RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate / Ms. MARIA LALRINAWMII year M.Sc Nursing
Florence College of Nursing
Bangalore – 43.
2. / Name of the institution / Florence College of Nursing
3. / Course of study and subject / M.Sc Nursing
Child Health Nursing
4. / Date of Admission to the course / 29th November 2009
5. / Title of the topic / “Effectiveness of a self instructional
module regarding prevention of
phototherapy complications among
paediatric staff nurses in selected
hospitals, Bangalore.”
6. BRIEF RESUME OF INTENDED WORK:
INTRODUCTION:
“It is health that is real wealth and not pieces of gold and silver”
- Mahatma Gandhi.
Jaundice is a relatively common abnormality in a newborn baby during the first week of life. Clinical jaundice manifests as yellowness of the skin when the bilirubin level exceeds 5 mg/dl. When the trunk of the baby is distinctly yellow stained, bilirubin level is likely to range between 10 and 15 mg/dl. Yellow staining of the palms and soles indicates that bilirubin level has exceeded 15 mg/dl. Onset of jaundice within 24 hours of age, with yellow staining of the palms and soles are suggestive of pathological jaundice. Jaundice which appears between 24 and 72 hours of age, and bilirubin level which is less than 15 mg/dl is physiological jaundice.1
In neonate, this condition may be caused by physiologic immaturity of liver function or by blood group incompatibility leading to increased erythrocyte destruction. Higher levels of bilirubin are reached in premature infants, with peak levels of 8 to 12 mg/dl. The goal of treatment of physiologic jaundice is to prevent the level of bilirubin from rising. The main form of therapy for infants with physiologic jaundice is phototherapy.2
Phototherapy is a non-invasive method to bring down the bilirubin level by exposing the skin of the baby to blue or cool white light. Light converts the bilirubin to non-toxic water soluble compounds which is excreted in urine and stool. Baby is undressed completely but diaper is kept on to protect the gonads. Eyes are covered to prevent damage to the retina. Nude baby is kept under the light source at a distance of 45 cm. The baby is turned every 2 hours or after each feed for maximum exposure. Phototherapy is stopped when severe bilirubin returns to a safe value as per unit protocol.3
Side effects for which the nurse should be alert include loose, greenish stools, transient skin rashes, mild hyperthermia, increased metabolic rate, priapism, dehydration and electrolyte disturbances. To prevent or minimize these effects, the nurse monitors the temperature to detect early signs of hypothermia or hyperthermia, and observes the skin for evidence of dehydration and drying. Oily lubricants or lotions are not used on the skin to prevent increased tanning or a frying effect. Full term infants receiving phototherapy may require additional fluid volume or feedings to compensate for insensible and intestinal fluid loss. Loose stool may indicate accelerated bilirubin excretion.4
Neonatal Deaths is a serious concern, both in developing and developed countries, although its magnitude is notably higher in developing countries. Every year in India, over one million newborns die before they complete their first month of life, accounting for 30% of the world’s neonatal deaths. Approximately three quarters of Indian neonatal deaths occur within one week of birth while 90% occur within the first two weeks of life. Therefore, it is important to know about specific neonatal disease, neonatal sepsis, pneumonia or neonatal jaundice.5
6.1 NEED FOR STUDY:
Jaundice is the most common condition that requires medical attention in newborns. In India 25 million newborn infants are born every year. About 60% - 70% of healthy newborn babies are likely to develop physiological jaundice. The number of readmissions to hospitals for jaundice has increased in recent years. This has been attributed to shorter length of postpartum hospital stays without comprehensive follow-ups.6
Phototherapy is the primary treatment in neonates with unconjugated hyperbilirubinemia, and is the most widespread therapy of any kind used in newborns. Generally, phototherapy is safe and has no serious long term effects in neonates. However, proper nursing care should be given to enhance its effectiveness and to minimize the adverse effects and its complications.7
An exploratory research study was done in three phases on hyperbilirubinemia and the effect of phototherapy among full term newborns at Kasturba Hospital, Manipal. The study findings showed that incidence of hyperbilirubinemia in a period of six months was found to be 198 per 1000 population i.e 20% of total population were diagnosed as having neonatal hyperbilirubinemia with bilirubin level >/= 12 mg/dl. All these newborns were treated with phototherapy. The study findings concluded that hyperbilirubemia can be managed with phototherapy unless there is urgent need for any other treatment.8
