RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Ms. TERESA RANI THOMAS
GOUTHAM COLLEGE OF NURSING,
MANJUNATHNAGAR,
WEST OF CHORD ROAD, RAJAJINAGAR,
BANGALORE – 10
2. / NAME OF THE INSTITUTION / GOUTHAM COLLEGE OF NURSING, MANJUNATHNAGAR,
WEST OF CHORD ROAD, RAJAJINAGAR,
BANGALORE – 10
3. / COURSE OF STUDY AND SUBJECT / M.Sc. NURSING I YEAR
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 30 /5 / 2007
5. / TITLE OF THE TOPIC:
/ A STUDY TO ASSESS THE EFFECTIVENESS OF COPING STRATEGIES ON LEVEL OF ANXIETY AMONG PATIENTS UNDERGOING CORONARY ANGIOGRAM IN SELECTED HOSPITALS, BANGALORE.
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1. /

NEED FOR THE STUDY:

Cardiac disease is a major cause of morbidity and mortality .so as a part of diagnosis the condition of the patient coronary angiogram is needed for the patient who are undergoing this procedure, they will have anxiety definitely. Anxiety is an emotional state or condition of the human organism that is characterized by subjective, consciously perceived feelings of tension and apprehension and heightened autonomic nervous activity. It may fluctuate overtime and can vary in intensity. By using anxiety scale, we can assess the level of anxiety of the patient.1
For each patient the coping strategies on level of anxiety may vary according to the demographic variables such as age, sex etc. Coping, quality of life and hope are important aspects when the effects of a disease from infancy to old age are examined. Coping reflects a process and includes active involvement over a period of concepts which have several dimensions. Coping also includes different strategies, but the total sum of the strategies does not constitute a global definition of the concept. Choice of strategy can influence outcome variables such as hope or quality of life positively or negatively. Coping is of importance for quality of life, and hope can be regarded as coping strategy .Hope can be seen as a variable that positively contributes to the experience of quality of life. Coping is defined by Lazarus and folk man as “constantly changing cognitive and behavioral efforts to manage, reduce or tolerate external and or internal demands that are appraised as taxing or exceeding the recourses of the person”. For the patients who are undergoing coronary angiogram their coping strategies on anxiety level may vary according to different demographic variables. So as a nurse, it is our responsibility to encourage the patient to cope up with the anxiety and threatening situations.2
A study conducted on incidence and patterns in patients after coronary artery bypass surgery. The purpose of this study was to describe the incidence and patterns of anxiety in older patients to undergo coronary artery bypass surgery and to determine the influence of gender and age on psychological recovery A sample of 31 patients was assessed pre and post operatively at 2-3 days and 12 weeks. Women had significantly higher trait and state anxiety and a higher, non significant incidence of depression at all times. Because women and younger patients are at higher risk for psychological distress, they should be target for intervention.3
A study conducted on anxiety and health-related quality of life in patients awaiting elective coronary angiography. The purpose of this study was to document the impact of waiting for first-time elective coronary angiography on patients anxiety and health related quality of life .Paired-sample test comparing mean anxiety levels at t1 and t2 indicated a statistically significant increase in anxiety level at t2 that did not seen to be related to the waiting time for coronary angiogram. Waiting for elective coronary angiogram may have a negative impact on patients psychological status and heath related quality of life.4
A study conducted on gender differences in fears related to coronary angiography, to compare levels of fear and the intensity of specific fears in women and men related to coronary angiography. The sample consisted of 54 women and 166 men undergoing scheduled coronary angiography. On average, men experienced more intensive fear of problems in their sex life than women. Therefore it is important to adapt information and support according to the treatment chosen for the patient.5
Stress is one of the prime factors that has to be eliminated especially in cardiac patients as it can have an adverse effect to their homeostasis. cardiac diagnostic procedure itself along with sophisticated environment can provoke anxiety .From the researcher’s experience working with cardiac patients those who are undergoing coronary angiogram observed that many patients were exhibiting symptoms of anxiety. The level of anxiety may vary with the personality of an individual but coping can help all individuals to overcome their worries and improve quality of life. Therefore the investigator felt that there is need to provide coping strategies to help the patients to become adaptive to the situation.
6.2. / REVIEW OF LITERATURE:
The extensive review of literature has been done and it is organized according to following headings.
a) Studies related to fear and anxiety among patients undergoing diagnostic procedure.
A study conducted on stressors and anxiety in patients undergoing coronary artery bypass surgery. To describe the concerns of patients undergoing coronary artery bypass surgery and to identify concerns that were to associated higher levels of anxiety .Multiple regression was used to determine the predictors of anxiety and. interviewed methods also. Patients waiting for coronary artery bypass surgery should be routinely assessed for anxiety before the procedure, and interventions to prevent or reduce anxiety should be provided. Interventions must be multifactorial, including information and support for pain management and realistic information about surgery schedules and resuming lifestyle after surgery.6
A study conducted on anxiety enhances the detrimental effect of depressive symptoms on health status following percutaneous coronary intervention. A series of 692 patients undergoing percutaneous coronary intervention as part of the Rapamycin-eluting stent done on hospital anxiety and depression scale at 6months and the short-form health survey at 6 and 12 months post percutaneous coronary intervention. Of 692 patients 471 had no symptoms of anxiety nor depression 62 had anxiety only 59 had depressive symptoms and 100 had co-occurring symptoms.7
A study was conducted on patients fear on coronary angiography .It was concerned with the objects of fear and the intensity of fears related to coronary angiography in 378 patients scheduled for coronary angiography. Intensity of fear was measured on a 10-point Likert-type scale which listed 26 objects of fear. Patients were asked to assess the intensity of their fears both before and after coronary angiography. The result show that the intensity of the fear varied depending upon the object of fear. Special attention should be paid to the fears of women patients under 45 years upper and lower level employes and the unemployed.8
A study was conducted on the effect of early education on patient anxiety while waiting for elective cardiac catheterization. The purpose of this study was to examine the effect of a psycho educational nursing intervention at the beginning of the waiting period on patient anxiety during the time for elective cardiac catheterization. This was a 2 group randomized controlled trial. Anxiety increased in both groups over the waiting time. The waiting period prior to elective cardiac catheterization has a negative impact on patients perceived anxiety and quality of life and a simple intervention, provided at the beginning of the waiting period , may positively affect the experience of waiting. 9
A study was conducted on fear and anxiety in patients at different time points in coronary artery bypass process. The purpose of this study was to examine fear and anxiety of coronary artery bypass patients. Anxiety was measured using state-trait-anxiety inventory. The highest levels of fear and anxiety were measured in waiting period to coronary artery bypass grafting.10
A study was conducted to evaluate the psychiatry anxiety disorder history to discriminate between women with and without angiography coronary disease in a population with chest pain. A total of 435 women with chest pain underwent a diagnostic battery including coronary angiography in order to improve testing guidelines for women with suspected coronary artery disease. Women referred for coronary angiography completed questionnaires assessing prior treatment history for anxiety disorder and current anxiety related symptoms. Forty four women reported receiving prior treatment for an anxiety disorder.11
A study was conducted on physiological correlates of anxiety in children with gender identity disorder. By using a established psychological challenge, involving provocation and frustration, we investigator whether children with gender identity disorder as compared to healthy controls react in a more anxious way under these experimental circumstances. The results showed that children with gender identity disorder had more negative emotions and a tonically elevated skin conductance levels.12
A study was conducted on early adversity and the prospective prediction of depressive and anxiety disorders adolescence. Participants were 816 adolescents with diagnostic information collected at age 15. Adolescents with “pure” anxiety disorders were compared with adolescent with “pure” depressive disorders and these groups were compared to never ill controls. Results suggest that anxiety disorders may be more strongly related to early stress exposure, while depressive disorders may be related to more proximal stressors.13
b) Studies related to coping strategies among cardiac patients
A study was conducted on evaluation of non cardiac chest pain; diagnostic approach, coping strategies and quality of life. A simple diagnostic approach was applied to 37 consecutive patients with angina and normal coronary angiograms 21 patients were found to suffer from psychiatric disorders and depression 10 panic disorder 3 somatization 3.patients with psychiatric disorders showed a diminished quality of life. Identification of psychiatric disorders seems warranted since these patients experience a reduced a quality of life and exhibit pathologic coping strategies.14
6.3. / STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of coping strategies on level of anxiety among patients undergoing coronary angiogram in selected hospitals, Bangalore.
6.4. / OBJECTIVES OF THE STUDY:
1.  Assess the level of anxiety and coping strategies among patients before undergoing coronary angiogram in the pretest.
2.  Assess the level of anxiety of patients and coping strategies after coronary angiogram in the post test.
3.  Correlate between post test scores of level of anxiety and coping strategies.
4.  Associate the level of anxiety and coping strategies with demographic variables
6.5. / OPERATIONAL DEFINITIONS:
1.  Effectiveness: refers to the changes in the scores of anxiety scale and coping scale measured in the post test with pre test scores.
2.  Anxiety: refers to a emotional status of patient who have undergoing coronary angiogram when they are faced with a situation for the first time and it measured in scale
3.  Coping strategies: refers to responses that direct the individuals to overcome anxiety related feelings are measured by modified Lazarus coping scale.
4.  Patients: refers to the person with coronary artery disease undergoing coronary angiogram.
5.  Coronary angiogram: is a special X-ray of heart to look abnormalities of heart muscle or heart valves and to see coronary arteries are narrowed or blocked.
6.6. / HYPOTHESIS:
There will be significant difference between the scores of level of anxiety and coping level among the subjects exposed to teaching than those who are not exposed.
6.7 / ASSUMPTIONS:
1.  Patients who are undergoing coronary angiogram will be able to identify the level of anxiety.
2.  Patients who are undergoing coronary angiogram will be able to cope up with the anxiety.
6.8. / DELIMITATIONS:
The effectiveness of coping is measured in terms of anxiety level and coping scale in one observation in the post test only.
