RAJIVGHANDHIUNIVERSITY OF HEALTH SCIENCES KARNATAKA , BANGALORE.

PROFORMA FOR REGISTRATIONOF SUBJECT FOR DISSERTATION

01 / NAME OF THE CANDIDATE AND ADDRESS / RAJESH PREM KUMAR
FIRSTYEARM.Sc.NURSINGRAJIVCOLLEGE OF NURSING HASSAN
02 / NAME OF THE INSTITUTION / RAJIVCOLLEGE OF NURSING HASSAN
03 / COURSE OF THE STUDY AND SUBJECT / M.Sc. NURSING Ist YEAR PEADIATRIC NURSING
04 / DATE OF ADDMISSION TO COURSE / 06 JUNE 2007
05 / TITTLE / EFFECT OF PLANNED TEACHING ON NURSES KNOWLEDGE ABOUT PAIN MANAGEMENT IN NEONATES.
05.1 / STATEMENT OF THE PROBLEM / A STUDY TO ASSESS EFFECT OF PLANNED TEACHING ON NURSES KNOWLEDGE ABOUT PAIN MANAGEMENT IN NEONATES ADMITTED IN SELECTED NICU’S OF HASSAN.

6. BRIEF RESUME OF THE INTENDED STUDY

INTRODUCTION

The International Association for the study of pain ha s defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.1 “ The interpretation of pain is subjective. Each person forms an internal construct of pain through encountered injury .Several experts suggest that the neonate’s expression of pain does not fit within the strict definition of the International Association for the study of pain because of the requirement for self – report. This lack of ability to report pain contributes to the failure of Health care professionals to recognize and treat pain aggressively during infancy and early childhood2. Because neonates cannot verbalize their pain, they depend on others to recognize, assess, and manage their pain. Therefore, health care professionals can diagnose neonatal pain only by recognizing the neonate’s associated behavioral and physiological responses3.

Research has revealed marked discrepancies between how healthcare professionals administer analgesia for infants and children as compared to adults. The study which was

Done on management of pain in infants and children found that infants and children received little or no analgesia in comparison to adults having similar diagnoses in comparison to adults having similar diagnoses or surgical procedure3. Pain medication for neonates is usually ordered PRN (pro re nata) which means “to give as needed” it also means that either the child must ask (“beg”) for pain medication or the nurse must identify when a neonate is in pain. A neonate in pain may meet neither of these requirements. Nurses are responsible for assessing infant pain deciding when it is appropriate to give analgesics, and then evaluating whether5 pain relief was achieved. A study which was done on 260 nurses about their knowledge and practices regarding pain assessment and management in infants and children found that nurses do not consistently assess pain in infants and children, and that pain management practices are not based on systematic assessment or utilization of pain instrument3. They also found that the amounts of analgesics chosen by nurses were consistently lower than permitted by the PRN order, and that nurses provided decreased amounts of analgesics over time, even when patients demonstrated high levels of pain.

Several studies have shown that although pain management is the part of the nursing care provided to the neonates, very few are aware of how to asses and mange pain in neonates.

6.1Need for the study

Pain assessment is the “fifth vital sign” and is an essential element of pain management. Research suggests that some differences in nociceptive processes exist between infants and adults1.

There are various physiological, metabolic, and behavioral responses to pain in neonates, which includes increased heart rate, respiratory rate, and blood pressure and increased secretions of catecholamines, glucagons and corticoseroids. The catabolic state induced by acute pain may be more damaging to infants who have higher metabolic rates and less nutritional reserves than adults. Pain leads to anorexia, causing poor nutritional intake and delayed wound healing; impaired mobility; sleep disturbances; withdrawal; irritability; and developmental regression. Pain causes significant morbidity and may increase the risk of mortality. In one study newborn infants undergoing cardiac surgery who received less anesthetic had more postoperative complications. Untreated pain can prolong hospitalizations and convalescence2.

