RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE
BANGALORE, KARNATAKA
1 / Name of the candidate and address / Mrs.Sheeba Rachel.TI year M.Sc.(N)
Roohi College of Nursing
Bangalore -43
2 / Name of the institution / Roohi College of Nursing
3 / Course of the study and subject / I year M.Sc.(N)
Medical Surgical Nursing
4 / Date of admission to course / 04.05.2010
5 / Title of the topic /
“A study to assess the effectiveness of SIM regarding knowledge on early identification and management of “angina” among staff nurses in selected Hospitals, Bangalore”
PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
6.0 BREIF RESUME OF INTENDED WORK
INTRODUCTION
“Life is a long lesson in humility” - James M. Barrie
The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all parts of the body's tissues the heart is like any other muscle, requiring blood to supply oxygen and nutrients for it to function. The heart's needs are provided by the coronary arteries, which begin at the base of the aorta and spread across the surface of the heart, branching out to all areas of the heart muscle. The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques, build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle may be compromised (slowed down), and this slowing of blood flow to the heart causes pain, or angina.1
Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is termed stable angina and is associated with high grade narrowing’s of the heart arteries. The symptoms of angina are often treated with beta-blocker therapy such as metoprolol or atenolol. Nitrate preparations such as nitroglycerin, which come in short-acting and long-acting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed. Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It may be treated with oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done. Angina pectoris is a form of cardiovascular disease. Symptoms include episodic tightness in the chest accompanied by pain in the jaw, back, shoulder or arm and normally last for between 1 to 5 minutes. Angina is classified according to its severity and may be treated with drugs, lifestyle modifications, education and counseling. Refractory angina is a form of angina that does not respond well to conventional treatments and patients experience limitations in their ability to undertake physical activity Angina is a common type of chest pain that can occur when the heartmuscle is not receiving sufficient blood flow and oxygen. Angina is a symptom of some heart diseases, especially atherosclerosis. 2,3
The chest pain of angina can be mild to severe. The chest pain of angina is different from the chest pain of a heart attack in that angina generally occurs with activity or exertion and goes away with rest and/or medication, such as nitroglycerin. In contrast, the chest pain of a heart attack does not go away with rest or after taking nitroglycerin. To learn more about other important symptoms and complications of angina, refer to symptoms of angina. 138,000 men self-reported having angina in Australia 2001 (ABS 2001 National Health Survey, Australia’s Health 2004, AIHW) and There were significant ecological correlations between study-level angina prevalence and country-level MI mortality rates in women (r=0.27, 95% CI 0.03 to 0.48, P=0.03) and men (r=0.42, 95% CI 0.20 to 0.60, P=0.0005). and 6,600,000 cases in the USA (National Health and Nutrition Examination Survey III, 1988-94) Other possible causes of chest pain, and there are numerous, can range from less life-threatening (e.g. reflux, heartburn, indigestion, GERD, etc.) to the extremely dangerous (e.g. heart attack, heart disorders, lung disorders and many other causes of chest pain). Always seek emergency medical attention for chest pain or other medical conditions similar to chest pain or angina. So nurses are needed to educate about early identification and management of angina. 4,5
6.1 NEED FOR THE STUDY
Angina a form of heart disease where the blood flow to the heart is restricted by a blockage in one or more of the arteries that carry blood into the heart. Usually, the first sign Angina is a pain in the chest, not unlike a squeezing or pressing sensation. Angina is also referred to as heart disease or coronary heart disease. Angina has a variety of presentations, and there may not even be specific chest pain. There may be shoulder or back ache, nausea, indigestion or upper abdominal pain. Women, the elderly, and people with diabetes may have different perceptions of pain or have no discomfort at all. Instead, they may complain of malaise or fatigue. Healthcare providers and patients may have difficulty understanding each other when symptoms of angina are described. Patients may experience pressure or tightness but may deny any complaints of pain. People with coronary artery disease usually have gradual progression of their symptoms over time. As an artery narrows over time, the symptoms that it causes may increase in frequency and/or severity. Healthcare providers may inquire about changes in exercise tolerance.6
