T.JOHN COLLEGE OF NURSING
GOTTIGERE
BANNERGHATTA ROAD
BANGALORE
SYNOPSIS
REGISTRATION OF SUBJECT FOR DISSERTATION
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA
PREPARED BY
LINU ELIZABETH BABU
1ST YEAR MSC NURSING
T.JOHN COLLEGE OF NURSING
GUIDED BY
MRS.P.NEELAVATHI
HEAD OF THE DEPARTMENT
MEDICAL SURGICAL NURSING
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / Name of the candidate and address(in block letters) / LINU ELIZABETH BABU
1ST YEAR M.Sc NURSING
T.JOHN COLLEGE OF NURSING
GOTTIGERE
BANGALORE
2. / Name of the institution / T.JOHN COLLEGE OF NURSING
GOTTIGERE
BANGALORE
3. / Course of study and subject / M.Sc. NURSING
MEDICAL SURGICAL NURSING
4. / Date of Admission to the course / 6.7.2010
5. / Title of the Topic
“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDIG ADVANCE GUIDELINES IN THE MANAGEMENT OF UNSTABLE ANGINA AND NON ST ELEVATION MYOCARDIAL INFARCTION AMONG NURSES WORKING IN THE SELECTED HOSPITALS AT BANGALORE”.
6.
7. / Brief resume of the intended work
Introduction
Medical surgical nursing is the health promotion, health care and illness care of adult based on knowledge from the arts and science and shaped by the knowledge (the science) of nursing1. Cardiology is the branch of medicine with deals with diagnosis and treatment of heart disease2.According to WHO estimation, in 2003, 16.7 million people around the globe die of cardio vascular disease each year. This is over 29 percent of all death globally3. According to recent estimates, cases of cardiovascular disease may increase from about 2.9 crore in 2000 to as many as 6.4 crore in 20154.
Many risk factors for coronary heart disease can be controlled through life style modification. Intact, with increased public awareness of risk factors related to coronary heart disease, mortality rates are declining by about 3.3% per year. Nevertheless, coronary heart disease remains a major public health problem. Both men and women are affected by coronary heart disease; in women however, the onset is about 10 years later because of the heart protective effects of estrogen1.
Coronary heart disease (CAD) is the most common type of cardiovascular disease and accounts for the majority of these death5. The most common cause of cardio vascular disease is atherosclerotic disease, an abnormal accumulation of lipid or fatty substances and fibrous tissue in the lining of arterial blood vessel walls. These substances create blockages and narrow the coronary vessels in a way that reduces blood flow to the myocardium6. Unstable angina and myocardial infarction are more serious manifestations of coronary artery disease and are termed as acute coronary syndrome6. Acute coronary syndrome is associated with deterioration of a once stable atherosclerotic plaque. The once stable plaque ruptures, exposing the intima to blood and stimulating platelet aggregation and local vasoconstriction with thrombus formation. This unstable lesion may be partially occluded by a thrombus, manifesting as unstable angina / non ST elevation myocardial infarction [UA/NSTEMI]6.
It is extremely important that a patient with acute coronary syndrome is rapidly diagnosed and treated to preserve cardiac muscle5. Care of patient should focus on aggressive management of risk factors to slow the atherosclerotic process and reduce the risk of complication7. Nurses will be dealing with cardio vascular patients more often, regardless of the practice setting7. For this reason, it is important for nurses to become familiar with various manifestations of coronary artery conditions and methods for assessing, preventing and treating these disorders medically and surgically6.
6.1 Need for the study
“CRITICAL THINKING IS THE USE OF THOSE COGNITIVE (KNOWLEDGE) SKILLS OR STRATEGIES THAT INCREASE THE PROBABILITY OF A DESIRABLE OUT COME.”
[Halpern]
Cardio vascular disease is the world’s leading killer disease, accounting for 16.7 million or 29.2 percent of total global deaths in 20038. While deaths from heart attacks have declined more than 50% since the 1960s in many industrialize countries, 80 percent of global cardio vascular disease related deaths now occur in low and middle income nations, which covers most countries in Asia. The World Health Organization estimates that 60 percent of the world’s cardiac patients will be Indian by 20108.
