RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
SYNOPSIS OF
THE M.SC.(N) DISSERTATION
A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON THE KNOWLEDGE ON PREVENTION OF VENOUS THROMBOEMBOLISM AMONG PATIENTS WHO HAVE UNDERGONE ORTHOPAEDIC SURGERY IN SELECTED HOSPITALS MANGALORE
Submitted By:
Mr. Sijo Sebastian
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) / MR. SIJO SEBASTIAN
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 / 31-05-2010
5. / TITLE OF THE TOPIC.
A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON THE KNOWLEDGE ON PREVENTION OF VENOUS THROMBOEMBOLISM AMONG PATIENTS WHO HAVE UNDERGONE ORTHOPAEDIC SURGERY IN SELECTED HOSPITALS MANGALORE
6.
7.
8. / BRIEF RESUME OF INTENDED WORK
6.1. Introduction
“Life is brief, art is long, opportunity is fleeting,
experience is fallacious, judgment is difficult”
(Hippocrates 460-370 B.C.)
The veins are the blood vessels that carry blood toward theheart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonaryand umbilical veins, both of which carry oxygenated blood. Veins serve to return blood from organs to the heart. Insystemic circulationoxygenated blood is pumped by the left ventriclethrough thearteriesto the muscles and organs of the body, where its nutrients and gases are exchanged atcapillaries, entering the veins filled with cellular waste andcarbon dioxide. The de-oxygenatedblood is taken by veins to theright atriumof the heart, which transfers the blood to theright ventricle, where it is then pumped through the pulmonary arteries to thelungs. Inpulmonary circulationthepulmonary veinsreturn oxygenated blood from the lungs to theleft atrium, which empties into the left ventricle, completing the cycle of blood circulation. The return of blood to the heart is assisted by the action of theskeletal -muscle pumpwhich helps maintain the extremely lowblood pressureof the venous system. In the legs there are two systems of veins – the deep and superficial. The deep system is the main way blood leaves the leg and returns to the heart. This system is buried deep in the leg and cannot be seen from the outside. The superficial system is just under the skin and can be seen1. A venous thromboembolism (VTE) is any thromboembolism event that occurs within the venous system. The majority of VTE start in the calf veins; from there, the thrombosis may progress to the proximal veins, and later, it may break free to lodge in the lungs, where it cause the potentially fatal condition, pulmonary embolism. In this study, VTE is defined as deep venous thrombosis (DVT); i.e., thrombosis of a deep vein in an extremity (leg or arm); and PE which is considered to be the obliteration of the pulmonary arterial network by one or several blood clots2.
Up to two million cases of VTE develop in the United States each year. It is estimated that about one-third of patients with symptomatic VTE manifest PE. According to the American Heart Association, VTE can be fatal; the mortality rate is about six percent in DVT cases and 12 percent in PE cases3.
In a study, symptomatic deep-vein thrombosis or pulmonary embolism was diagnosed in 2.1% and 2.8% of patients after primary total knee arthroplasty or total hip arthroplasty, respectively. Even more striking is the fact that the events were diagnosed after hospital discharge in 47% and 76% of patients under going total knee arthroplasty or total hip arthroplasty4. In patients undergoing hip fracture surgery, although the incidences of total and proximal deep vein thrombosis (46-60% and 23-30%, respectively) are comparable with those in patient sunder going hip or knee arthroplasty, the incidence of pulmonary embolism is markedly higher5. The overall incidence of pulmonary embolism in patients undergoing hip fracture surgery has been estimated to be between 3% and 24%, while fatal pulmonary embolism has been reported in between 2.5% and 13% of patients. In one study, veno graphically confirmed deep-vein thrombosis was present in18% of patients one week after knee arthroscopy6. So prevention of venous thromboembolism in postoperative orthopaedic patients is so important. VTE can be prevented, especially if patients who are considered at high risk are identified and preventive measures are instituted without delay.