A study was conducted to assess the prevalence of phototherapy induced hypocalcemia on 153 jaundiced neonates (62 premature, 91 fullterm) who received phototherapy in Iran. Serum calcium level was checked on arrival, 48 hours after starting phototherapy and 24 hours after discontinuation. The study findings showed that 22 neonates (14.4%) developed hypocalcemia; premature (22.6%) and fullterm neonates (8.7%) (p=0.018). The researchers concluded that neonates under phototherapy were at high risk of hypocalcemia and risk is greater in premature infants.9
A study was conducted to assess transepidermal water loss during Halogen Spotlight Phototherapy on 18 preterm infants in Leiden University Medical Center, Germany. The transepidermal water loss was measured before and after 1 hour of halogen spotlight phototherapy. The study findings revealed that the mean TEWL before and after 1 hour of phototherapy was 13.6 +/- 6.3 g/m2/h and 16.5 +/- 6.2 g/m2/h (p= 0.003) respectively.10
From the literature reviewed, it was found that phototherapy is the most common treatment used for neonates with unconjugated hyperbilirubinemia. The nurses working in this area must possess adequate knowledge regarding phototherapy as well as the assessment and care of neonates during this treatment in order to reduce the complications. So the investigator found it relevant to evaluate the effectiveness of a self instructional module for paediatric staff nurses on prevention of phototherapy complications.
6.2 REVIEW OF LITERATURE:
The review of literature is an organized critique of the important scholarly literature that supports a study and a key step in the research process. The overall purpose of review of literature in the research study is to present a strong knowledge base for the conduct of the research project. The main goal of a literature review is to develop the foundation of a sound study, but it also is used for other scholarly, or educational and clinical practice activities.11
A study was conducted on transepidermal water loss and skin hydration on 31 preterm infants (gestational age 25 to 36 weeks) during phototherapy in Israel. Transepidermal water and skin hydration was measured in 7 body areas before and during phototherapy. The study findings revealed that there was a mean increase of 26.4% in transepidermal water loss during phototherapy.12
A study was conducted to evaluate transepidermal water loss during conventional phototherapy in non-hemolytic hyperbilirubinemia term infants in Thailand. Samples were 40 healthy infants and 40 non-hemolytic jaundiced infants, divided into case group and controlled group. Case group received phototherapy in an open crib. The study findings showed that evaporation rate before phototherapy, at 30 minutes and 6 hours in case group and controlled group were 7.2, 7.8, 8.4 g/m2h (p<0.01) and 7.3, 7.6, 7.5 g/m2h (p=0.30) respectively. The researchers concluded that TEWL is increased in infants receiving phototherapy in an open crib.13
A study was conducted to assess the effectiveness of clear topical ointment in reduction of transepidermal water loss in jaundiced preterm infants receiving phototherapy. Samples were 40 jaundiced preterm infants, divided into treatment group and control group. Treatment group received 3.0 ml of clear topical ointment just before phototherapy. The study findings showed that during phototherapy, the ER in control group was increased by 8.0% (p = 0.01) at 30 minutes and 14.5% (p < 0/001) after 5 hours. In treatment group, clear topical ointment decreased ER by 19.2% (p < 0.001) at 30 minutes and 13.2% (p = 0.003) after 5 hours. The researcher concluded that during conventional phototherapy, the application of clear topical ointment reduce TEWL significantly, without effect on serum micro bilirubin.14
A study was conducted to assess the efficacy of phototherapy for non hemolytic hyperbilirubinemia and rebound bilirubin levels in breast fed and mixed fed newborns in Turkey. Sample consisted of 53 full term healthy newborns, divided into 2 groups. Group I (breast fed newborns, n = 28) and group II (mixed fed newborns, n = 25). The study findings showed that amount of weight loss at the start of phototherapy in group I and group II were (8.1 +/- 3.9% and 5.4 +/- 2.6%; p = 0.004). The duration of phototherapy in group I and group II were (38.6 +/- 12.6 hrs and 26.8 +/- 9.4 hrs; p < 0.001). The overall rate of decrease in bilirubin concentration in group I was significantly lower than in group II (0.06 +/- 0.05 mg/dl/d vrs 0.22 +/- 0.09 mg/dl/d; p = 0.01).15
