RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / MRS.SIKHA VIJAYAN
GAYATHRI COLLEGE OF NURSING,KOTTIGEPALYA, BANGALORE.
2 / NAME OF THE INSTITUTION / GAYATHRI COLLEGE OF NURSING,KOTTIGEPALYA, BANGALORE.
3 / COURSE OF THE STUDY AND SUBJECT / FIRST YEAR M. Sc NURSING MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO COURSE / 11.06.2012

5, TITLE OF THE TOPIC

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME (STP) REGARDING IMPLANTABLE CARDIOVERTER DEFIBRILLATOR THERAPY IN TERMS OF KNOWLEDGE AND PRACTICE AMONG STAFF NURSE WORKING IN A PRIVATE CARDIAC HOSPITAL AT BANGALORE”

6. BRIEF RESUME OF AN INTENDED WORK

INTRODUCTION

‘‘Health is Wealth”

ICD is a device that detects and terminates life-threatening episodes of VT or ventricular fibrillation in high-risk patients. Patients at high risk are those who have survived sudden cardiac death syndrome, usually caused by ventricular fibrillation, or have experienced symptomatic VT (syncope secondary to VT). In addition, an ICD may be indicated for patients who have survived an MI but are at high risk cardiac arrest. An ICD consists of a generator and at least one lead that can sense intrinsic electrical activity and deliver an electrical impulse. The device is usually implanted much like a pacemaker. ICDs are designed to respond to two criteria: A rate that exceeds a predetermined level, and a change in the iso-electrical line segments. For treating arrhythmias is the automatic implantable cardioverter defibrillator (AICD) This type of cardiac rhythm. Sensing device provides an electrical discharge to the myocardium (shock) when tachycardia rate goes above a preset limit. Increasing sophistication of this device will allow them to analyze the heart’s electrical signal and provide pacemaker regulation (stewast and others, 1993) Patients with implanted pacemakers often are apprehensive and fearful the primary responsibilities of nurse include helping the patient to accept the instrument and relieving fear and apprehension.1

The implantable cardioverter defibrillator is are served for use in clients who have experienced at least one episode of sudden cardiac death un related to myocardial infarction, clients who were successfully resuscitated, or clients in whom conventional middle attempts to control life threatening dysrhythmia have not been successful clients undergo electrophysiological studies to assess the inducibility of ventricular tacydysrhymias and their response to medication. If the dysrythmias can be considered a candidate for a ICD implantation. A psycho logic profile is done to determine whether the client will be able to cope with the discomfort and fear associated with internal defibrillation from the ICD. Animplantable cardioverter-defibrillator(ICD) is a smallbattery-powered electrical impulse generator that is implanted in patients who are at risk of suddenventricular fibrillationandventricular tachycardia. The device is programmed to detectcardiac arrhythmiaand correct it by delivering a jolt ofelectricity. In current variants, the ability to revert ventricular fibrillation has been extended to include bothatrialandventricular arrhythmias. There also exists the ability to perfume biventricular pacing in patients with congestil implantation.2

The process of implantation of an ICD is similar to implantation of apacemaker. Similar to pacemakers, these devices typically includeelectrodewire(s) that pass through a vein to the right chambers of the heart, usually lodging in the apex of the right ventricle. The difference is that pacemakers are more often temporary and are generally designed to correct bradycardia, while ICDs are often permanent safeguards against sudden arrhythmias.3

The most recent development is the subcutaneous ICD (S-ICD). Current state-of-the-art electronics and batteries have enabled an implantable device to deliver enough energy to defibrillate the heart without the need for a lead in or on the heart. This prevents lead-related problems and the risk of dangerous infections in or near the heart. This ICD is positioned just under the skin and outside the ribcage. It can be placed during a minor procedure under conscious sedation. The S-ICD was approved by the USFood and Drug Administration(FDA) in September 2012.4

ICDs constantly monitor the rate and rhythm of the heart and can deliver therapies, by way of an electrical shock, when the heart rate exceeds a preset number. More modern devices can distinguish between ventricular fibrillation andventricular tachycardia(VT), and may try to pace the heart faster than its intrinsic rate in the case of VT, to try to break the tachycardia before it progresses to ventricular fibrillation. This is known as fast pacing, overdrive pacing, or anti-tachycardia pacing (ATP). ATP is only effective if the underlying rhythm is ventricular tachycardia, and is never effective if the rhythm is ventricular fibrillation.5