6.2. Need For The Study
Venous thromboembolism (VTE) is one of the major complications that affect the individuals during the postoperative period especially after orthopaedic surgeries.VTE is defined as deep venous thrombosis (DVT); i.e., thrombosis of a deep vein in an extremity (leg or arm); and PE which is considered to be the obliteration of the pulmonary arterial network by one or several blood clots2. Deep vein thrombosis and pulmonary embolism are the major health problems with two possible serious outcomes. PE can be fatal.
DVT can lead to chronic venous insufficiency and affect the ‘quality of life’ and at the same time increase the cost of patient management. Epidemological data indicates that annual frequency in general population is approximately 160 per 100,000 for DVT and 20 per 100,000 for the symptomatic non fatal PE.7
The actual incidence of PE – it may be the cause of death in 3 to 10 patients out of 1000 hospital deaths. All the precautions and anticoagulation prevents at least 5 to 6 deaths out of 1000 deaths in the hospitals.3 Venous thrombosis is a complication and major source of mortality and morbidity in healthy patients above 40 yrs of age undergoing extensive elective surgery like arthroplasty and cardiac surgeries and immobility. As nurses, our duty is to prevent venous thrombosis by teaching exercises preoperatively and applying elastic stockings after surgery.8
‘Prevention is better than cure’, having identified patients at high risk of thromboembolism, the nurses select the most appropriate prophylactic measures. Having identified patients at high risk of venous thromboembolism, the nurses select the most appropriate prophylactic measures. Early mobilization of patients, as soon as possible after surgery is thought to reduce the chances of thromboembolism. Physiotherapy is categorized as an important mechanical method. Graded compression stockings have been shown to be effective in reducing post operative venous thrombosis.9
The symptoms of VTE commonly develop after hospital discharge. Indeed, VTE is the most common cause of emergency hospital readmission following total hip replacement surgery. In one study, approximately 20% of patients who had undergone total hip replacement surgery, and had no detectable DVT before hospital discharge, developed a new thrombus during the next three weeks. The risk of VTE continues to be higher than in the general population for at least two months after elective hip or knee replacement surgery.10
A multi faceted approach to prevention of thromboembolism on 529 cases was conducted which revealed that morbidity and incidence ofthromboembolism complications could be reduced by patient awareness and nursing staff concern. Nursing staff concern with exercise instructions, early ambulation, calf exercise, post operative circle bed turning and use of the trendelenburg position form the foundation of prophylaxis of DVT.11
There is no recent study on prevention of venous thromboembolism among postoperative orthopaedic patients in Mangalore region and also in this population. The investigator would like to undertake the present study to evaluate post operative orthopaedic patients who are admitted in selected hospitals in Mangalore, to improve their knowledge on prevention of venous thromboembolism by administering a structured teaching programme. Hence the study is relevant to this area, to this population and to this period.
6.3. Review of Literature
A study was done on venous thromboembolism in trauma patients, standardized risk factors and found that the risk of DVT after trauma is highest (40%) in older and more severely injured patients. The risk also increases in patients (30%) with spinal fracture and spinal cord injury. several commonly reported risk factors, such as head injury, pelvic fracture, or long bone fracture (30%) were found to increase risk of VTE.12
A study on incidence of post operative DVT in Indian patients undergoing major lower limb surgeries was carried out. A total of 104 adult patients were enrolled. Venous thrombosis was observed in 35.6% of patients who underwent total hip arthroplasty, 46% with total knee arthroplasty and 18.3% with fixation involving the proximal femur. In this group overall 52.1% showed venographic evidence of VTE. The study has shown that postoperative venous thrombosis is common in Indian population.13
A study was done on the risk of DVT in orthopaedic patients and found that DVT is responsible for 50,000 deaths annually in industrialized countries. It is probably the common preventable cause of death in elective orthopaedic surgery patients. The overall risk of DVT rate is more than 40% of patients undergoing hip or knee arthroplasty or suffering from multiple injuries. The proximal DVT rate for the patients is more or less equal to 15% and the fatal PE rate is more or less equal to one percent. Risk factors associated with DVT are related to the vascular injury, activation of blood coagulation and venous stasis. Lower extremity orthopedic procedures carry a risk factor than that of surgery itself. Thus orthopedic patients are highest risk for DVT condition.14