A study was conducted on 66 community health workers to assess the knowledge, attitude and practice on neonatal jaundice and its management in Nigeria. The study findings revealed that only 51.5% of the respondents gave a correct definition, 75.8% know how to examine for this condition, 54.5% had adequate knowledge of effective treatment namely phototherapy and exchange blood transfusion. The study findings concluded that primary health care workers may have inadequate knowledge on neonatal jaundice, exchange blood transfusion and phototherapy, and the complications which can occur due to this treatment.16
A large population based study was conducted to assess the association between neonatal phototherapy and risk of childhood asthma in Sweeden. Perinatal data for singleton children who were prescribed anti-asthmatic medication (n=61256) were compared with corresponding data for all singleton children born in Sweeden from 1st January 1999 to 30th June 2003 (n=1,338,319). The study findings showed that neonatal phototherapy and/or icterus were risk determinant for children who developed asthma before the age of 12 years. The odds ratio for phototherapy and/or icterus was 1.30 (95% CI 1.16-1.47). The study confirms an association between neonatal phototherapy and childhood asthma.17
A study was conducted to assess the gut hormone levels in neonates under phototherapy on 45 healthy term neonates in Greece. Samples were divided into three groups- A, B, and C. Group C were treated with phototherapy for at least 24 hours. The study findings showed that infants in group C had significantly lower gastrin levels and the vasoactive intestinal peptide (VIP) levels were significantly higher. Increased frequency of stool was also noted in group C.18
A study was conducted on 120 icteric full term neonates to determine the effect of hat on phototherapy-induced hypocalcemia in Iran. All the samples were treated with phototherapy and were divided into control group (Group A, n=60) and case group (Group B, n=60). Case group wears hat that covers the occipital area. Serum bilirubin and calcium was checked on arrival and 48 hours after starting phototherapy. It was found that 18 neonates (15%) developed hypocalcemia and the prevalence in group A and B were 77.77% and 22.22% respectively. The researchers concluded that covering neonates head and occipital area during phototherapy decreases phototherapy induced hypocalcemia.19
A study was conducted to assess the effect of phototherapy on urinary calcium excreation in 50 breast fed icteric neonates in Iran. Samples were devided into group A(n=27) and group B(n=23). Group A received continous phototherapy. Urine samples were collected at the beginning and 24 hours after the start of phototherapy. The study findings showed that 6 out of 27 samples in group A has urine calcium(Uca)/ urine creatinine(Ucr) ratio higher than 0.85. The reasercher concluded that phototherapy might increase Uca excreation in infants.20
A study was conducted to assess the effect of phototherapy on neutrophils in Texas. Based on the level of evidence-based research, original publications were selected from Pubmed, Medline, Ovid, and the Cochrane Library. The literature search revealed a total of 22 controlled laboratory studies that evaluated the role of phototherapy on neutrophils. Evidence indicates that phototherapy has a significant impact on neutrophils which varies according to the specific type of phototherapy.21
6.3 STATEMENT OF THE PROBLEM:
“A study to evaluate the effectiveness of a self instructional module regarding knowledge on prevention of phototherapy complications among paediatric staff nurses at selected hospitals in Bangalore.”
6.4 OBJECTIVES OF THE STUDY:
The objectives of the study are to:
1. Assess the knowledge of paediatric staff nurses regarding prevention of phototherapy complications.
2. Prepare a self instructional module on prevention of phototherapy complications.
3. Evaluate the effectiveness of the self instructional module on prevention of phototherapy complications.
4. Determine the association between the knowledge of staff nurses with selected socio-demographic variables.
6.5 HYPOTHESIS:
H1: The mean post test knowledge scores of the staff nurses regarding prevention of phototherapy complications will be significantly higher than their mean pre-test knowledge scores.
H2: There will be a significant association between the mean pre-test knowledge scores regarding prevention of phototherapy complications with the selected demographic variables.
6.6 OPERATIONAL DEFINITION OF TERMS:
In this study it refers to:-
Evaluate:
the findings of the value of a self instructional module on knowledge of paediatric staff nurses regarding prevention of phototherapy complications.
Effectiveness:
the desirable changes brought about by the self instructional module as measured in terms of significant knowledge gain in the post test and graded as adequate knowledge, moderately adequate and inadequate knowledge.
Self Instructional Module:
a booklet in English prepared by the investigator, which contain information about various aspects of prevention of phototherapy complications.
Phototherapy complications: