RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
SYNOPSIS ON
THE M.SC.(N) DISSERTATION
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE OF ELECTROCARDIOGRAM AMONG STAFF NURSES IN A SELECTED HOSPITAL IN MANGALORE
Submitted By:
Ms. Anitha Paul
1st year M.Sc. Nursing student,
Srinivas Institute of Nursing Sciences,
Valachil Padavu, Arkula, Mangalore – 574 143.
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE
AND ADDRESS
(IN BLOCK LETTERS) / MS. ANITHA PAUL
1st YEAR M. Sc. (NURSING)
MEDICAL SURGICAL NURSING
SRINIVAS INSTITUTE OF NURSING SCIENCES,
VALACHIL PADAVU, ARKULA,
MANGALORE – 574 143.
2. / NAME OF THE INSTITUTION / SRINIVAS INSTITUTE OF NURSING SCIENCES,
VALACHIL PADAVU, ARKULA,
MANGALORE – 574 143.
3. / COURSE OF STUDY SUBJECT / M.Sc. NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION / 01-06-2011
5. / TITLE OF THE TOPIC.
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE OF ELECTROCARDIOGRAM AMONG STAFF NURSES IN A SELECTED HOSPITAL IN MANGALORE
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19. / BRIEF RESUME OF INTENDED WORK
Introduction
“The most beautiful things in the world cannot be seen with the eyes, but can only felt with the human heart”.
- Nursing journal of India
The heart is a hollow, cone-shaped organ approximately the size of an adult’s fist, weighing less than 0.450 Kgs. Cardiac muscle cells possess an inherent characteristic of self-excitation, which enables them to initiate and transmit impulses. The SA node, located at the junction of the superior venacava and right atrium act as the normal pacemaker of the heart generating an impulse 60-100 times per minute. This impulse travels across the atria via the internodal pathways to the atrioventricular (AV) node. It then passes through the bundle of His at the atrioventricular junction and continues down the interventricular septum through the right and left bundle branches and out to the purkinje fibers.1
Electrocardiography (ECG or EKG from the German Elektrokardiogramm) is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body. The etymology of the word is derived from the Greek word ‘electro’, because it is related to electrical activity, ‘kardio’, for heart, and ‘graph’, a Greek root meaning "to write".2

Fig 1:ECG wave
An initial breakthrough came when Willem Einthoven, working in Leiden, Netherlands, used the string galvanometer that he invented in 1903. Einthoven assigned the letters P, Q, R, S and T to the various deflections, naming of the waves in the ECG and described the electrocardiographic features of a number of cardiovascular disorders. In 1924, he was awarded the Nobel Prize in Medicine for his discovery. 2
Epidemiologists in India and international agencies such as the World Health Organization (WHO) have been sounding an alarm on the rapidly rising burden of cardiovascular disease (CVD) for the past 15 years. The reported prevalence of coronary heart disease (CHD) in adult has risen four-fold in 40 years and even in rural areas the prevalence has doubled over the past 30 years. In 2005, 53% of the deaths were on account of chronic diseases and 29% were due to cardiovascular diseases alone. It is estimated that by 2020, CVD will be the largest cause of disability and death in India.3
With the epidemiologic transition, the CVD burden continues to rise in developing countries including India. The projected rise in disease burden due to CVD is expected to make it the prime contributor of total mortality and morbidity. Almost 2.6 million Indians are predicted to die due to coronary heart disease (CHD), which constitutes 54.1% of all CVD deaths in India by 2020. Additionally, CHD in Indians has been shown to occur prematurely, that is, at least a decade or two earlier than their counterparts in developed countries. Demographic and health transitions, gene-environmental interactions and early life influences of fetal malnutrition are the likely causes of increased CVD burden in India.4
Need For The Study
Cardiovascular disease is the leading cause of death and disability in the United States. Over 64 million people have some type of cardiovascular disease. Coronary heart disease is responsible for 1 in 5 deaths in the United States. The economic costs of CVD, both direct and indirect, to the nation are estimated at $368 billion annually.1
