Proforma for Registration Of s1

PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
DISSERTATION PROPOSAL
A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME REGARDING KNOWLEDGE ON
NEONATAL JAUNDICE AMONG STAFF NURSES IN SELECTED
HOSPITAL, BANGALORE.
SUBMITTED BY,
JOPPY JOSEPH
1ST YEAR, M. SC. NURSING
(PAEDIATRIC NURSING)
JOSCO COLLEGE OF NURSING
NELAMANGALA
2008-2009
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 .NAME OF THE CANDIDATE
AND ADDRESS / JOPPY JOSEPH
JOSCO COLLEGE OF
NURSING
NELAMANGALA.
BANGALORE
2. NAME OF THE INSTITUTION
/ JOSCO COLLEGE OF
NURSING,
NELAMANGALA
BANGALORE
3. COURSE OF THE STUDY AND SUBJECT / 1ST YEAR M.Sc. NURSING
PEDIATRIC NURSING
4.DATE OF ADMISSION TO THE COLLEGE / 30/6/2008
5.TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE ON NEONATAL JAUNDICE AMONG STAFF NURSES IN SELECTED HOSPITAL, BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Jaundice is the most common condition that requires medical attention in newborns.
Unconjugated bilirubin is neurotoxic and can cause death in newborns and lifelong neurologic
sequelelae in infants who survive (kernicterus). The incidence of neonatal jaundice is
increased in infants of East Asian, American Indian and Greek descent. Neonatal jaundice first
visible in the face and forehead, gradually become visible on the trunk and extremities1
The study on “Trends in hospitalization for neonatal jaundice and kernicterus in united
states between 1988 -2005” shows 2.7 per 1,00,000 diagnosed with the kernicterus on
phototherapy or exchange transfusion and jaundice was recorded for 15.6% new borns 2
The study on “Neonatal surgical jaundice revisited” shows nearly 25 – 50 % of all new
borns and a much higher percentage of premature babies develop hyper bilirubinemia . It also
consider a possibility of extra hepatic biliary atresia early . During management of a case of
direct hyper bilirubinemia as surgical intervention results in a better out come3.
A study conducted on “Exchange transfusion for neonatal jaundice in Nigeria” to
determine the indication for exchange blood transfusion(EBT) in neonatal jaundice and what
proportion of EBT was possibly avoidable. Of the 1686 babies admitted to the neonatal unit,
90 (5.3%) had BBT. Fourteen (15.6%) were inborn while 76(84.4%) were out born babies.
Fifty six (62.2%) babies were primarily for neonatal jaundice while 34(37.8%) developed
neonatal jaundice (NNJ) during admission. Thirty six (40%) of the babies had phototherapy
for more than 24 hours prior to EBT either because they were of very low birth weight or NNJ
was detected very early therapy was commenced. Sixty-eight (75.6%) babies had single EBT
while the remaining 22 (24.4%) had two sessions of EBT. The study concluded that EBT rate
in the center was high. With more effective phototherapy, EBT could be avoided in most of the
babies, who initially had phtotherapy for more than 24 hours before EBT and repeated EBT
sessions4.
The study on “Molecular basis of glucose-6- phosphatase dehydrogenase deficiency
(G-6-PD) in India” shows the results of an epidemiological study on G-6-PDdeficiency
and the mutations among 14 heterogenous populations of India. Of the 3166 males tested, 332
(10.5%) were found to be G-6-PD deficient and the prevalence rate varied from 5.7% to 27.
9% in the different population groups. Molecular characterization revealed that G-6-PD
mediterranian (563c-t) was the commonest (60.4%) deficient followed by G-6-PD Kerala-
Kalyan (949G-A 24.5%) and G-6-PD Orrissa (131C-G 13.3%). The absence of large number
mutations causing G-6-PD deficiency points to the fact that the genetic diversity of these
population is considerably lowered than expected.5
The study on “Management of neonatal hyperbilirubinemia”shows among the total of 114
newborns,33.3% (38/114) underwent exchange transfusion by push-pull and 66.7% (76/114)
iso volumetric technique. When these two techniques are compared, 59.2% in iso volumetric
and 57.9% in push-pull group had more than 40% reduction in bilirubin level. In neonatal
hyperbilirubinemia exchange transfusion reduces the bilirubin level rapidly by about 40% .The
iso volumetric and push pull techniques are comparable in efficiency.6
The study on “Dehydration and hypernatremia in term healthy neonates”to determine the
incidence of significant weightloss, dehydration, hypernatremia and hyperbilirubinemia in
exclusively breastfeed term healthy neonates and compare the incidence of these problems in
the warm, cool months. During the study period 496 neonates were recruited. 157 neonates
(31.6%) had significant weight loss (>10%), cumulative weightloss or per day weight loss
( >5%). Clinical dehydration was present in 2.2% of neonates. Of these 157 neonates, 31.8%
had hyper natremia and 28% had hyper bilirubinemia. Conclusion of this study was the
incidence of the above mentioned problems were higher in the warm months but the
difference was not statistically significant.7
A study on “Practical approach to neonatal jaundice, kernicterus and neurological sequelae
are preventable condition” . Total serum bilirubin or transcutaneous bilirubin levels should be
routinely monitered and these measurements must be plotted in a nomogram according to the
infants age in hours. Another nomogram that consists of age in hours, risk factors and total
bilirubin levels can provide guidance on when to initiate phototherapy8.