Experience of pain during the neonatal life has effects on subsequent pain perception and responses. Two studies suggest that pain experience in the Neonatal Intensive Care Unit ( NICU) may alter the normal course of development of pain expression in toddlers and preschoolers. Animal research suggest that pain and stress in the neonatal period results in altered pain sensitivity, decrease weight gain, decreased ability to learn, and increased preference for alcohol. Humans and animals do not become tolerant to pain and are likely to be sensitized to the effect of pain over time. Thus recognition and treatment of pain is important for the immediate well being of infants and for their long – term development. Studies show that nurses does not consistently asses pain in infants children, and that pain management practices are not based on systematic assessment or utilization of a pain instrument4.

In the clinical area it is observed that nurses do not have adequate knowledge about pain management in neonate. Thus the investigator felt the need of assessing the knowledge of nurses working in Neonatal Intensive Care Unit about pain management in neonates and to see the effect of planned teaching on their knowledge.

6.2Review of literature

A randomized study conducted , controlled, double blind study on 201 newborns undergoing venipuncture which shows that 30% glucose solution was more effective than EMLA cream in reducing symptoms associated with pain from veinpuncture 2.

Pain medication for infants is usually ordered PRN (pro re nata), making nurses responsible for assessing infant pain and deciding when it is appropriate to give analgesics, and then evaluating whether pain relief was achieved. Jacob and Puntillo studied this phenomenon and demonstrated that nurses do not consistently assess pain in infants and children, and that pain management practices are not based on systematic assessment or utilization of a pain instrument3.

A study found that infants and children received little or no analgesics in comparison to adults having similar diagnosis or surgical procedures. For example, in adults, endotracheal intubation and mechanical ventilation are generally regarded as noxious, and patients frequently receive opioids and sedative - hypnotics to tolerate these interventions. However, infants are commonly intubated with no anesthesia or analgesia, and often receive mechanical ventilation without analgesia or sedation3

Healthcare professionals first concern should be treatment of stress or pain, which later can be followed by managing the consequences of the stress or pain treatment4.

An infant’s heart rate initially decreases and then increases in response to short, sharp pain; oxygen saturation decreases during painful procedures such as circumcision, lumbar punctures, and intubations4.

A study conducted on Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. With a sample of 151 neonates recorded all painful procedures, including the number of attempts required, and analgesic therapy used during the first 14 days of neonatal intensive care unit admission. These data were linked to estimates of the pain of each procedure, obtained from the opinions of experienced clinicians. Results of the study shown that on average, each neonate was subjected to a mean +/- SD of 14 +/- 4 procedures per day. The highest exposure to painful procedures occurred during the first day of admission, and most procedures (63.6%) consisted of suctioning. Many procedures (26 of 31 listed on a questionnaire) were estimated to be painful (pain scores >4 on a 10-point scale). Preemptive analgesic therapy was provided to fewer than 35% of neonates per study day, while 39.7% of the neonates did not receive any analgesic therapy in the neonatal intensive care unit. Researcher concluded. Clinicians estimated that most neonatal intensive care unit procedures are painful, but only a third of the neonates received appropriate analgesic therapy. Systematic approaches are required to reduce the occurrence of pain and to improve the analgesic treatment of repetitive pain in neonates5.

A study conducted on Prevention and management of pain in the neonate. An update.The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures6.

A study conducted on Prevention and management of pain in the neonate: an update.The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures7.

Physiologic responses to pain include skin color changes, palmer sweating (in infants >37 week gestation), decreased oxygen saturation, alterations in stress hormone production, and increased heart rate, blood pressure, respirations, and intracranial pressure8.

However, it is important to remember that absence of objective signs of pain does not mean that pain is not present9. The occurrence of apnea and respiratory depression in infants and children as reaction to drugs used for pain relief is related to dose of drug and route of administration. If the infant experiences adverse effects of opiod medications, such, effects can usually be reversed with opiod antagonists such as naloxone9.

