RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Mr.SUJITH.A
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 / 03.06.2009.
5. / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON EXTERNAL COUNTER PULSATION THERAPY AMONG STAFF NURSES WORKING IN SELECTED HOSPITALS AT BANGALORE.
6. / BRIEF RESUME OF THE INTENDED WORK
6.1. / NEED FOR THE STUDY
“Don’t wait for a heart attack to take an action,
Don’t wait for a second life we are not cat”
Acute coronary artery disease is a common form of heart disease that results when the heart receives inadequate amounts of oxygen-rich blood through its arteries. Acute Coronary Syndrome is mainly two type, angina pectoris and myocardial infarction. Myocardial infarction(MI) oracute myocardial infarction(AMI), commonly known as aheart attack is the interruption ofblood supplyto part of theheart, causing some heart cells to die. This is always almost due to formation of occlusive thrombus at the site of rupture of an atheromatous plaque in a coronary artery. Angina pectoris is the term used to describe discomfort due to transient myocardial ischemia and constitute a clinical syndrome rather than a disease, it can occur whenever there is an imbalance between myocardial oxygen supply and demand1.
The WHO estimated that in 2002, 12.6% of death world wide from ischemic heart disease. In the United States, coronary artery diseases are the leading cause of death and it’s around 1 in 5 death and this mortality ratio is higher than the mortality ratio of cancer (malignant neoplasm). Coronary heart disease caused 445,687 deaths in 2005 and it is the single leading cause of death in America today. The ischemic heart is the leading cause of death in the developing countries. 1,200,000 people suffering from coronary artery heart diseases (new or recurrent) and around 40% of them die as a result of heart attack. Every 65 second, an American dies as a result of a coronary event. Prevalence of angina pectoris increases with age in both males and females. It has been estimated that 2–4% of the adult European population is affected by angina pectoris2.
Cardiovascular disease (CVD) kills 2.6 million people in every year or an average 300 people every hour in China. CVD is a number one killer disease in the Western countries and it is the epidemic risk in China. The number of people affected increasing by 25 percent annually3.
In the 80 per cent of global cardiovascular diseases related deaths now occur in low and middle-income nations, which cover most countries in Asia. Cardiovascular disease is the world's leading killer, accounting for 16.7 million or 29.2 per cent of total global deaths in 2003.Statistics suggested that South Asians seem more naturally vulnerable to heart disease than other ethnic group4.
InIndia, CVD is the leading cause of death. According to World Health organization 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 and expecting 2.03 million in 2010. 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.Mortality estimates due to CVD vary widely by state, ranging from 10% in Maghalya to 49% in Punjab. In the Punjab (49%), Goa (42%), Tamil Nadu (36%) and Andhra Pradesh (31%) have the highest CVD related mortality estimates. CVD also affects Indians at a younger age (in their 30s and 40s) than is typical in other countries. An estimated 9.2 million productive years of life were lost in India in 2000, with an expected increase to 17.9 million years of life in 2030 due to cardiac diseases. In Assam 9.1%, Karnataka 7.1%, West Bengal 5.9% and Uttar Pradesh 3.2% people affected with CAD and suffering from angina. Indian total average for CAD and related angina is 8.8%. The prevalence of coronary artery disease (CAD) and related anginal pain in India is increasing day by day5.
According to National Commission on Macroeconomics and Health (NCMH) New Delhi, background paper- Burden Disease in India, September2005, in the age of 30 to 39 years, males 7.35% and female 7.49% in urban areas and in rural areas 3.78% males and 2.90% females affected with CHD. In the age of 40 to 49yrs the rate of CHD increasing to 9.11% in males, 12.26% females in urban areas and 3.55% males, 7.39% females in rural areas. In the age of 50 to 59yrs, in urban areas 12.68% males and 12.62% of females affected and in case of rural areas 4.93% females, male 11.88%. In the age of 60 to 69years the prevalence of getting CHD is 19.50% in males and 19.14% in females in urban areas, in rural areas it is 11.24% in males and 11.02% in females6.
Treatment of angina pectoris is traditionally aimed at reduction of symptoms as well as prevention of future cardiac events such as myocardial infarction or death. Pharmacological agents such as nitrates, aspirin, beta-adrenoreceptor antagonists and calcium channel blockers are used as well as surgical therapies aimed at restoring blood flow, e.g. coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) . As many as 15% of the patients either fail to respond fully to therapy as described above or are ineligible to further intervention, thus said to suffer from refractory angina pectoris. These patients suffer from marked limitation of everyday physical activity due to their pain, which in some cases are more or less constant. In the last few years, the lack of efficient therapy for refractory angina pectoris in combination with increased survival rates after myocardial infarction and an ageing population has caused increased need for new therapeutic methods. Intense research has yielded methods such as external counter pulsation (ECP), laser revascularization, left stellate ganglion blockade and spinal cord stimulation (SCS) are invented7.
External Counter Pulsation (ECP) is the alternative medicine for CVD especially chronic angina patient are not receiving adequate relief from angina by taking nitrates and who are not qualify as a candidate for invasive procedures (bypass surgery, angioplasty or stenting). ECP has been used as a treatment for angina in China for two decades, but has only recently sparked interest in the U.S. This noninvasive technique provides augmentation of diastolic blood flow and coronary blood flow similar to the intra-aortic balloon pump, utilizing the serial inflation of three sets of cuffs which wrap around the calves, thighs and buttocks8.