The study on “Jaundice- the newborn babies” shows the yellow discoloration of the skin
and sclera that results from raised levels of bilirubin in the blood. Neonates it appears when
serum bilirubin concentration reach 85- 120 mol/l with cephalo caudal progression as levels
increase. Asian and Native American babies usually have higher bilirubin levels than
Caucasian infants whereas babies of African origins have lower levels. Preterm babies are
more likely to deveop jaundice. Pathological jaundice in newborn appears within 24 hours of
birth. Rh D incompatibility can occur when a women with Rh negative blood type is pregnant
with a fetus with Rh positive blood type. This is commonest among Caucasians about 15%,
8% in Africans and 1% in Asian population.9
There are so many complications related to the neonatal jaundice such as mortality,
hearing loss, incidence of kernicterus, adverse events caused by hospitalizations as parent
infant bonding, failure of treatment, length of hospital stay and need for transfusion.
Kernicterus refers to the yellow staining of the deep nuclei of the brain, which includes
symptoms such as athetoid cerebral palsy, hearing loss, failure of upward gaze and dental
enamel dysplasia. By educating the staff nurses about neonatal jaundice and its complications
they can do interventions in clinical area to prevent complications10.
For successful management, the staff nurses should have adequate knowledge on early
detection, level of serum bilirubin and interventions. The overall aims of the study is to
provide information about neonatal jaundice to prevent complications of neonatal jaundice by
staff nurses. Considering the above study findings the researcher understood that the staff
nurses need to be specially trained.
The investigator while working in neonatal intensive care unit (NICU) had cared for the
babies with jaundice. Most of the babies treated with phototherapy and some babies with
exchange transfusion to reduce the bilirubin level. From there the investigator found that
neonatal jaundice is very common and become very serious to cause death in neonates from
inadequate interventions. So the investigator felt the need for the study.
6.2 Review of Literature
Review of literature is a systematic identification, location scrutiny and summary of
written material that contain information on research problems.
The studies related to the topic are organized and presented under the following headings.
A. Study related to incidence and prevalence of neonatal jaundice.
B. Studies related to risk factors of neonatal jaundice.
C. Studies related to management of neonatal jaundice.
D. Studies related complications of neonatal jaundice.
E. Studies related to structured teaching programme.
A. Study related to incidence and prevalence of neonatal jaundice.
The study on “Redcell pyruvate deficiency in neonatal jaundice in India”(2006) to screen
newborns in India for pyruvate kinase (PK)deficiency in relation to unconjugated
hyperbilirubinemia(2006).. 7 of the 218 cases of neonates were PK deficient with 30-40%
reduction in PK activity. The study concluded that the prevalence of PK deficiency in Indian
neonatal jaundice case is 3.2%, which is relatively high. This emphasis the need for screening
neonatal hyperbilirubinemia cases in India for PK deficiency prevalence-estimated people
managing neonatal jaundice incidence-annual diagnosis.11
B. Studies related to risk factors of neonatal jaundice.
A study conducted on “maternal and neonatal factors affecting physiological jaundice”
(2007), fifty pregnant mothers and their fifty two newborn were studied. Newborn of bipara
mothers were found to have significantly lower serum bilirubin level on day 1 as compared to
primipara mothers but higher on day 3 as compared to either primi or multipara mothers.
Significantly higher serum bilirubin on day 1 was also observed in preterm neonates than full
term ones12.
A study on“Role of genetic factors in occurance of neonatal jaundice” (2005). Totally 109
umblical cord blood samples were collected for the screening of G-6-PD activity. According to
G-6-PD activity and G71R or A388 G genotype, the genotypes were allocated into different
groups. The study concluded that UGTIAI G71IR gene mutation combined with G-6-PD
deficiency or A388G gene mutation combined with G-6-PD deficiency play a co-ordinate role
in the development of neonatal hyperbilirubinemia13.