6.9. / PROJECTED OUTCOME:
1.  The study will enhance the coping strategies of coronary angiogram patients.
2.  The study will generate new and potentially more cost effective teaching methods and their effects on patients learning outcome and behavior including the transfer of knowledge.
7. / MATERIALS AND METHODS
7.1 / SOURCE OF DATA / Coronary artery disease patients who are undergoing coronary angiogram in selected hospital Bangalore
7.2 / METHODS OF COLLECTION OF DATA:
7.2.1. / SAMPLE CRITERIA:
INCLUSION CRITERIA / 1.  Those who are admitted for Coronary angiogram in selected hospitals Bangalore.
2.  Those who are willing to participate in the study.
3.  Available during the period of study.
4.  Able to understand and speak English.
EXCLUSION CRITERIA / 1.  Those who are not cooperative.
2.  Associate with some neurological diagnosis.
3.  Not able to understand and speak English and kannada.
7.2.2. / RESEARCH DESIGN / The research design adopted for the study is Quasi Experimental design
7.2.3. / VARIABLES :
1.  INDEPENDENT
VARIABLE
2.DEPENDENT
VARIABLE / Coping strategies
Level of anxiety
7.2.3. / SETTING / The setting for the study is selected cardiac hospitals Bangalore
7.2.4. / SAMPLING TECHNIQUE / The sampling technique adopted for the study is convenience sampling technique.
7.2.5. / SAMPLE SIZE / The proposed sample size of the study is 40. Both experimental and control group comprising of 20 each.
7.2.6. / TOOLS OF RESEARCH / Standardized tool will be used to assess the anxiety level of the subjects and coping strategies assessment will be done using a structured questionnaire developed by the investigator.
7.2.7. / COLLECTION OF DATA / Investigator will assess the level of anxiety and coping in the pretest before the subjects undergo coronary angiogram. Subsequently a planned teaching on coping strategies will be given to subjects. Following the coronary angiogram, post test will be done using the same tool to assess coping level and anxiety. The proposed study duration is for 30 days.
7.2.8. / METHOD OF DATA ANALYSIS AND PRESENTATION: / 1.  The investigator will analyze the data obtained by using descriptive and inferential statistics.
2.  Assessing the pretest level of anxiety on coronary angiogram patients will interpreted by descriptive statistic such as mean.
3.  Effectiveness of coping strategies will be analyzed by ‘t’test.
4.  Association of coping strategies with demographic variables will
be done using (χ2) chi square.
7.3. / DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.
Yes, Study will be conducted on patients, who are admitted in medical ward who are undergoing coronary angiogram in selected hospitals.
7.4. / HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?
Yes, informed consent will be obtained from the community leader and subject. Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartiality.

REFERENCES:
1.  Charles DS. State anxiety and trait anxiety .available from http:// cps.nova.edu/
2.  Lazarus and Folkman. Stare anxiety and trait anxiety .available from http:// cps.nova.edu/
3.  McCrone S. anxiety and depression; incidence and pattern in patients after coronary artery bypass graft 2001 Aug available from http:// www.ncbi.nlmn.gov/sites/entrez
4.  De Jong Watt. Anxiety and health related quality of life in patients awaiting elective coronary angiography 2004 July available from http:// www.ncbi.nlmn.gov/sites/entrez
5.  Heikkila J. gender differences in fears related to coronary angiography 1999 Jan available from http:// www.ncbi.nlmn.gov/sites/entrez
6.  Pedersen SS. Anxiety enhances the detrimental effect of depressive symptoms on health status following percutanous coronary intervention 2006 Dec. available from http:// www.ncbi.nlmn.gov/sites/entrez
7.  Gallagher R. stressors and anxiety in patients undergoing coronary artery bypass 2007 May available from http:// www.ncbi.nlmn.gov/sites/entrez
8.  Heikkila J. Patients fear in coronary angiography available from http:// www.ncbi.nlmn.gov/sites/entrez
9.  Harkness K. the effect of early education on patient anxiety while waiting for elective cardiac catheterization 2003 July. Available fromhttp//:www.documents and settings
10.  Koivula M. fear and anxiety in patients at different time points in the coronary artery bypass process 2002Nov available from http:// www.ncbi.nlmn.gov/sites/entrez
11.  Thomas Rutledge. History of anxiety disorders is associated with decreased likelihood of angiographic coronary artery disease in women with chest pain2001 available from http://content.onlinejacc.org/cgi/abstract.
12.  Wallien MS. Physiological correlates of anxiety in children with gender identity disorder 2007 Aug available from http:// www.ncbi.nlmn.gov/sites/entrez
13.  Phillips NK. Early adversity and the prospective prediction of depressive and anxiety disordes in adolescents 2005 Feb available from http:// www.ncbi.nlmn.gov/sites/entrez
14.  Husser D. evaluation of non cardiac chest pain: diagnostic approach, coping strategies and quality of life 2006Jan Available fromhttp//:www.documents and settings.
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