Implantable cardioverter defibrillators have demonstrated clear life-saving benefits, but concerns about patient acceptance andpsychologicaladjustment to the ICD have been the focus of much research.Researchers including those from the field ofcardiac psychologyhave concluded that the quality of life (QoL) of ICD patients is at least equal to or better than, that of those takinganti-arrhythmic medications.The largest study of examined 2,521 patients with stable heart failure in the SCD-HeFT trial.Results indicated that there were no differences between ICD-treated and medication-treated groups at 30 months in patient-reported QoL.Psychological adjustment following ICD implantation has also been well studied.6

6.1 NEED FOR THE STUDY

Matta conducted a survey study at Escort’s heart institute and research center, Delhi to assess cardiac patients need for educational program. It was found the majority 72% of cardiac patients said that they wanted to participate with their physicians in decision making about their health care. Findings of the study also revealed that patients were most likely to follow suggestions’ related to altering lifestyle related to risk factors, when the message conveyed by personal physician but its fact full that detailed explanation was not given regarding health matters unless specifically asked which makes that patients lack in information about their own healthy aspect.

Plach. Wierenger and Heidrch studied the effect of a post discharge education class on CAD knowledge and self reported health promoting behavior. The study was conducted in mind western community hospital using descriptive two group post- test survey method among 114 patients who have experienced a cardiac catheterization of which 52 attended a post discharge coronary artery disease education class and 61 did not attend the class. The tool used for collection was an interview scheduled. The result of the study revealed that knowledge of CAD and its risk factors was significantly higher among the subjects who attended the post discharge class and they presented with better health promoting behaviors.

Baairey, Fleando and klin surveyed the cholesterol management practice among CHD patients enrolled and not enrolled in cardiac rehabilitation to find out their cholesterol awareness and treatments complaints in patients. A total of 379 men and women were surveyed according to their cholesterol awareness, serum cholesterol level, frequency of lipid lowering medication use and frequency of lipid lowering medication use and frequency of achievement of serum total cholesterol <5.2mm ol/1 corresponding the 1987 NCEP( natural cholesterol education program) guidelines for CAD patients. Result of this study showed that overall 71% of the patients were aware of their cholesterol of 5.5/100mmol/1. Use of lipid lowering medication was 26%, 43% had a total cholesterol < 5.2mmol/1 patients enrolled in a long term cardiac rehabilitation demonstrated enhanced cholesterol awareness 78% lowered total cholesterol values 5.2+ 0.9mmol/1 higher use lipid lowering therapy(34%) and more frequent achievement of total serum cholesterol of <5.2mmol/1(48%) compared to the other groups. This study showed that there was a need of effort to develop programs to optimize cholesterol management in patients CAD.

Jaarsana, Ka stumans, Dassesn and Philipsen conducted a study at the university hospital: Netherland, to assess the problems of post MI, CABG patients in early recovery 82 patients were interviewed after six month of discharge using a tool that required them to describe problems they experienced in early recovery and what information they needed. Majority of the problems developed according to their response were emotional reactions (59%) deleterious effect of treatment 56% and convalescence (54%). Most of the patients needed additional to different information on topic like deleterious effects of treatments (26%) physical condition (24%) risk factor(24%), convalescence(24%) and knowledge disease (24%).

Win slow EH conducted a study to access the roll of nurse in cardiac patient education. The evident sited shows that nurse are not doing effective, consistent patient teaching and are not perceived by patients. It appears that nurses do not view patient teaching as a priority and that nurse are not held accountable for patient teaching. Patient teaching seems to be done only if “there is time” it is often done on an informal and largely voluntarily basis by motivated nurse. Nurse must awaken to the fact that patient education is not a luxury, but a necessity if patients are to receive maximum benefit from today’s knowledge of treatments prevention and control of dise.7

A study was conducted to determine the effectiveness of a structured teaching programme on pacemaker implantation among student nurses. Samples were selected randomly and they were 100 in number. A structured knowledge questionnaire was used to assess the knowledge of participants. The study revealed that post test knowledge score (22.9) the students were significantly higher than the pretest knowledge score (10.12)8

Due to the advancement in the technology and medicine, we are now able to fight with cardio vascular diseases more effectively and efficiently. The ICD is one of the sophisticated electronic instruments, which are used to initiate the heart beat when the S A node is seriously damaged and is unable to act as the pacemaker of the heart. Now day’s patients did not get health educations regarding exercise, diet, food plan, quality of life from hospital. At present time fast foods are one of the major drawbacks for youngsters and children. These types food habit makes new generation become Cardiac patients. Hospitals and care takers have to give the detailed and proper guidelines is importance for better and healthy living.

