary hospitals, to find the probability of the stroke among hypertensive patients. A total of 1,402 hypertensive patients treated by cardiology departments at 37 general hospitals nationwide were enrolled. The results shown that the proportion of patients who have uncontrolled hypertension despite use of anti hypertensive’s was 37.2% women, 37.3% men. The average probability of stroke in hypertensive patients was 24.17% women, 24.39% men, approximately 2.4 times higher than of the risk of stroke observed in the Korean Cancer Prevention Study cohort.10
A prospective cohort study was conducted on presence of baseline pre hypertension and risk of incident stroke to qualitatively and quantitatively assess the association of pre hypertension with incident stroke through a meta-analysis of prospective cohort studies. Pre hypertension was associated with risk of stroke. Seven studies further distinguished a low pre hypertensive population systolic blood pressure is 120–129 mm Hg and diastolic blood pressure is 80–84 mm Hg or a high pre hypertensive population is 130–139 mm Hg and diastolic blood pressure is 85–89 mm Hg. Among persons with lower-range pre hypertension, stroke risk was not significantly increased rate is 1.22, 0.95–1.57. However, for persons with higher values within the pre hypertensive range, stroke risk was substantially increased rate is 1.79, 95%. The study concluded that Pre hypertension is associated with a higher risk of incident stroke. This risk is largely driven by higher values within the pre hypertensive range and is especially relevant in nonelderly persons.11
A prospective study was conducted to assess the risk factors of stroke among Congolese black hypertensive diabetics. Out of 492 followed-up patients 279 women, 213 men, 57+or -10 years, 41.9% were old of age > or = 60 years, and 16.5% experienced acute stroke. In univariate analysis, a significant association between age >or = 60 years, cigarette smoking, excessive alcohol intake, diabetes duration > or = 2 years, pulse pressure > or = 60 mmHg. However, multivariate analysis identified only acute bacterial pneumonia, diabetic retinopathy, diabetic neuropathy, chronic renal failure and pulse pressure > or = 60 mmHg as the independent risk factors of stroke onset among these black Congolese hypertensive diabetics. The study concluded that the rate of stroke onset is high among these hypertensive diabetics.12
A prospective population based cohort study was conducted on the relation between knowledge about hypertension and education in hospitalized patients with stroke in Vienna. Five hundred ninety-one consecutive patients with stroke with a medical history of hypertension were interviewed about knowledge concerning hypertension within a multicenter hospital-based stroke registry. The results shown that seventy-seven percent of the patients stated to have known about hypertension being a risk factor for stroke, but only 30% felt at increased risk of stroke. Less than half 47% could identify 140 mm Hg or less as the maximum tolerated systolic blood pressure, and 53% had their blood pressure only controlled monthly or less often. Approximately half of patients were acquainted with the non-pharmacologic treatment options of physical activity 49%, reduction of salt intake 54%, and reduction of caloric intake 48%, whereas relaxation techniques were only known to 17%. The study concluded that Knowledge in our population was insufficient and partly associated with educational level. Furthermore, we found a gap between knowledge of the increased risk for stroke in patients with hypertension and awareness of their own risk.13
A questionnaire study was conducted on Knowledge of stroke risk factors among primary care patients with previous stroke or TIA, to study primary health care patients with stroke regarding their knowledge about risk factors for having a new event of stroke. A questionnaire was distributed to 240 patients with stroke diagnoses, and 182 patients 76% responded. The results shown that Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%.Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. Better teaching strategies for stroke patients should be developed, with special attention focused on diabetic patients.14
A cross sectional study was conducted on Perceived and actual stroke risk among men with hypertension. The authors performed a cross-sectional analysis of 296 men with hypertension who were enrolled in the Veterans Study to Improve the Control of Hypertension. The median 10-year FSR was 16%, but the median perceived risk score was 5 ranges, 1 lowest to 10 highest. There was no significant correlation between patients' perceived risk of stroke and their calculated FSR. Patients who underestimated their stroke risk were significantly less likely to be worried about their blood pressure than patients with accurate risk perception 12.4%. The lack of correlation between hypertensive patients' perceived stroke risk and FSR supports the need for better patient education on the risks associated with hypertension.15
Anexploratory study was conducted on Arterial hypertension patients: attitudes, beliefs, perceptions, thoughts and practices, to know arterial hypertension patients through their attitudes, beliefs, perceptions, thoughts, and practices related to the disease. An exploratory study was carried out in 32 hypertensive patients seen at 2 health care units in the municipal district of RibeirãoPreto,The findings of the study shown that about half the patients 41% were not able to define hypertension. They believed the main symptoms were headaches and neck pain 18% and the possible consequences of the disease were stroke and heart attack 39%.The study concluded that psychosocial aspects and health beliefs seem to affect directly with patients' knowledge on hypertensive disease and their health practices. Given that all patients had already received some kind of information about arterial hypertension before the beginning of the study, it would be important to propose new forms of educating these patients.16
A population-based case-control study was conducted on Prevalence, treatment, control, and awareness of high blood pressure and the risk of stroke in Northwest England, to assess the prevalence of the high blood pressure and risks for stroke. A total of 267 stroke cases and 534 controls were included. Sixty-one percent of cases and 43% of controls had BP >= 160/95 mm Hg on >= 2 occasions within 3 months or received antihypertensive. High proportions of cases 82% and controls 85% were on treatment. There was a continuous relationship between the risk of stroke and levels of BP control. Of 73 cases and 135 controls who were hypertensive and responded to the postal questionnaire, 56 and 83%, respectively, were aware of hypertension (P<0.01). The prevalence of hypertension was high among stroke patients. In those treated, <30% of patients had their BP adequately controlled to <140/90 mm of Hg. Patient awareness of previous hypertension or high BP was very poor and attention needs to be paid to patient education.17