Coronary heart disease (CHD) in women is an enormous problem and remains the number one killer of women. As a result, there is a great deal of research available. However, in spite of the research and the media attention focused on educating women, there are still misconceptions about this life-threatening disease. Nurses must work to bridge the gap between the evidence and the women who are failing to heal the signs and symptoms of CHD. Education is essential to overcoming these barriers. As client advocates, nurses have key roles in the areas of assessment, education, and referral. Formal and informal culturally appropriate education programs need to be developed and implemented to disseminate CHD information. A wealth of information is available regarding women and CHD.7
A prospectic cohort study was conducted to determine or assess the knowledge of patients regarding experience the chest pain and subsequent consultation of CHD. A sample size of 4002 Adults taken and data were collected by questionnaires. Results shown that 65% of patients ignore Angina at beginning and tent to developed CHD in future. The researcher concluded that Early identification of angina and its management is very important.8
A study was conducted to assess the prevalence of weekly angina among patients with chronic stable angina in primary care patients in order to determine the quality of life of patients with angina. The study included 207 participating primary care practitioner recruited 2031 consecutive patients. The angina frequency was quantified with the Seattle Angina Questionnaire (SAQ). The result shown that Among primary care practice patients with stable angina, 29% (95% confidence interval [CI], 26%-31%) experienced weekly (> or =1) angina, which was associated with greater physical limitations and worse quality of life (24% and 27% lower SAQ scores, respectively; P < .05) compared with those with minimal angina (angina less than once a week over the preceding 4 weeks). The proportion of patients with weekly (> or =1) angina within a clinic ranged from none (14% of clinics) to more than 50% (18% of clinics). Patient characteristics associated with weekly (> or =1) angina included female sex (odds ratio [OR], 1.42; 95% CI, 1.13-1.78), a history of heart failure (OR, 1.59; 95% CI, 1.22-2.08), and peripheral artery disease (OR 1.89; 95% CI, 1.42-2.51; P < .001 for all comparisons).The study conclude that Almost 1 in 3 patients with stable angina attending primary care practices had angina at least once a week, which was associated with worse quality of life. The potential role of an angina performance measure to improve patients' outcomes, including symptom control, warrants further consideration.9
Angina pectoris is a debilitating indication of the presence of ischemic heart disease that affects millions of Americans. Although a number of pharmacologic treatments are available, the annual number of revascularization surgeries continues to rise in the United States Other symptoms or conditions associated with angina or more generally heart disease are a high cholesterol level, high blood pressure, smoking, diabetes, a family history of heart disease, especially early on in life and menopause in women is also a condition that can suggest or contribute to developing heart disease.10
A study was conducted to assess the knowledge and attitude of nurses towards the immediate management and care of Critically ill patients; A sample size of 60 staff nurses working in different settings were randomly selected and their knowledge was assessed by pretest after structured training programmed. The post test score of the nurses was increased up to 30% than the pretest knowledge score which is about 60%. Hence the study concluded that education would improve the knowledge and attitude of Nurses in managing Angina patients.11
From the available literature reviewed it has been found that angina is common among adults and its early identification and management has significantly reduced mortality among many patients. Hence the researcher felts the need to assess the knowledge of people regarding the identification and management of angina.
