“A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON PRACTICE REGARDING MANAGEMENT OF PATIENTS WITH HYPOVOLEMIC SHOCK AMONG STAFF NURSES WORKING IN SELECTED HOSPITALS, BAGALKOT”.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
MS.SOLLY ELIZABETH JOSEPH
SHRI. B.V.V.SANGHA’S
SAJJALASHREE INSTITUTE OF NURSING SCIENCES,
NAVANAGAR, BAGALKOT, KARNATAKA.
2012

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) / MS.SOLLY ELIZABETH JOSEPH,
I YEAR M. Sc. NURSING,
B.V.V.S.SAJJALASHREE INSTITUTE OF NURSING SCIENCES, NAVANAGAR,BAGALKOT-587102
2.  / Name of the Institution / SAJJALASHREE INSTITUTE OF NURSING SCIENCES, BAGALKOT.
3.  / Course of Study and Subject / M. Sc. NURSING,
MEDICAL SURGICAL NURSING.
4.  / Date of Admission to the course / 04/08/2012
5.  / Title of the Topic
“A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON PRACTICE REGARDING MANAGEMENT OF PATIENT WITH HYPOVOLEMIC SHOCK AMONG STAFF NURSES WORKING IN SELECTED HOSITALS,BAGALKOT”.
6.BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
‘’Water is the life’s mater and matrix, mother and medium. There is no life without water.’’
Can we imagine a life without water? Of course not, because water is essential to sustain life. Likewise, body fluids are vital to maintain normal body functioning. The body reacts to internal and environmental changes by adjusting vital functions to keep fluids and electrolytes in balance, maintaining homeostasis .When there is a marked fluid loss from our body, the body maintains homeostasis and the patient may be asymptomatic. But a reduction of intravascular fluid volume of 15% to 25% lead to imbalance in the homeostasis, resulting in metabolic changes continuing into shock.1
Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the build up of waste products. Shock can result in serious damage or even death. As poetically stated by John Collins Warren, shock is a 'momentary pause in the act of death'. Hypovolemia has historically been termeddesanguination(from Latinsanguis, blood), meaning a massive loss of blood. The word was possibly used to describe the lack of personality (by death or by weakness) that often occurred once a person sufferedhaemorrhageor massive blood loss.2
Hypovolemic shock refers to a medical or surgical condition in which rapid fluid loss results in multiple organ failure due to inadequate perfusion. The intravascular fluid loss can be caused by traumatic injury, burns, surgery, sustained vomiting, diarrhoea or severe dehydration and use of vasodilators. Internal fluid collection such as ascitis, peritonitis may also cause hypovolemic shock.3
With a fluid loss of less than 750ml, the body may enter into a compensated state and changes to vital signs may be subtle and difficult to detect. As the fluid loss increases to more than 750ml, cardiac output begins to fall and changes in vital signs occur. The patient may develop symptoms like weakness, dizziness, light headedness, taste of sweetness and even loss of consciousness. The blood pressure of the patient will decrease, develops and the skin is usually pale and cool and may display a bluish discolouration. After approximately a 40% fluid loss, the situation can become life threatening. Multi organ damage and cellular necrosis can occur with impending death likely.4
Hypovolemic shock recognised early and treated promptly is associated with a good outcome. However, advanced stages of hypovolemic shock with a fluid loss of more than 25% of total body fluid are considered irreversible shock and are usually associated with a poor outcome.5
Primary prevention of shock is an essential focus of nursing intervention. Hypovolemic shock can be prevented in some instances by close monitoring patients who are at risk for fluid deficits and assisting in fluid replacement before intravascular volume is depleted. In other circumstances, hypovolemic shock cannot be prevented, and nursing care focuses on assisting with treatment targeted, treating its cause and restoring intravascular volume.6
Thomas Ahrens and colleague suggest intravenous fluid replacement with normal saline to help restore fluid balance and reduce the risk of hypovolemia, if appropriate.7 The management of shock depends on identifying its cause while supporting the stricken patient. Depends upon the cause the management differs. External bleeding should be controlled by direct pressure. If direct pressure fails, other techniques such as elevation of pressure points should be considered. If a first-aid provider recognizes internal bleeding, the life-saving measure to take is to immediately call for emergency assistance. Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life-saving. The use of IV drip may help compensate for lost fluid volume, and blood substitutes like colloid or crystalloid IV fluids will also used. These all information figures out that clinical persons especially nurses, should have sufficient knowledge about different causes and treatment and should act immediately for to save the life of a person.8
6.1 NEED FOR THE STUDY
“Good practice is dependent upon sound theoretical knowledge and in no profession is this more self-evident than in that of nursing, that most practical of all callings.”