Coronary heart disease is becoming more common in the developing world such that in India, cardiovascular disease (CVD) is the leading cause of death.5 The deaths due to CVD in India were 32% of all deaths in 2007 and are expected to rise from 1.17 million in 1990 and 1.59 million in 2000 to 2.03 million in 2010 6. Although a relatively new epidemic in India, it has quickly become a major health issue with deaths due to CVD expected to double during 1985–2015 7. Mortality estimates due to CVD vary widely by state, ranging from 10% in Meghalaya to 49% in Punjab (percentage of all deaths). Goa (42%), Tamil Nadu (36%) and Andhra Pradesh (31%) have the highest CVD related mortality estimates.8 State-wise differences are correlated with prevalence of specific dietary risk factors in the states. Moderate physical exercise is associated with reduced incidence of CVD in India (those who exercise have less than half the risk of those who don't).7
The ECG is an essential tool in evaluating the heart rhythm. Electrocardiography detects and amplifies the very small electrical potential changes between different points on the surface of the body as the myocardial cells depolarize and repolarize, causing the heart to contract. The same electrical impulses spread outward from the heart to the skin, where they can be detected by electrodes attached to the skin. The ECG displays the electrical action of the heart. The ECG is the gold standard for noninvasive diagnosis of cardiac arrhythmias and conduction abnormalities and useful tool in evaluating the function of implanted devices such as pacemaker and implanted defibrillators.9
According to Drew BB, the critical care nurses should learn how to use ST segment monitoring to detect acute ischemia, which is often asymptomatic in patients with acute coronary symptom. ECG monitoring is becoming more common in both in-patient and out-patient care settings. Nurses have significant diagnostic influences in areas of cardiac rhythm monitoring and dysarrhytmia identification. It is essential that nurses who care patients at risk for cardiac dysarrhytmia have a thorough understanding of accurate electrode placement.10
Monitoring the routines of critical care nurses has indicated that nurses do not select leads according to diagnosis (or history of coronary disease). A survey was conducted on769 ICU in 2009 by AACN. The results revealed that 53% of the nurses stated that routine leads (standard lead choice) were used to monitor patients regardless of the diagnosis.11
A qualitative study was conducted on arrhythmia knowledge with the objective to identify and describe critical care nurse’s perception of arrhythmia knowledge. The sample consisted of 70 critical care nurses who worked in acute care settings where they read ECG data and made treatment decisions. The data collection method included 5 focus groups which were conducted over a period of 12 months. Group size ranged from 4 to 8 participants. The result showed a deficit in nurse’s ability to recognize and identify specific arrhythmia, including heart block, aberrant conduction and tachyarrhythmia.12
A descriptive study was conducted in North West America among nurses on interpreting 12 lead ECG for acute ST-elevation of myocardial infarction. The objective of the study was to assess the nurse’s knowledge of interpreting ECG. The sample consisted of 75 nurses who were given asset of 6 patients and asked to identify the presence or absence of ischemia and were unable to determine the correct leads, location and amplitude of ST-segment elevation. For 3 non-ischemia ECG’s 37(49%) of the nurses identified them as a normal ECG, 47 (63%) determined that an early repolarization pattern was ischemic and 34 (45%) indicated that a left bundle branch block pattern was ischemic. These results not only identify educational opportunities but also provide important information for researchers implementing clinical trials.13
Nurses will continue to need ongoing education and mentoring in correct application of ECG leads and principles of monitoring. Audits of nursing practice should include physical placement of electrodes and lead selection. The results from audits will highlight improvement in practice and ongoing educational needs. Involvement of staff nurses in the audit process is an excellent method of highlighting evidence-based practice at the bedside.11
Nurses play a critical role in arrhythmia identification and management at the bedside. On the basis of the nurse’s interpretation of the electrocardiographic (ECG) monitor recording, the nurse may simply gather more data, notify the physician who makes treatment decisions based on the rhythm interpretation of the nurse, or institute pharmacologic and counter shock therapies consistent with unit-specific protocols. Therefore understanding the nurse’s perception of arrhythmia knowledge, and ultimately, developing tools to evaluate this knowledge, and competence in the recognition of ECG rhythms, are of critical importance to nursing.12 So the investigator felt the need to conduct the study on this group.