6.2 REVIEW OF LITERATURE
The purpose of a research literature review is to assemble knowledge on topic. Literature review helps in the identification of research problem, development of hypothesis, identification of suitable designs, data collection method. It also provides knowledge about data analysis and interpretation.12
A cross-sectional study was conducted to assess the management of major cardiovascular risk factors among urban population in India. A structured questionnaire and a brief physical examination were used to collect data’s from 345 adults aged 20 to 90. The mean systolic blood pressure was 116 (114-117) mm Hg, diastolic blood pressure 73 (114-120) mm Hg, total cholesterol 4.6 (4.5-4.7) mmol/L, HDL-cholesterol 0.8 (0.8-0.9) mmol/L, LDL-cholesterol 3.2 (3.1-3.3) mmol/L and triglyceride 1.3 (1.2-1.4) mmol/L. The prevalence of current smoking was 19.9% (15.4-24.4%), hypertension 20.3% (16.2-24.4%), diabetes 3.7% (1.8-5.5%), overweight 16.9% (12.3-21.5%) and obesity 4.4% (1.9-6.8%). A medical diagnosis of cardiovascular disease (previous heart attack, stroke or angina) was reported by 2.5% (1.1-3.9%) and a further 1.1% (0.1-2.1%) had angina by the 'Rose' classification. The study was concluded to the possibility of increasing cardiovascular risk factors and prevalence of vascular disease in areas of rural India represent a public health concern. Larger and repeated epidemiological studies focusing on chronic diseases are required to inform treatment and prevention strategies suitable for use in these areas and other resource poor settings.13
A study was conducted to assess the prevalence of angina among urban adult males. The study sample size of 1000 males aged less than or equal to 35 year, were selected by systematic random sampling. The study result shown that the prevalence of CHD in the study population was 5.7 %.( 95% confidence interval: 4.26-7.31). The significant associated risk factors included tobacco use, history of HTN, and family history and age. Hence the research concluded that early identification and prompt management of angina among adults holds much importance to present CHD in future.14
A study was conducted to determine the knowledge of adult’s man about the risk factors of angina and CHD. The study sample size of 1128 male patients were selected by simple random sampling; and data were collected by structured questionnaires. The result shown that about 53% about of the sample had poor knowledge, 45% had average knowledge about risk factors of CHD. Here the researcher concluded that evaluation and education helps the public in the matter of risk factors related about heart diseases.15
A study was conducted to compare the outcome among moderate alcohol drinkers before angina to effect of continued versus discontinued alcohol intake after the angina. The study sample size of 325 patients whose changes in drinking patterns assessed. The result shown that the initial 325 moderate drinkers at baseline, 273 (84%) remained drinking and 52 (16%) quit. In fully adjusted models, Physical Component Scale scores (beta 6.47, 95% confidence interval 3.73 to 9.21, p <0.01) were significantly higher during follow-up in those who remained drinking. Persistent moderate drinkers had a trend toward less angina (relative risk 0.65, 95% confidence interval 0.39 to 1.10, p = 0.11), fewer re hospitalizations (hazard ratio 0.79, 95% confidence interval 0.44 to 1.41, p = 0.42), lower 3-year mortality (relative risk 0.75, 95% confidence interval 0.23 to 2.51, p = 0.64), and better disease-specific quality of life (Seattle Angina Questionnaire Quality of Life, beta 3.88, 95% confidence interval -0.79 to 8.55, p = 0.10) and mental health (Mental Component Scale, beta 0.83, 95% confidence interval -1.62 to 3.27, p = 0.51) than quitters. The study result concluded there was less chance of developing angina in discontinued alcohol intakers.16
A study was conducted to determine clinical characteristics, management and in hospital outcomes of diabetic patients with angina. Data were analyzed from 1583 consecutive patients. The patients were stratified in to those with and without Diabetes mellitus. The result showed that 588 (37%) patients were diabetic with a mean age of 59 years and included more female than male diabetics (43% versus 33%; p<0.001). Diabetic patients were more likely to present with unstable angina (55% versus 44%; p<0.001) and less likely to present with ST elevation myocardial infarction (20% versus 27%; p=0.001). Both groups received ACS treatment equally; however, diabetic patients were more likely to be treated with glycoprotein IIb/IIIa antagonists and angiotensin-converting enzyme inhibitors or receptor blockers. Diabetic patients experienced more recurrent ischemia (12% versus 8%; p=0.043), heart failure (29% versus 23%; p=0.009), carcinogenic shock (7.5% versus 4.6%; p=0.018), and ventilator requirement (7.3% versus 4.1%; p=0.006). When adjusted for age and gender, diabetes status was an independent risk factor of in-hospital mortality in Acute coronary syndrome (ACS) patients (adjusted odd ratio, 1.68; 95% confidence interval, 1.022.77; p=0.042). The study concluded that Present treatment strategies are not sufficient to counter the adverse impact of diabetes. More effective and evidence-based therapeutic strategies should be identified and used in diabetic ACS patients.17