Hypovolemic shock is a life threatening medical emergency and one of the leading causes of death for critically ill patients. Definitive care of hypovolemic patient require hospital and sometimes surgical intervention needed for the patient. Hypovolemic shock is the common form of shock, starts insidiously but progresses with startling rapidity to a life threatening situation. Knowing the early signs and symptoms and how to deal with the situation can help to prevent a devastating chain of events.9
In the year 2005, Department of Health, England published a hospitalization statistics of shock that occurred between the year 2002-2003.During this period, 92% of people with shock required hospital admission. In that 51% of hospital consultant episode occurred in >75years old and 11% occurred in 15-59 years old people. 6 to 7days was the average length of stay in hospitals for shock and 0% of hospital consultant episodes for shock were single episodes.10
In the United States, the hospital emergency department reports more than 1million cases of shock each year.11 Mortality rate is variable according to the cause. All over the world more than10 million children are dying each year. India accounts for 25% of global child death, in that 18% of children are dying due to dehydration and hypovolemic shock. In Karnataka, under five mortality rate is 72 per1000 live births and diarrhea accounts for 23% of under five deaths.12
A prospective study was conducted to determine the frequency, etiology, type and outcome ofshockin hospitalized children in the age group of 1 month to 15 years in Punjab in the year 2006.There were 98 cases ofshock, constituting 4.3% out of total admissions. Mean age was 2.8 +/-3.4 years. Maximum number of patients (39) was seen in infancy. Hypovolemic shock due to acute diarrheal disease is the commonest type [45.9%].Compensated stage was common in hypovolemic shock [88.9%] and the survival rate was best in hypovolemic shock [97.7%]. Inotropes and ventilatory support were required in 46% and 23% patients, respectively. Diagnosis and management ofshockin compensated stage carried better prognosis than in uncompensatedshockirrespective of the age of the patient. So close monitoring of patients general condition and vital signs are necessary for a good outcome.13
India has a maternal mortality rate of 200/1, 00,000 live births estimated for the year 2010 due to bleeding and shock.14 In initial stage, because of compensatory mechanism patients may be asymptomatic. Shock is a potentially life-threatening situation and the nurse aider must therefore be able to recognize itsdevelopmentand take immediate act.4
According to WHO, in India over 10 lakh people are moderately or severely burnt by every year and nearly 1.05 lakh people die in road accidents 15.Post operative hypovolemia and dengue hemorrhagic fever also have high mortality rate in India. A significant number of these deaths are the result of hypovolemic shock. Rapid identification and ensuring correct, aggressive treatment are necessary for patient survival. The critical care nurse plays an important role as part of the team involved in the resuscitation and ongoing care of these patients. Understanding the underlying pathophysiology, recognizing signs and symptoms and being prepared to effectively respond will further enable the nurse to contribute to positive patient outcomes.4
A retrospective study was conducted to find out pattern of chest injuries in road traffic accident victims in Belgam, Karnataka. In this study a total of 227 samples, fatal cases of thoracic trauma autopsied during the period 01/01/2004 to 31/12/2009 were analyzed at the department of forensic medicine and toxicology. The result of the study was, 67.8% of victims were 40years old or younger and women were less involved than men.63 people [27.8%] were died due to shock and hemorrhage, the lungs were injured in 40.1%, the major blood vessels in 25.5% and the heart was injured in 20.3%cases. Haemothorax was seen in 38.3% cases and pneumothorax was seen in 20.7%cases.They concluded the study as in a trauma patient shock is considered to be hypovolemic and should be manage before decompensation.16
Hypovolemic shock can occur any of the hospital settings such as emergency department, intensive critical care unit, neonatal intensive critical care unit or any of the wards. Nurses have the responsibility to monitor closely the patients who are at risk, proper positioning, safe administration of fluids and medicines and safe administration of fluids and medicines.6
