R AJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE – I I
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / Name of candidate and Address( In block letters ) / MS. BETTY. A. BABY
I YEAR MSc. NURSING
SHREE DEVI COLLEGE OF NURSING
MAINA TOWER , BALLALBAGH
MANGALORE - 575003
2 / Name of the Institution / SHREE DEVI COLLEGE OF NURSING
MAINA TOWER , BALLALBAGH
MANGALORE - 575003
3 / Course of Study and Subject / MSc NURSING,
(MEDICAL SURGICAL NURSING )
4 / Date of Admission to the Course / 29-6-2012
5 / Title of the Topic
“A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON REPERFUSION STRATERGIES IN THE MANAGEMENT OF ST SEGMENT ELEVATION MYOCARDIAL INFRACTION AMONG STAFF NURSES IN A SELECTED HOSPITAL, MANGALORE.”
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/ BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
BACKGROUND OF THE STUDY
STEMI in an acronym meaning “ST elevation myocardial infarction”, which is a type of heart attack. This is determined by an electrocardiogram test. There is clear evidence that reperfusion strategies improves survival in selected patients with an STEMI .Reperfusion therapy is defined as the first reperfusion therapy used to restore blood flow through a suspected or know occluded coronary artery immediately on diagnosis and indulges intravenous thrombolytic , primary angioplasty , intracoronary thrombolytic or immediate coronary artery bypass gaffing surgery1 .
The management of STEMI continues to undergone major changes. Good practices should be based on sound evidenced derived from well- conducted clinical traits. The benefits of reperfusion therapy for patients with acute coronary artery syndrome have been established, but there is much variation in the type of reperfusion given about which patient are eligible2.
6.2 NEED FOR THE STUDY
In the year 2010, It was estimated that heart attacks are the leading cause of death among both men and women all over the world. Cardiovascular In diseases are the world’s leading killer, accounting for 16.7million or 29.2 per cent of the total global deaths3.
In the year 2011, WHO estimated that globally 29 per cent of deaths were due to cardiovascular diseases and among them, 25-28 per cent of deaths were due to Myocardial Infarction and more than one million Americans had a new or recurrent acute coronary syndrome and responsible for more than 250,000 deaths annual It is estimated that cardiovascular diseases in USA Cost 274 billion each year, including the health expenditures and productivity4.
In the developing countries like India, Myocardial Infarction is one of the leading causes of deaths. The prevalence of Myocardial Infarction has increased from 40 per 1000 in 2000 to nearly 110 per 1000 in 2007. The prevalence of coronary heart disease in urban population has increased from 3.5 per cent in 2008 to 9.5 per cent in 2009, and in rural areas it has been increased from 2 per cent in 2004 to 4 per cent in 200. In the year 2005, it was estimated that 30 per cent of deaths in India were due to coronary syndrome5.
The population based surveys conducted in India shows there is an increase in the prevalence rate of Ischemic heart disease from 1-4 per cent to 10 per cent. According to the hospital statistics in 2008 Coronary Artery Bypass Grafting (CABG) accounted for less than 10% of all cardiac surgeries. Today, it accounts for more than 60%. Every year 25,000 coronary bypass operations and 12,000 Percutaneous coronary Angioplasties (PTCAs) are carried out3.
In the year 2006, WHO estimated that 60 per cent of the world’s Cardiac Patients will be Indians by the year 2010.The medical NGO in coordination with WHO estimated that nearly 50 per cent of Cardio vascular related diseases in India occur below the age of 70, compared with just 22 per cent in the West. This trend is alarming because of its potential on Indian Economics3.
Ratio of cardiac patients in Karnataka studied 2320 patients (median age 68 years, 73% men), of whom 83% had ST segment elevation infarction (STEMI). Reperfusion therapy was used for 53% of patients with STEMI (thrombolytic 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality.
The basis for this distinction in treatment regimens is that ST segment elevations on an ECG are typically due to complete occlusion of a coronary artery. On the other hand, in NSTEMIs there is typically a sudden narrowing of a coronary artery with preserved (but diminished) flow to the distal myocardium. Anticoagulation and ant platelet agents are given to prevent the narrowed artery from occluding. Reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) is the most important component of treatment, as it strongly influences short- and long-term patient outcome. The main objective of healthcare providers should be to achieve at least 75% of reperfusion therapy applied to patients suffering from STEMI in a timely manner, and preferably within the first 3 h after onset of symptoms6.
