RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / : / Mrs. JAYALAKSHMI
I YEAR MSc NURSING,
GOVERNMENT COLLEGE OF NURSING,
FORT, BANGALORE-02
2 / NAME OF THE INSTITUTION / : / GOVERNMENT COLLEGE OF NURSING,
FORT, BANGALORE-02
3 / COURSE OF STUDY AND SUBJECT / : / I YEAR MSc NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION / : / 14-06-2010
5. / TITLE OF THE TOPIC / : / “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SELECTED COMPLICATIONS OF CIRRHOSIS OF LIVER AMONG STAFF NURSES AT SELECTED HOSPITALS, BANGALORE.”

INTRODUCTION:

“Is life worth living? It all depends on the liver.”
William James

Age does not depend upon years, but upon temperament and health. Some men are born old, and some never grow so, and we humans we live because we have liver Most liver diseases, including fatty liver, cirrhosis, primary biliary cirrhosis and primary sclerosing cholangitis, result from injury to the liver.

Cirrhosis is the seventh leading cause of death by disease, killing about 25,000 people each year globally. Also, the cost of cirrhosis of liver in terms of human suffering, hospital costs, and lost productivity is high, majority of the patients land up in hospitalization with one or the other complications such as oesophageal varices, hepatic encephalopathy, portal hypertension, bleeding and kidney disorders.1

The term "cirrhosis" was first used by René Laennec in 1781–1826 to describe the abnormal liver color of individuals with alcohol-induced liver disease. The word cirrhosis comes from the Greek word kirrhos, the name for a yellowish-brown color.

Cirrhosis of liver represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and formation of regenerative nodules. It is generally considered to be irreversible in its advanced stages at which point the only option may be liver transplantation. In earlier stages, specific treatments aimed at the underlying cause of liver disease can improve or even reverse cirrhosis. Furthermore, there has been exciting progress in understanding hepatic fibrosis, which represents a paradigm for wound healing in other tissues, including skin, lung, and kidney, since it involves many of the same cell types and mediators. An understanding of these mechanisms has a number of clinical implications, including the development of interventions designed to impede or reverse hepatic fibrosis.

Patients with cirrhosis of liver are susceptible to a variety of complications and their life expectancy can be markedly reduced. Cirrhosis and chronic liver disease accounted for more than 25,000 deaths and 373,000 hospital discharges in the United States in 1998 according to a report from The National Center for Health Statistics.2

Nursing care for individuals with acute disease is multifaceted, complex, and dictated by the stage of the disease and presenting symptomatology. Careful monitoring is needed to spot early signs of life-threatening complications, such as hepatic encephalopathy or esophageal bleeding. Chronic care focuses on education. Individuals need to understand that this disease is chronic in nature and requires continuous care to reduce or prevent serious complications. Prompt treatment needs to be sought at any sign of complication.3

NEED FOR THE STUDY

The key to a better life for hundreds thousands people suffering from cirrhosis of liver depends on research globally shows estimated 25,000 individuals in the United States died from liver disease in 1998, making liver disease the tenth leading cause of death. For individuals between 45 and 64 years of age, chronic liver disease had an associated mortality rate of 19.6 per 100,000 persons and was the seventh leading cause of death.2

The following statistics relate to deaths and Cirrhosisof the liver :26,259 deaths reported in USA 1999 including 11,958 for alcoholic liver disease ,27,035 deaths from alcohol related chronic liver disease and cirrhosis each year in the US 2001 ,13.2 per 100,000 men died from chronic liver disease or cirrhosis in USA 2001 ,6.2 per 100,000 women died from chronic liver disease or cirrhosis in USA 2001 ,15.8 per 100,000 Hispanic/Latino people died from chronic liver disease or cirrhosis in USA 2001 ,16.9 per 100,000 Asian/Pacific Islander people died from chronic liver disease or cirrhosis in USA 2001.2

The exact prevalence of cirrhosis is unknown, but it has been estimated, through autopsies, to be between 5 and 10 percent. Incidence of cirrhosis varies by country and region, and reflects relative contributions from different risk factors. In countries where alcohol consumption is common, alcoholic cirrhosis is the major contributor to the overall prevalence of cirrhosis of liver.3