In India, in the past five decades, the rates of coronary disease among urban populations have been raised from 4% to 11%8. According to recent estimates, cases of cardio vascular disease may increase from about 2.9 crore on 2000 to as many as 6.4 crore in 2015. Most of this will occur on an account of coronary heart disease- Acute Myocardial Infarction, congestive heart failure and inflammatory heart disease. Data also suggest that although prevalence rates of cardio vascular disease in rural population will remain lower than that of urban population, they will continue to increase, reaching around 13.5% of the rural population in the age group of 60 to 69 years by 2015. The prevalence rates among young adults (age group of 40 years and above) are likely to increase. The largest share in non-communicable disease is cardio vascular disease (31%) when compare to cancers (10%), diabetes (2%), mental health disorders (26%), blindness (4%), COPD and asthma (5%), oral disease (1%) and other diseases (21%)4.
As per the statistical data, the global and national population has a high prevalence of cardio vascular disease. Among them Unstable Angina and Non ST Elevation Myocardial Infarction [UA/NSTEMI] is a common but heterogeneous disorders with patients exhibiting widely varying risks9. For the past decade, it has been appreciated that unstable angina and non ST elevation myocardial infarction form a continuum, with similar pathophysiologic and clinical features. The most common presenting symptom is chest pain, which is one of the most common complaints of patients coming to emergency department, estimated at 5.3 million visits per year. Interestingly, the number of hospital admission for patients with unstable angina and non ST elevation myocardial infarction has been rising9.
Patients with coronary artery disease (CAD) often seek health care after experiencing angina or myocardial infarction (MI). Coronary artery disease is directly implicated in other cardiovascular diagnosis such as dysarrhythmias, heart failure and cardiomyopathy. All nurses need to be familiar with the collaborative care management of coronary artery disease because of its high prevalence in the industrialized world10.
This is supported by a study conducted in USA about the treatment guidelines for the nurse practitioners on non ST segment elevation acute coronary syndrome. The purpose of the study was to increase the awareness among nurse practitioners. Findings showed that familiarity with the patient as well as current management recommendations can improve clinical outcomes for patients with unstable angina and non ST elevation myocardial infarction11.
Another study was conducted in USA regarding the contemporary treatment of unstable angina and non ST segment elevation myocardial infarction. The study was conducted as large randomized controlled study. The study showed that the optimal treatment strategy for unstable angina and non ST elevation myocardial infarction is the corner stones of prevention in risk stratification12.
As per the above mentioned studies and observations, investigator feels that it is important to update the knowledge level of the nurses regarding the current guidelines in the management of unstable angina and non ST elevation myocardial infarction and structured teaching programme will be an effective way to impart this knowledge. Hence the investigator decided to give a structured teaching programme on current guide lines in the management of unstable angina and non ST elevation myocardial infarction to the staff nurse who will make them competent and confident to work in the cardiology department.
6.2 Review of the literature
Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the project13. A literature review early in the reports provides readers with a background for current knowledge on a topic and illuminates the significance of the new study14.
The literature can be reviewed under following headings:
I. Literature related to management of unstable angina and non ST elevation myocardial infarction.
II. Literature related to nurses knowledge regarding management of unstable angina and non ST elevation myocardial infarction.
III. Literature related to role of nurse in the management of unstable angina and myocardial infarction.
IV. Literature related to effectiveness of structured teaching programme.
1. Literature related to management of unstable angina and non ST elevation myocardial infarction
A prospective study was conducted on antiplatelet usage in patients with acute coronary syndrome. The objective of the study was to evaluate medical practices in managing acute coronary syndrome patients. The method used was prospective observational study in 27 hospitals. A total of 1331 patients with unstable angina and non ST elevation myocardial infarction (UA/NSTEMI) discharged from the hospitals were analyzed. The result showed that the prescription of dual anti platelet agent declined rapidly from 61.8% at discharge to 12.6% at 12 months. The result showed that most common reason for clopidogrel discontinuation was recorded as physician’s judgment which leads to one year mortality15.