A study on the risk of thromboembolism after knee arthroplasty in UK among 184 patients scheduled for knee arthroplasty, risk of VTE was evaluated. Among 184 patients who had adequate venography, DVT was detected in 33 ; of these 9 are proximal DVT(27.27%), out of 33 patients only 14 (42.42%) with DVT has symptoms while 10 (30.30%) were asymptomatic. The results of the study demonstrated that the risk of thromboembolism was significantly higher among patients after knee arthroplasty.15
A study was done on incidence of VTE in hospitalized patients and found that VTE is a common disease among hospitalized patients with an average annual incidence of over one per 1000. There are 10% to 30% of surgical intensive care unit patients who developed DVT within the first week of admission. Approximately 60% trauma patients developed DVT within first 2 weeks of admission. The estimated prevalence of DVT in surgical patients is 22% to 35%. The incidence of DVT in spinal cord injury patients is in the range of 50% to 80%. The study concluded that to improve the survival rate and prevent complications, the incidence of DVT has to be reduced.16
A randomized controlled study on the effect of sequential foot compression on prevention of VTE after total knee arthroplasty on 48 patients in India. Two common prophylactic measures were used, in which controlled group used with low molecular weight heparin, where as the other group received foot compression therapy for 7 days after surgery. Results revealed that lower limb swelling and pain were significantly reduced for the foot compression group(78%) in relation to the controlled group (50%).ultrasound and venography demonstrated as significantly VTE in this group .Study emphasized on foot compression therapy as an important prophylactic method in venous stasis.17
The effect of active movement of the foot on venous blood flow after total hip replacement was studied and investigated the effect of active movement of one foot on the venous blood flow. They compared the two groups –controlled group and exercise group. The results confirmed that beneficial hemodynamic effects of active movement of the foot in the post operative period and has been suggested that the patients has to move the feet and ankles as part of prophylaxis to decrease the risk of DVT.18
An experimental study was done to find out the effect of exercise as an nursing intervention in prevention of selected complications of patients with lower limb fractures. A total of 30 orthopedic patients were included in the study. The findings of the study revealed that severity of selected complications was only 3% in experimental and 50-85% in control group. This shows that regular exercises minimize the occurrence of complications in orthopedic patients.19
A study on compression therapy in DVT reviewed the most clinical investigations about early use of external compression in DVT results in reduction on the growth of the thrombus. Finally the authors confirmed that the use of physical therapy with early mobilization and external compression in prevention of DVT is most effective.20
A study on patient compliance and satisfaction with mechanical devices for preventing VTE after joint replacement was conducted and reported that a higher degree of compliance and satisfaction for foot pumps as prophylaxis against VTE.21
6.4 Statement of the Problem
A study to assess the effectiveness of structured teaching program on the knowledge on prevention of venous thromboembolism among patients who have undergone orthopaedic surgery in selected hospitals Mangalore.
6.5. Objectives of the Study
Objectives of the study are to
Ø  assess the existing knowledge on prevention of venous thromboembolism among patients who have undergone orthopaedic surgery.
Ø  develop and deliver structured teaching program on prevention of venous thromboembolism among patients who have undergone orthopaedic surgery.
Ø  assess the effectiveness of structured teaching program on knowledge of patients undergone orthopaedic surgery regarding prevention of venous thromboembolism.
Ø  find out the association between selected demographic variables and knowledge of patients who have undergone orthopaedic surgery regarding prevention of venous thromboembolism.
6.6. Operational Definitions
·  Effectiveness:
In this study effectiveness refers to the extent to which the structured teaching program delivered has achieved the desired improvement as assessed by gain in knowledge of patients who have undergone orthopaedic surgery regarding prevention of venous thromboembolism.
·  Structured teaching program:
In this study the STP refers to a structured teaching program on prevention of venous thromboembolism for the patients who have undergone orthopaedic surgery in the selected hospital, Mangalore.