6.3 Statement of the problem

A study to assess effect of planned teaching on nurses knowledge about pain management in neonates admitted in selected NICU’s of Hassan.

6.4Objectives of the study

To assess nurses knowledge about pain management in neonates.

To assess effectiveness of planned teaching on nurses’ knowledge about pain management in neonates.

To co-relate the nurse’ knowledge about pain management with selected demographic variables.

6.5 Definition of terms and variables (operational definition)

Effectiveness – according to oxford dictionary the effectiveness means checking for the desired effect, intended result or an outcome.

In this study effectiveness means outcome of planned teaching in terms of nurses’ knowledge about pain management in neonates

Planned teaching – according to oxford dictionary means giving systematic information to the people

In this study it means giving systematic information to nurses about pain management in neonates.

Nurse – according to oxford dictionary “a nurse is a person whose job is to care for a patient”.

According to this study nurses working in Neonatal Intensive Care Unit, and holding General nursing and Midwifery (GNM) or Basic or post basic B.Sc nursing qualification.

Knowledge - according to oxford dictionary, knowledge is what one knows

In this study knowledge about management of pain in neonates

Pain – the international association for the study of pain has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

In this study pain is behavioral and physiologic changes shown by neonates in response to painful procedures performed in Neonatal Intensive Care Unit.

6.6 Assumption

Nurses working in Neonatal Intensive Care Unit, have some knowledge about pain management in neonates

Neonates have pain and they express their pain by certain behavioral and physiologic changes.

6.7Hypothesis

Null hypothesis(Ho) -there will be no significant difference in nurse’s knowledge about pain management in neonates after the planned teaching.

Alternative hypothesis (H1) –there will be significant difference in nurse’s knowledge about pain management in neonates after the planned teaching.

6.8 Delimitations

The study is limited,

  • To assess the effectiveness of planned teaching programe in the form of knowledge gain.
  • It is limited to selected Hospitals with NICU’S in Hassan.

7.0 Material and Methods

7.1 Source ofdata-:

Formal consent will be obtained from selected hospitals of hassan and questionnaire

method will be used to collect data.

7.1.1 Research design-:

Research design intended for this study is pre experimental one-group pretest posttest design. The test will be the knowledge test and the experimental variable will be the panned teaching.

7.1.2 Setting

The study will be conducted in selected NIC’S in Hassan

7.1.3 Population

The Population of the present study comprised of the nurses working in Neonatal Intensive Care Unit (NICU) of selected hospitals in Hassan district.

7.2Methods of data collection

7.2.1 Sampling Technique

Purposive sampling technique will be used for selecting the samples

7.2.2 Sample size

Sample size was 50 trained nurses working in Neonatal Intensive Care Unite of selected hospitals.

7.2.3 Inclusion criteria

  • Nurses who are trained i.e., having General Nursing and Midwifery (GNM), basic B.Sc. Nursing or post-basic B.Sc. Nursing qualification
  • Nurses with minimum 1 year of experience of working in Neonatal Intensive Care Unit.

7.2.4 Exclusion criteria

  • Auxiliary Nurse Midwives (ANM)
  • Paramedical trained Nurses
  • Student nurses

7.2.5 Instruments intended to be used

Structured questionnaire will be used

7.2.6 Data collection methods

Data will be collected directly from staff nurses through a questionnaire

7.2.7 Plan for data analysis

The data will be analyzed using descriptive inferential statistics.

7.3 Does the study require any investigation or interventions to be conducted on patients or other human or animals?

Yes

7.4Has ethical clearance been obtained from your institution in case of 7.3?