In 1953, Kantrowitz and Kantrowitz initially described the concept of diastolic augmentation as a technique to improve coronary blood flow. During the early 60's, laboratory studies with animals demonstrated the potential efficiency of counter pulsation as a treatment following coronary occlusion. Scientists provided the first evidence that counter pulsation could quickly enhance the development of coronary collateral circulation. It also suggested the possible clinical application of counter pulsation to the treatment of patients with coronary insufficiency and angina. Several studies on 1960’s demonstrated that the use of ECP to increase survival in patients with myocardial infarction and cardiogenic shock as well as relief of angina pectoris. A large multi-center study used the ECP device on 258 myocardial infarction patients in 25 institutions was undertaken in the late 1970's. Results showed that myocardial infarction patient received therapy within the first 24 hours after admission had a mortality rate of 6.5% versus 14.7% in the control group9.
External Counter Pulsation (ECP) is not recommended for patients who have certain types of valve disease, uncontrolledarrhythmias (irregular heart rhythms), severehypertension, uncontrolled congestive heart failure, significant blockages or bloodclotsin the leg arteries, or those who have had a recentcardiac catheterization (angioplasty) or bypass surgery10.
FDA approved ECP on 1995 and has been recently utilized in clinical studies by the group of scientist from the State University of New York. They examined this outpatient therapy when performed for an hour each day for 7 weeks in 18 patients. Subjects had symptomatic angina despite medical and surgical interventions and evidence of ischemia by exercise thallium testing. In all 18 patients, there was symptomatic improvement in angina and in 16 out of 18, activities of daily living could be performed asymptomatically. Thallium-201 imaging showed resolution of thallium defects in 12 patients (67%), a decrease in ischemic area in 2 (11%) and no change in 4 patients (22%). Exercise treadmill tests saw an improvement in exercise duration. A sustained benefit was seen in most of these patients as 13 of 18 patients reported being angina free at three year follow-up without interval coronary events11.
In India more than 10 hospitals have the facility of the external counter pulsation. In India Randhawa Hospital, one of the leading and renowned hospitals situated in Amritsar, Punjab, introduced ECP in the year of 2003, for coronary artery disease with a success rate of more than 90%. ECP is absolutely natural, harmless, non-invasive, non-surgical and non-pharmaceutical out patient therapy now approved by USA (FDA), NHS (Eng), CE Mark Certification (Europe) and ISO (China) 12.
Technology for treating cardiovascular disease is slowly moving from very invasive to less invasive methods. In the seventies, bypass surgery was the big news in the treatment of coronary artery disease. In the eighties, it was balloon angioplasty and in the nineties, it was the stent. Now, we can move still a step further to a totally non-invasive treatment with ECP. External counter pulsation is a low risk and painless therapy that can be provided to a patient at a fraction of the cost of surgical alternatives for managing angina patients. In the coming decade the use of external counter pulsation will increase in India, because External Counter Pulsation (ECP) therapy is a safe and effective treatment that provides sustained duration of benefit in patients with disabling angina and angina equivalents, left ventricular dysfunction (LVD), and heart failure. The researcher observed that the staff nurses are lacking the knowledge regarding external counter pulsation in India. So the researcher felt that, it s necessary to update the knowledge of staff nurses regarding external counter pulsation therapy. It will help them to update their knowledge with advanced technologies13.
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6.2
6.2.1
6.2.2
6.2.3
6.2.4
6.2.1
6.2.2
6.2.3
6.2.4 / REVIEW OF LITERATURE
The extensive review of literature has been done and it is organized according to the following aspects:
STUDIES RELATED TO THE PREVALENCE OF CORONARY ARTERY DISEASES.
STUDIES RELATED TO THE PURPOSE OF EXTERNAL COUNTER PULSATION.
STUDIES RELATED TO EFFECT OF EXERNAL COUNTER PULSTION THERAPY ON ANGINAL PATIENTS.
STUDIES RELATED TO THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON STAFF NURSES
STUDIES RELATED TO THE PREVALENCE OF CORONARY ARTERY DISEASES.
A study was conducted to assess the prevalence and five year incidence of cardiovascular disease risk factors. The study started in December 2002 included 1514 men and 1528 women (>18 years) living in the Attica region of Greece. In 2006, the 5-year follow up was performed (941 of the 3042 participants, 31%, were lost to follow up). Development of CVD during the follow-up period was defined according to the WHO-ICD-10 criteria. Results showed 88 male and 102 female cases with hypertension per 1000 individuals, 237 male and 177 female cases with hypercholesterolemia per 1000 individuals, 58 male and 53 female cases with diabetes per 1000 individuals. The prevalence of obesity reduced in males by 0.7% (p=0.66), but increased in females by 2.4% (p=0.10). Regarding smoking, its prevalence in 2001 was 47.2% in males and 39.6% in females. However 27.5% of males and 24.5% of females stopped smoking, while 21.7% of males and 24.7% of females started smoking during the study period. The 5-year incidence of CVD was 11.0% in men and 6.1% in women (p<0.001) the case fatality rate was 1.6%. The study concluded that burden of CVD risk factors is increasing at alarming rates in the investigated population14.
A study was conducted to assess the prevalence of weekly angina among patients with chronic stable angina by cardiology unit. A total of 2031 consecutive patients participated in this study. Angina frequency was quantified with the Seattle Angina Questionnaire (SAQ), and weekly angina was defined as having 1 or more episodes per week over the preceding 4 weeks. patients with stable angina, 29% (95% confidence interval [CI], 26%-31%) experienced weekly (> or =1) angina, which was associated with greater physical limitations and worse quality of life (24% and 27% lower SAQ scores, respectively; P < .05) compared those with minimal angina (angina less than once a week over the preceding 4 weeks). The proportion of patients with weekly (> or =1) angina within a clinic ranged from none (14% of clinics) to more than 50% (18% of clinics). The study concluded that almost 1 in 3 patients with stable angina attending primary care practices had angina at least once a week, which was associated with worse quality of life15.