Establishing networks of reperfusion at regional and national level, implying close collaboration between all the actors involved in reperfusion therapy, namely hospitals, departments of cardiology, PCI centres, emergency medical systems (EMS), (Para)medically staffed ambulances, private cardiologists, primary care physicians, etc., is a key issue. All forms of reperfusion, depending on local facilities, need to be available to patients. Protocols must be written and agreed for the strategy of reperfusion to be applied within a network. Early diagnosis of STEMI is essential and is best achieved by rapid ECG recording and interpretation at first medical contact, wherever this contact takes place (hospital or ambulance). Tele-transmission of ECG for immediate interpretation by experienced cardiologists is an alternative.
An experimental study was conducted to assess the knowledge of nursing personnel’s on first 24 hours care of the patients with Myocardial Infarction ,50 nursing personnel’s were randomly selected and structured questionnaire was used for data collection. The results of the study showed that 26 per cent of nursing personnel’s had below average knowledge, 44 per cent had average level of knowledge, and 30 per cent had above average knowledge on care of patient with STEMI. The study concluded by saying that the nurses need to be given special training in caring the cardiac patients in ordered to improve their knowledge7.
Nurses must incorporate scientific knowledge and technical advances into their practice to assist the patients in remaining well and functioning at the maximum level. Especially in critical care units of hospitals, with the advancing science and technology on par with doctors, the nurses should upgrade their knowledge. They must be able to identify elevation of the st segment and life threatening arrhythmias on the electrocardiogram and to perform reperfusion therapy and emergency resuscitation measures if necessary without the aid of the doctor on standing orders8.
The nurses specialized in the care of the patients with Myocardial Infarction and experience in cardiac care units have truly become a significant and responsible figure in the total field of health care. She meets the demands of patients and at the same time rehabilitates in such a way that the patient fits in the society. Different studies says that the staff nurses have poor knowledge regarding reperfusion strategies in the management of STEMI 8.
Based on the above study findings and own experiences, the researcher identified the need to improve the knowledge of staff nurses on reperfusion strategies in the management of STEMI, by administering self instructional module.
6.3 THE REVIEW OF LITERATURE
The review of literature of reperfusion strategies in the management of STEMI and its divided into:
· Literature related to incidence & prevalence of STEMI
· Literature related to the knowledge of staff nurse about reperfusion strategies in the management of STEMI
· Literature related to SIM as an effective teaching module
Literature related to incidence & prevalence of STEMI
A study was conducted in a community based population who hospitalized for incident of myocardial infarction between 1999 to 2008 .Based on the age and sex adjusted incidence rate were calculated for myocardial infarction overall and separately for ST elevation myocardial infarction and non ST elevation myocardial infarction .After research they identified 46,086 people hospitalized for myocardial infarction during the period of 1999 to 2008. The age –sex adjusted incidence of myocardial infarction increased from 274 cases per 100,000 person years in 1999 to 287 cases per 100,000 person year in 2000 .208 cases per 100,000 person Year in 2008.The age sex adjusted incidence of ST elevation myocardial infarction decreased throughout the study period. The study concluded by saying that within a large community based population, the incidence of myocardial infarction decreased significantly after 2000, and the incidence of STEMI decreased markedly after 19999.
Literature related to the knowledge of staff of staff nurses about reperfusion strategies in the management of STEMI
A descriptive study was done to assess the knowledge regarding reperfusion strategies in the management of STEMI among the nurses working in intensive coronary care units. The data was collected by using questionnaire from a selected group of 100 groups of nurses, which consisted items regarding causes signs and symptoms and management of patients with STEMI. The result of studies shows that 70 per cent nurses had below average knowledge, 28 per cent of nurses had average knowledge & 2 per cent of nurses had above average knowledge. The study concluded by saying that the nurses needs to improve their knowledge regarding reperfusion strategies in the management of STEMI10.