A study was conducted in USA regarding the use of heparins in non ST elevation acute coronary syndromes. The samples was who were characterized according to the early and continued use of lower-molecular-weight heparin, unfractionated heparin, any crossover of heparin therapy (change in early Vs late heparin treatment) and no heparin treatment. Data from 23,172 patients with non-ST segment elevation myocardial infarction or unstable angina were analyzed. The rates of major bleeding and death were lower with low-molecular weight heparin(1.4% and 1.8%, respectively) compared with unfractionated heparin(1.9% and 2.5% respectively), crossover heparin(2.0% and 2.3%) or neither heparin(1.5%and 2.4%). The conclusion was there is a significant variability in heparin use in patients with acute coronary syndromes. The early use of low-molecular-weight heparin in the setting of an acute coronary syndrome is associated with better short-term outcomes16.
A study was conducted in UK on improving the management of non-ST elevation acute coronary syndrome. The aim was to improve the patient care and out comes. The method used was a multi-centre cluster randomized study. Thirty eight hospitals receive a quality improvement programme. And the sample size is estimated at 2000 to 4000 patients. The result shows that the demonstration of quality improvement programme can lead to a greater acceptance in routine health training for health professionals and hospital managers17.
2. Literature related to nurses knowledge regarding unstable angina and myocardial infarction.
A study was conducted in UK related to nurses and patients knowledge of cardiac related symptoms and cardiac misconceptions. The objective was to compare knowledge of cardiac related symptoms among patients with nurses’ knowledge. Method was retrospective collection of patient data by means of postal questionnaire and postal survey of hospital nurses. The results was the percentage of nurses who correctly estimated the incidence of symptoms was low, 25% of nurses did not make any correct estimates. And the nurse’s score was not significantly associated with experience or place of work. The conclusion was the nurses should be provided with sound knowledge on cardiac symptoms and risks so that they can educate patients accordingly18
A study was conducted in London related to knowledge of psychological care for patients with symptoms of myocardial infarction among nurses. The aim was the provision of psychological care to this group with the aim of improving practice. The method was by the literature search to identify articles linking the nurses’ role with myocardial infarction, the patients view with myocardial infarction and the need for psychological care within acute medicine. Results suggest that the patients with symptoms of myocardial infarction experience some level of anxiety and they are not always offered psychological interventions to alleviate this anxiety. Outcome was an anxiety assessment tool was developed to help nurses to assess patient’s level of anxiety and suggest appropriate interventions to offer psychological care to patients with symptoms of myocardial infarction19.
A study was conducted on health professional’s knowledge of initial prevention of acute myocardial infarction. The aim was to determine doctors and nurses knowledge of the initial presentation of acute myocardial infarction who works in the emergency unit and coronary care unit. The method used was a descriptive, non experimental survey of 155 doctors and nurses working in emergency unit and coronary unit in three general hospitals. Prodromal symptoms associated with acute myocardial infarction were poorly recognized by both doctors and nurses. The surveyed health professionals indicated that they were aware of the listed typical symptom presentation of acute myocardial infarction but this trend was not evident with the listed typical symptoms. It is also clear that acute myocardial infarction prodromal symptoms recognition in both professional groups in the sample is lacking. More respondents disagree or don’t know if there are sex-based differences in the initial presentation of acute myocardial infarction than agree20.
3. Literature related to role of nurse in the management of unstable angina and non ST elevation myocardial infarction.
A study was conducted on nursing intervention on patients with acute myocardial infarction. The objective was to study the active nursing intervention for patients with acute myocardial infarction effect. Method used was 120 patients with acute myocardial infarction were randomly divided into two groups, experimental group of 60 patients and the control group of 60 patients. Patients in the test group received nursing intervention in their psychological, diet, rest, activity, dug treatments and disease related knowledge, while in the control group patients only received the conventional care. Results showed that test group of patients with symptoms of time, hospitalization time and costs were lower than the control group. The conclusion was active nursing intervention can improve the therapeutic effect in patients with acute myocardial infarction to reduce the length of stay save the hospital cost21.
A study was conducted in Greece regarding the role of nurses in the sexual counseling of patients after myocardial infarction. The aim was to investigate practices and nurse’s knowledge, comfort, ease, responsibility and practical application of sexual counseling among post infarction patients. The data were collected by interviews using a 35-item questionnaire. Data analysis was performed by using t-test, ANOVA and SPSS statistical package. Result was only 20.7% said that nurses do in fact undertake sexual counseling and although 39.1% said that they carry it out themselves. Study concluded that sexual counseling is essential to meet the sexual integrity and quality of life needs of the patient and partner after myocardial infarction. So the study insists that nurses must be trained in the necessary knowledge and skills22.