From the above findings of literature it is realized that the cardiac patients were rarely provided with sufficient information related to the health behavior which aids in the secondary prevention of heart disease. The researcher in her own view found that the nurse don’t have sufficient knowledge and practice of ICD care. Patient education program for cardiac patient is an essential part of the quality of nursing staff working in cardiac unit.

6.2 REVIEW OF LITERATURE

The review of literature is a broad, comprehensive, in depth, systematic and critical review of the scholarly publications, unpublished scholarly articles, audio-visual materials and personal communication.

According to Polit and Beck, Review of literature is a written summary of the existing knowledge on a research problem.

The review of available literature was organized under the following heading.

§  Studies related to incidence and prevalence of dysrhythmia.

§  Studies related to role of ICD in preventing cardiac complication.

§  Studies related with home care of ICD patient.

§  Studies related with knowledge and practice of staff nurses regarding cardiac problems and management.

1. Studies related to incidence and prevalence of dysrhythmia.

Monarrez CN, Strong WB, Rees AH (1978) et al conducted a study” Exercise electrocardiography in the evaluation of cardiac dysrythmias in children” Exercise electrocardiography is a useful means to evaluate dysrhythmias in children and young adults. Exercise may suppress a dysrhythmia present at rest and thus suggest a relatively benign problem. It may provoke a latent dysrhythmia which is absent at rest but suggested by a history of exercise intolerance or palpitation with exertion. Exercise may also modify a dysrhythmia. Maximum exercise testing has been used to evaluate each of these situations in children. The results of testing will be presented. Since no dysrhythmias were provoked in 170 healthy children, we think that any dysrhythmia initiated by exercise in the young should be considered abnormal.9

Sri Jayewardenepura(1994) conducted a study about Cardiac dysrhythmias during anesthesia. Factors that may influence the incidence of dysrhythmia such as age, pre-existing heart disease, hypertension and anesthetic technique were noted. Cardiac monitoring was commenced on each patient before the induction of anesthesia and continued up to the recovery period. Any dysrhythmia that occurred was noted and a tracing obtained. RESULTS: 42 patients developed dysrhythmia of whom 21 were nodal rhythms. These occurred during maintenance of anesthesia and needed no treatment. Fourteen patients developed ventricular ectopics commonly triggered by intubation. Only one patient needed treatment with lignocaine. Sinus bradycardia occurred in 6 patients who were treated with intravenous atropine.10

Teresa S.M Tsang, MD, FACC; George W Petty, MD; Marion E Barnes (2003) a longitudinal case-control study of ischemic stroke, the prevalence of AF and of selected co morbid conditions among incident stroke cases and age- and gender-matched controls between 1960 and 1989 was determined. The mean age ± standard deviation for the 1,871 stroke cases (45% men) and matched controls was 75 ± 11 years. For cases, age-adjusted estimates of AF prevalence for 1960 to 1969, 1970 to 1979, and 1980 to 1989 were 11%, 13%, and 16%, respectively, for men, and 13%, 16%, and 20% for women. For controls, the rates were 5%, 8%, and 12%, respectively, for men, and 4%, 6%, and 8% for women. Increasing AF prevalence was associated with increasing age (doubling of odds per decade of age in both cases and controls) and calendar time adjusted for age and gender (cases: odds ratio [OR] per 5 years 1.13, 95% confidence interval [CI], 1.05 to 1.22; controls: OR per 5 years 1.24, 95% CI 1.12 to 1.37). The rates of increase with calendar time were significant for cases (p = 0.001) and controls (p < 0.001) and comparable between the genders.11

Aline P. Marcassi1, Daniel C. Yasbek1 (2010) et al conducted a study was to evaluate the prevalence of VA and to investigate the factors associated with their occurrence in incident kidney transplant recipients. A total of 100 incident kidney transplant recipients were included in the study (39.7 ± 10.1 years, 55% male, 43.6 ± 10.1 days of transplantation, 66% living donors). All the patients underwent 24 h electrocardiogram, echocardiogram and multi-slice computed tomography. Thirty percent of the patients had VA. Left ventricular hypertrophy was observed in 57% of the patients while heart failure was found in 5%. Coronary artery calcification (CAC) was observed in 26 patients, from which 31% had severe calcification. The group of patients with VA was predominantly male, had been on dialysis therapy for a longer time and had more coronary calcification. In the multiple logistic regression analysis, male gender and CAC score were independently associated with the presence of VA.12