C. Studies related to phototherapy for neonatal jaundice.
The study on “An audit of phototherapy units” (2007)shows total of 58 photo therapy
units examined had wide variety in relation to their build. There were only 21 units (36.2%) in
which all the lights were in working order. Only five of the units (8.6%) had the recommended
blue lights. Only 18 of the units provided an acceptance level of irradiance phototherapy
demonstrates a close response relationship. By not providing optimum irradiance, efficiency
is compromised. This prolongs hospital stay and treatment costs. Acceptable standards should
be insisted upon in purchase and maintenance of equipments.14
A study conducted on “Phototherapy of the newborn: a predictive model for the outcome”
(2005), the work aims at finding a predictive model for the decrement of blood bilirubin
followed conventional phototherapy . It is possible to predict the total blood bilirubin of the
patient under phototherapy by knowing its birth weight, bilirubin level at the beginning of
treatment,duration of exposition, and irradiance. Besides, it is possible to infer the time
necessary for a given decrement of bilirubin, under approximately constant irradiance.15
A study conducted on “Treatment of physiological and pathological neonatal jaundice”
(2004) , if hyperbilirubinemia necessitates, treatment involves phototherapy and /or exchange
transfusion of donor blood. In cases of pathological jaundice the underlying cause must also be
treated. Parental involvement is important to minimize the trauma of having a sick baby and its
effect on bonding.16
D. Studies related complications of neonatal jaundice.
A study on “sensorineural hearing loss in infants with neonatal jaundice in Lagos:
a community based study” (2009). Fourteen (6%) of the 234 infants with neonatal
jaundice(NNJ ) had sensorineural hearing loss(SNHL). The study concluded that SNHL is
prevalent among infants with NNJ17.
The study on “Magnetic resonance imaging (MRI) in Kernicterus” (2008) shows
kernicterus is a disease entity with very high rate of mortality in neonates. The children who
survive are left with neurological deficits such as choreoathetosis, sensorineural deafness and
mental retardation. Magnetic imaging of the brain in this condition has specific findings
which aid in the accurate diagnosis of the condition, along with clinical and biochemical
criteria. Reports have shown involvement of the globus pallidus, putamen and less commonly
thalamus.18
A study on “Kernicterus: epidemiological strategies for its prevention through systems
based approaches” ( 2004). Early detection, prevention and treatment of severe
hyperbilirubinemia should make kernicterus a preventable disease. Increased knowledge about
the incidence and consequences of severe hyperbilirubinemia is essential to the planning,
implementation and assessment of interventions to ensure that infants discharged as healthy
from their birth hospitals have a safer transition to home, avoiding morbidity due to
hyperbilirubinemia and other disorders.19
E. Studies related to structured teaching programme
A study on “Visual assessment of jaundice in term and late preterm infants” (2009).
Nurses assessment of jaundice extent was only moderately correlated with bilirubin
concentration. The correlation was particularly weak among infants <38weeks’ gestational
age. Compared with infants 38 weeks gestation but complete absence of jaundice had high
sensitivity (95%) and excellent negative predictive value (99%). The study concluded that
clinicians should not use extent of cephalocaudal jaundice progression to estimate bilirubin
levels during the birth hospitalization, expecially in late pretem infants. The complete absence
of jaundice can be used to predict with the very high accuracy which infants not develop
significant hyperbilirubinemia.20
A study on “Better care and better teaching. New model of postpartum care for early
discharge programmes”. Newborn infants and their mothers are seen by a family physicians, a
family medicine resident and a nurse within 48 hrs of discharge. An assessment protocol
development by the interdisciplinary group promotes standardized mother and child care and a
structural learning experience for trainees. The study concluded that assessement occurs in a
teaching mileu, a comprehensive learning experience can be combined with defined objectives
that emphasize and encourage newborn and maternal assessement for ambulatory
patients.21
STATEMENT OF THE PROBLEM
A study to assess the effectiveness of structured teaching programme regarding
knowledge on neonatal jaundice among staff nurses in selected hospital Bangalore .
6.3 OBJECTIVES OF THE STUDY
1. Assess pre test knowledge scores of staff nurses regarding neonatal jaundice .
2. Determine the effectiveness of structured teaching programme by comparing pretest and
post test knowledge scores.
3. Explore the association with the post test level of knowledge score and selected
demographic variables such as age, sex, language, religion , parental occupation and income.
6.4 OPERATIONAL DEFINITIONS
*Effectiveness:-Refers to differences in post test knowledge scores with that of pre test
knowledge scores on neonatal jaundice among staff nurse.
*Structured teaching programme:-Refers to the systematically developed institutional
method and teaching aids designed to provide information on neonatal jaundice – its detection,