The study was done to enhance the professional nurse’s recognition of the signs, symptoms and complications of end-stage liver disease, as well as the critical nursing assessment and intervention approaches. Prior to the development of safe methods for liver transplant, most patients with acute or chronic liver failure died within months to years. Despite increased technology and medical advances, end stage liver disease remains the 12th leading cause of death in the United States. Almost 16,000 individuals are currently waiting for a liver transplant. With the average national waiting time being slightly more than one year before receiving a liver transplant, individuals with end-stage liver disease will continue to be hospitalized for acute illness related to their disease (Scientific Registry of Transplant Recipients, 2009).The most common admissions are related to ascitis, hepatic encephalopathy, and variceal bleeding. Each of these conditions requires accurate identification and treatment for successful outcomes.3

The major physiologic changes that occur as a result of cirrhosis of liver include loss of hepato cellular synthetic and metabolic functions and the development of portal hypertension as a result of increased resistance to flow through the liver secondary to fibrous tissue and regenerative nodules. There is also active intrahepatic vasoconstriction that accounts for 20-30% of the increased intrahepatic resistance. Altered liver function can affect the heart and circulatory system, the brain, the lungs, the immune system, and the kidneys.2

Nursing care of the patient with chronic liver disease is becoming increasingly complex. The nursing challenges include close monitoring of coagulopathy, intravascular volume, renal function, electrolyte balance, cardiovascular status, and nutrition. The focus of assessment and physical examination will be on detection of signs and symptoms of altered liver function.2

Ascitis is the most common of the three major complications of cirrhosis and results from portal hypertension, hypoalbuminemia, splanchnic vasodilation, and increased secretion coupled with impaired liver inactivation of aldosterone. Approximately 50% of patients with compensated cirrhosis develop ascitis within ten years. Approximately 50% of patients with ascitis die within two years Patients with ascitis are at significant risk for developing spontaneous bacterial peritonitis Symptoms are typically mild and include abdominal pain, worsening ascitis, fever, and progressive encephalopathy.3

Hepatic encephalopathy results from nitrogenous substances from the gut adversely affecting brain function by producing alterations of neurotransmission that affect consciousness and behaviour resulting in a mild confusional state and progressing to coma.

Hepatic encephalopathy is frequently precipitated by infection, diuretic use, metabolic alkalosis, constipation, CNS depressant usage, hypoxia, sepsis, azotemia, electrolyte abnormalities, gastrointestinal bleeding, and acute deterioration of liver function. Treatment of hepatic encephalopathy must include identification and eradication of the precipitating cause.3

Gastroesophageal varices are present in approximately 50% of patients with cirrhosis, with haemorrhage occurring at a yearly rate of 5-15%. . Bleeding from oesophageal varices ceases spontaneously in up to 40% of patients but is associated with 20% mortality at six weeks .

Patients who survive acute variceal haemorrhage have a high risk of re-bleeding and death. The median re-bleeding rate in untreated individuals is 60% within 1-2 years with a mortality rate of 33%.1

The frequency with which patients with end-stage liver disease will be admitted to the acute care setting will increase as medical advances continue and patients continue to wait for liver transplantation. The challenges of caring for these patients are complex and require that nurses recognize the key complications and associated diagnoses, including ascitis,

Hepatic encephalopathy, and gastroesophageal variceal bleeding. All of these patients will require astute nursing assessment, emotional support and encouragement, and multiple interventions to prevent or reduce morbidity and mortality. As the above article and clinical experience of the investigator, feel to take up this study and enhance the knowledge of staff nurse and extend the service as their best in caring and monitoring of complications and appropriate intervention in decline mortality and morbidity rates .2

Nurses are the primary care givers for patients, they play a major role. The researcher working in various clinical setting came across patients with cirrhosis of liver and related complications and the investigator also observed that many nurses did not have adequate knowledge regarding complications of cirrhosis of liver. Further reviewing the literature in this area it was found that only few Indian nursing researchers have done a systematic and scientific study to explore the knowledge level of nurses. Hence it was felt that there is a need for a scientific study related to this aspect. So the investigator has taken the study to evaluate the effectiveness of structured teaching programme on knowledge selected complications of cirrhosis of liver among staff nurses at selected hospitals Bangalore.