Brendan Docherty,[ Critical Care Manager, Queen Elizabeth Hospital , London, 2002], says that nurses have to be aware of the implications of fluid management and should be empowered to advocate for the patient and for best practice within the health-care team . With reduced junior doctor hours and the advent of nurse prescribing, nurses are not only responsible for monitoring and detecting fluid problems, but are now starting to prescribe fluid regimens in some clinical areas. The management of fluid balance requires the nurse to have a complex mixture of skills, including an understanding of the principles of fluid balance in the body and of the different intravenous fluids. The nurse must also have an understanding of the body's responses to fluid depletion and be able to recognise those signs and respond appropriately.17
These all data clearly proves that the prognosis from the hypovolemic shock completely depend on the nurse to detect the hypovolemia as early as possible. The nurse should have a confidence to manage the emergencies. For this, a thorough knowledge about disease process, pharmacology is necessary. The work experience also helps to act quickly. The nurse should monitor the heart rate, respiratory rate, blood pressure, peripheral vascular changes, and urine output of the patient. A minute changes in these all signs may be an indicator of life threatening complications. Nurses are the only health professional who can detect a minute changes in patients health. So her improper care or delay in treatment may lose the life of a person.17
The researcher herself had an experience when working as a staff nurse in a major hospital in north India. A patient was brought to the emergency department, with crushed injury in the left lower limb. At that time the patient was severely bleeding and GCS score was low. The staff nurses were only aware of how to control the bleeding. The patient’s condition was getting worse. At that time casualty doctor was busy in managing other critically ill patients. After the doctor came, then only the treatment got started. This incidence motivated the researcher to select the topic as the research problem, to improve the nurse’s practice regarding management of patients with hypovolemic shock.
6.2 REVIEW OF LITERATURE
Good research generally builds upon existing knowledge. The more developed the network linking a new study with other research is, the more of the contribution it is likely to make. The accumulation of scientific knowledge is very much analogous to the fitting together of a jig saw puzzle. Every piece of the puzzle, small though it may be, may help to link together other parts of the puzzle. Review of literature is important step in research process. It refers to an extensive, exhaustive and systematic examination of publication relevant to the research project.
A prospective study was conducted to find out the occurrence, etiology of shock in paediatric age group and to find out association of various clinical and laboratory parameters of shock with outcome in Indira Gandhi institute of child health , Bangalore in the year 2007. Children who admitted in the paediatric intensive care unit between >1month to 16 yrs were selected by simple random technique. The result of the study was total 100 cases of shock were identified out of 784 PICU admissions, which accounts for 12.7% of admissions. Most common age group was between >1month –5 years. Male children are more common than females. Most common etiology was septic shock (48%) followed by hypovolemic and cardiogenic shock .Least mortality was seen in hypovolemic and anaphylactic shock. Persistence of tachycardia, low blood pressure, decreased urine output, low GCS score, low platelet count, low oxygen saturation, hypoxemia, hypercarbia, high creatinine levels were noted in nonsurvivors, Most common etiology was septic shock followed by hypovolemic shock and cardiogenic shock. They concluded the study as persistence of tachycardia, low blood pressure, decreased urine output, low oxygen saturation may be an indicator of shock and it will lead to organ damage and eventually death. So early detection and management is necessary for a good outcome.18
A retrospective study was conducted with the objective of protective measures against hypovolemic shock after severe loss of blood which can occur after total knee arthroplasty and to ensure safety of the patient post total knee arthroplasty surgery in Thailand. A total number of 139 subjects who received total knee arthroplasty surgery are selected for this study. The result of the study wasout of the 139 subjects, 20 subjects experienced hypovolemic shock after total knee arthroplasty surgery and 119 subjects did not.The study concluded that total knee arthroplasty surgery can cause severe blood loss that can lead to hypovolemic shock, which can cause life threatening complications for the patient. Therefore, it is critical to maintain proper care and close observation for post-surgical patients who received the procedure 4 hours prior.19