Review of Literature
An experimental study was conducted on nurse’s ability to identify anatomic location and leads on 12-lead electrocardiograms with ST elevation in myocardial infarction in United States, 2010. The objective of the study was to determine the nurse’s knowledge to identify the presence of ST elevation in myocardial infarction (STEMI), selection and location of leads. The sample consisted of 75 nurses from the emergency department, coronary care unit and the progressive care. The nurse’s were given 6 patient scenarios (3 STEMI and 3 non - STEMI) and a corresponding 12-lead ECG. This was followed by a brief in-service education on ECG by hand held tool. The nurse then interpret the same six ECGs (in a different order) using the hand held tool. The results showed that identification of STEMI location improved when the tool was used. Lead identification improved in 2 of the 3 STEMI scenarios.14
A study was conducted to determine the proficiency of ICU nurse’s and emergency room (ER) nurses in performing ECG procedure and nursing management in selected hospitals in Iligan city, Philippines in 2010.The objective of the study was to assess the knowledge on fundamentals of ECG, including 12 lead placement, nursing management and the basic interpretation of rhythm strips. The sample consisted of 66 ICU and ER nurses and data were collected by using questionnaire. The results revealed that the overall total average score yielded a mean proficiency of 58.02% of the respondents which was below the expected range of 75%.
This showed the insufficiency of ICU and ER nurses on the knowledge and skill on ECG. The study concluded that skill enhancement program and continuing education should be provided to both ICU and ER nurses to render quality nursing care to the patients.15
A study was conducted on Cardiac Surgical Nurse’s in North America regarding the use of Atrial Electrograms to Improve Diagnosis of Arrhythmia in 2010. The objective of the study was to determine whether use of atrial electrograms significantly improves nurse’s ability to diagnose cardiac arrhythmias. A sample of 282 nurses completed a test consisting of 5 electrocardiographic rhythms for which use of atrial electrograms might improve interpretation. A standardized educational session on obtaining and interpreting atrial electrograms was given to 165 nurses who had not previously received such education. In a second test, the same rhythms were provided along with atrial electrograms to 261 nurses. The results showed that use of atrial electrograms significantly increased overall arrhythmia interpretation scores.16
A descriptive study was conducted to evaluate the nurse’s current knowledge related to electrocardiographic (ECG) monitoring. The objective of the study was to determine the nurse’s knowledge on ECG monitoring. The sample consisted of 1739 nurses working on adult cardiac units in 17 hospitals (15 in the US, 1 in Canada, 1 in Hong Kong) from September 2008 to June 2009. The results had shown that nurses had the highest mean score (52; SD ± 6) on the essentials of ECG monitoring and had the lowest mean score (36; SD± 23) on ischemia monitoring. The study concluded that nurse’s knowledge about ECG monitoring can be improved and education should particularly target less experienced nurses.17
A prospective study was conducted to determine the accuracy of diagnosing atrial fibrillation on ECG by primary care practitioners and interpreting diagnostic software in England, 2007. The objective of the study was to assess the accuracy of general practitioners and practice nurses in the use of different types of ECG to diagnose atrial fibrillation. The sample consisted of 49 general practitioners and 49 practice nurses who were given 2595 patients. The results showed that general practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead ECG. The practice nurses misinterpreted 114 out of 1355 cases of sinus arrhythmia as atrial fibrillation. The study concluded that many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram.18
An experimental study was conducted to assess the effectiveness of planned teaching programme among GNM students on ECG in West Bengal in 2002. A sample of 30 final year GNM students were selected by lottery method and data were collected by questionnaire and observation checklist. The results shown that sum of the mean knowledge scores of students were 26.23 in pretest and 73.66 in post-test, the ‘t’ value was 26.86.The findings suggested that the planned teaching programme had effect on the knowledge of GNM students.19
Statement of the Problem
A study to assess the effectiveness of self instructional module on knowledge of electrocardiogram among staff nurses in a selected hospital in Mangalore.
Objectives of the Study
Objectives of the study are to