REVIEW OF LITERATURE

Review of literature is an important source for development of a research project, it helps to gain an insight into the research problem, and provides information of what has been done previously. It provides for helpful suggestions for significant investigation as it is the basis for future investigations. The review of literature for the present study has been taken up from different sources like text books, journals, articles and publishes and unpublished research studies.

A study was conducted on world wide mortality from cirrhosis of liver .Age- standard cirrhosis mortality rates per 100,000 were computed for 41 countries world wide over the period 1980-2002 using data from the WHO mortality database. Result showed that in the early 1980’s the height rates were in Mexico, chile(around 55/100,000 men and over 14/100,000) France, Italy, Portugal, Austria, Hungary and Romania (around 30-35/100,000 men and 10-15/100,000 women) in the southern Europe, rates in the early 2000’s were less than halved compared to earlier decades in contrast, rates have been raising in eastern European countries to reach extremely high values in the mid 1990’s and declined only their after. In the UK rates were still steadly raising. Study concluded as mortality from cirrhosis of liver shows favourable trends in most countries of the world, following the reduction in alcohol consumption and Hepatitis B and C virus infection.4

A study was conducted on cirrhosis of liver in Italy; regarding epidemiological aspects in Italy in order to improve knowledge of the incidence of liver cirrhosis, they conducted two epidemiological studies the first study showed that about 15% of asymptomatic subjects with persistent increase in alanine amino transferase had historical evidence of cirrhosis, cirrhosis of liver associated with viral etiology was 91.4% of cases in the second study, which enrolled cirrhosis patients from 13 centres from all regions of the country viral infections were detected in 82.6% of patients, the large majority of whom ,71.2% were positive for hepatitis c virus, alcohol abuse was present in 88.7% of cases as exclusive aetiological factor the age distribution showed that about 55% of cirrhosis patients were less than 60 years of age these data show that hepatitis c viral infection represents the predominant aetiological factor of cirrhosis in Italy.5

A study was conducted on alcohol consumption and the risk of chronic liver disease by department of internal medicine and public health, university of L’Aquila, Italy. 655 patients with chronic liver disease were involved in the study in order to estimate the dose-response relationship between alcohol consumption and the occurrence of chronic liver disease. They found an experimental positive association

A cross sectional study was conducted in northern Taiwan .the purpose of the study was to examine the level of awareness on portal hypertension guidelines and associated factors among nurses in Taiwan. A total of 1418 nurses were included in the analysis among 10 hospitals in Taiwan . Portal hypertension management questionnaire was developed based on the Taiwan hypertension guidelines and the 7th report of the joint national committee on prevention, detection ,evaluation and treatment of high blood pressure . Results suggested that a large proportions of the nurses in northern Taiwan had insufficient knowledge on hypertension guidelines.6

A study was conducted on critical care nurses revealed that there were recognised knowledge deficits of Abdominal compartment syndrome amongst surveyed nurses. The incidence of abdominal compartment syndrome is reported to be up to 35% in the intensive care population with reduced survival when compared to other intensive care patients. Physiological changes that occur with Abdominal compartment syndrome include compromise to the cardiovascular, respiratory, renal and neurological systems and development of metabolic acidosis. Management may incorporate percutaneous drainage of ascitic fluid, use of muscle relaxants, prone positioning and surgical intervention to open, decompress and gradually close the abdomen. Throughout this care the critical care nurse should ensure accurate monitoring of organ function, assessment for recurrence of Abdominal compartment syndrome as well as the amount and type of drainage, appropriate wound management and provision of physical and psychosocial support of the patient. These aspects of care have the potential to impact significantly on patient outcome.7

A study was conducted on nurses knowledge regarding cirrhosis and its prevention in St. joseph Hospital, Phio. 71 nurses were selected for the study. Questionnaire was used for quality of life and to identify the knowledge level of nurses regarding cirrhosis and its prevention. Study showed inadequate knowledge (22%) about cirrhosis, 28% about prevention. The problems faced because of cirrhosis by the patient further reduce the quality of life.8

Another study was conducted to assess the effectiveness of planned teaching programme on nurses regarding cirrhosis of liver and its prevention. 75 nurses were selected by purposive sampling. The pre test and post test design was used for the study. The findings of the study indicated that the planned teaching programme enhanced the knowledge of nurses regarding cirrhosis of liver and its prevention as the post test score (76%) was more than the pre test score (32%).9