Literature related to SIM as an effective teaching module
To assess the knowledge of the staff nurses and to determine the effectiveness of self instructional module (SIM) in gained knowledge regarding nursing management of patients having chest tube drainage. By adopting quasi experimental study design and 100 staff nurses selected randomly working in hospitals. A single group pre-test –post- test design was used to assess the existing knowledge and their improvement in the knowledge after the introduction of SIM within an interval of 7-10 days on individual basis. The maximum knowledge scores were found in age group of 20 -25 years during pre-test and post-test (12.84 and 20.03 ) respectively .Based on the above results , the study concluded that there is a great need for giving information to nurses related to nursing management of the patient having chest tube drainage and also the information given through self –instructional module proved beneficial in improving the knowledge and skill of nurses11.
6.4 STATEMENT OF PROBLEM
“A study to assess the effectiveness of self instruction module on reperfusion strategies in the management of STEMI among staff nurses in a selected hospital, Mangalore.”
6.5 OBJECTIVES
1. To assess the prior knowledge of staff nurses regarding the reperfusion strategies in the management of STEMI
2. To develop SIM regarding the care of patients with STEMI.
3. To find out the effectiveness of SIM in terms of gain in post test knowledge score.
4. To associate the pre test knowledge score with selected demographic variables.
6.6 OPERATIONAL DEFINITION
· Assess: In the present study, asses means judging the status of pretest and post test knowledge of staff nurses on reperfusion strategies in the management of STEMI.
· Effectiveness: In the present study, effectiveness refers to the extent to which the SIM has achieved the desired objectives, that means improvement of knowledge scores among staff nurses on STEMI and reperfusion strategies.
· Self Instructional Module: In the present study, SIM refers to learning package planned and prepared from the reperfusion strategies in the management of STEMI. Provided to staff nurses with an aim to facilitate self learning.
· Reperfusion strategies: In the present study reperfusion strategies refers to is treatment for blocked arteries are opened to establish blood flow to the heart muscles .it may accomplished through thrombolytic therapy , primary percutaneous transluminal angioplasty and emergency coronary artery bypass graft.
· Management of STEMI: In the present study management of STEMI refers to diagnosis and initiation of appropriate reperfusion therapy. Immediate management prior to reperfusion adjunctive antithrombotic medication and nursing care giving to support the reperfusion therapy.
· Staff Nurses: In the present study, staff nurse refers to person who is having a diploma or basic degree in nursing from a recognized university or board, registered under a state nursing council and is working in selected hospital, Mangalore.
· Selected Hospital: In the present study selected hospital refers to the place where the researcher obtains permission & intents to conduct the study.
6.7 VARIABLES
· Independent Variable: The SIM on reperfusion strategies management of ST elevation myocardial infarction.
· Dependent Variables: Staff nurses knowledge regarding reperfusion strategies management of ST elevation myocardial infarction.
6.8 ASSUMPTION
The study assumes that,
· Staff nurses will have some knowledge regarding reperfusion strategies in the management of STEMI.
· Knowledge may vary from person to person
6.9 DELIMITATION
The study will be delimited to the staff nurses working in selected hospitals Mangalore.
6.10 HYPOTHESES
All hypotheses will be tested at 0.05 level of significance.
H1: The mean post test knowledge score of the staff nurses on reperfusion strategies in the management of STEMI will be significantly higher than mean pre test knowledge.
H2: There will be significant association between pre test knowledge score of the staff nurses
on reperfusion strategies in the management of STEMI with their selected demographic variables.
MATERIALS AND METHODS
7.1.1 SOURCE OF DATA:
Data will be collected from the staff nurses in a selected hospital, Mangalore.
7.1.2 RESEARCH DESIGN:
The research design selected for this study is pre experimental one group pre and post test.
The schematic representation of the design as follow.
O1 --- X --- O2 E = O2 - O1 O1= Pre test knowledge of staff nurse on reperfusion strategies in the management of STEMI. X = Intervention with Self Instruction Module on reperfusion strategies in the management of STEMI. O2= Post test knowledge of staff nurses on reperfusion strategies in the management of STEMI.