Yes

8.0References

  1. American pain society. The assessment and management of acute pain in infants, children and adolescents Journal of the AmericanAcademy of Pediatrics volume 14 No 1 pg 52-55.
  2. Gradin, M ,Eriksson M, Schollin J. “Reducing the Pain Sweet Way” pediatrics today. vol VI no 2 pg 113.
  1. Jacob, E., and Puntillo, R.A . ‘A Survey of nursing practice in the assessment and management of pain in children’. ‘Pediatric nursing’, 1999volume 25 (3) pg 278-286.
  1. Anand KJS, and Hickey PR. ‘Pain and its effects in the human neonate and fetus’. New England Journal of medicine 1987; volume 317 pg 1321 – 1329.
  1. Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2004 Jun;158(6):600.
  1. American Academy of Pediatrics; Committee on Fetus and Newborn; Canadian Paediatric Society; Fetus and Newborn Committee Prevention and management of pain in the neonate. An update. Adv Neonatal Care. 2007 Jun;7(3):151-60.
  1. American Academy of Pediatrics Committee on Fetus and Newborn; : Pediatrics. 2006 Nov;118(5):2231-41.
  1. McGrath PJ, Unruh AM, Finley GA. Pain measurement in children. Pain clinical updates 1995 3(2) 26
  1. Pain clinical update. ‘Pain measurement in children” International Association for the Study of Pain volume III issue 2, July 1995’ Halcyon.com/iasp
  1. Archives of disease in children.fetal and neonatal edition. July 2001 volume 85 No. 1 pg 36-41
  2. Behrman E. Richard. Nelsons textbook of pediatrics. 16th edition . WB: Saunders publication;2000.p 487.
  1. Cloherty P. John. ‘Manual of Neonatal Care.’ 4th edition .Philadelphia ,New York: Lippincott – raven publishers;1998. p 667 – 673.
  1. Friedman M. Marilyn. ‘Family nursing research theory and practice.’ 4th edition. Appleton and Lange atamford publication; 2002. p 153 – 158.
  1. Guhn Dipak K. ‘Guha’s Neonatology – principles and practice.’ 3rd edition .New Delhi : Jaypee Brothers publication;2005. p 83.
  1. Jacqueline Flowler Byers and Kristen Thornley MSN.Baby’s don’t feel pain; a century of denial in Medicine. The American Journal of Maternal Child Nursing. March / April 2004 Volume 29 Number 2 Pg No. 84-89.
  1. Jane W Ball , Ruth C Bindler. “Pediatric nursing caring for children.” 2nd edition. Simon and Schuster company publication;1999. p 266 – 286.
  1. Klaus H Marshall. ‘Care of high risk neonates.’ 5th edition.New Delhi: Harcourt publication; 2001. p 228.
  1. Polit D, Hungler. B.P’Nursing research, principles, methods.Philadelphia: J.B Lippincott publisher;1999. p 50-96
  2. McColl Particia J “Pain management: An assessment of surgical nurses’ knowledge” the Journal of adult health vol 10 No – 4 Aug 2001.
  1. Taeusch William H. ‘Averys Diseases of the Newborn.’ 8th edition. India: Elsevier publication; p 438-444
  1. The Pediatric clinics of North America acute pain in children June 2000 W.B Saunders publication Philadelphia vol 47 no3.
  1. Watt-Watson Judith H. Pain management nursing perspective.12 edition.U.S.A: Mosby publication ;1996 Pg 203.
  1. Wong D.L. Essentials of Pediatric Nursing. 5th edition.U.S.A: Mosby publication;1997. p 238-240.

09 / Signature of candidate
10 / Remarks of guide
11 / Name and designation
11.1 / Guide
11.2 / Signature
12 / Head of the department
12.1 / Signature
13 / Remarks of principal
13.1 / Signature

Conceptual framework

A frame work for a research study helps to organize the study and provides a context for the interpretation of the study findings. Conceptual framework provides a background or foundation for a study. A conceptual framework helps to explain the relationship between concepts. The conceptual; framework formalizes the thinking process, so that others may read and know the framework of references, basic to the research problem. The conceptual framework also enlightens the investigator regarding relevant questions on the phenomenon under study. This framework is influenced by system model.