M.Sc Nursing Dissertation Protocol Submitted To s1

A STUDY TO ASSSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING USE OF PATIENT CONTROLLED EPIDURAL ANALGESIA IN LABOUR WARD AMONG STAFFNURSES WORKING IN A SELECTED HOSPITAL,BANGALORE

M.Sc Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

By

MS. REMYA K SKARIAH

M.Sc NURSING 1ST YEAR: 2012-14

Under the Guidance of

HOD, Department of OBG Nursing

Nightingale College of Nursing

Guruvanna Devara Mutt,

Magadi Road, Bangalore –23

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

SYNOPSYS PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRES / Ms. REMYA K SKARIAH
1ST YEAR MSc. (NURSING)
NIGHTINGALE COLLEGE OF NURSING,
GURUVANNA DEVARA MUTT
NEAR BINNYSTON GARDEN
BANGALORE – 23
2. / NAME OF THE INSTITUTION / NIGHTINGALE COLLEGE OF NURSING, BANGALORE-560023
3. / COURSE OF THE STUDY AND SUBJECT / 1ST YEAR M.Sc (NURSING),
OBSTETRIC AND GYNAECOLOGICAL NURSING
4. / DATE OF ADMISSION TO THE COURSE / 01/05/2012
5. / TITLE OF THE STUDY / “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE USE OF PATIENT CONTROLLED EPIDURAL ANALGESIA IN LABOUR WARDS AMONG STAFF NURSES WORKING IN A PARTICULAR HOSPITAL IN BANGALORE.”
INTRODUCTION
“The delivery of the infant into the arms of a conscious and pain-free mother is one of the most exciting and rewarding moments in medicine”- Moir1
Pain relief in labour has always been surrounded with myths and controversies. Hence, providing effective and safe analgesia during labour has remained an ongoing challenge. Historically, the era of obstetric anaesthesia began with James Young Simpson, when he administered ether to a woman with a deformed pelvis during childbirth. His concept of “etherization of labour” was strongly condemned by critics. But as he proposed,the patients themselves has forced its use upon the profession in the present generation.By 1950, neuraxial techniques were introduced for pain relief in labour and, during the last two decades, there have been several advances that lead to comprehensive and evidence-based management of labour pain2.
Modern neuraxial labour analgesia reflects a shift in obstetrical anesthesia, thinking away from a simple focus on pain relief towards a focus on the overall quality of analgesia. Analgesia is the absence of sensibility to pain, particularly the relief of pain without loss of consciousness; absence of pain or noxious stimulation. The termepiduralis a Greek word, means "on, upon" +dura mater) is a simplified and all-inclusive term often used to refer to techniques such as epiduralanalgesiaandepiduralanaesthesia. Epidural techniques frequently involveinjectionof drugs through acatheterplaced into theepidural space. The injection can result in a loss ofsensation—including the sensation ofpain—by blocking the transmission of signals throughnervesin or near thespinal cord. Continuous epidural analgesiais the continuous injection of an anesthetic solution into the sacral and lumbar plexuses within the epidural space to relieve the pain of childbirth, in general surgery to block the pain pathways below the navel, or to relieve chronic unremitting pain.3
Patient controlled analgesia(PCA) is an apparatus used to relieve acute pain. It consists of a pump attached to an intravenous or subcutaneous injection site and filled with multiple doses of medication that are available when the system is activated by the patient. The pump is programmed to “lock-out” the patient for specified intervals making over dosage unlikely. Patient controlled epidural analgesia is a patient controlled analgesiain which a narcotic or local anesthetic is administered into the epidural space via a catheter4.
PCEA is a novel method of the drug delivery system, providing several advantages, including the ability to reduce the drug dosage. Self-control and self-esteem may be vital for a positive experience in childbirth, and PCEA achieves both. Thus, it is a useful alternative for the maintenance regime.The method of PCEA was welcomed by obstetric and anesthesia personnel because of fewer patient complaints.As per the studies conducted so far using PCEA, patients titrated their own requirements. Than the continuous infusion instilling overdose, PCA is simple and uncomplicated to use and boluses can easily be increased as contractions become more painful.5
Pain relief can be viewed in three main groups, some of which overlap with each other. These groupings are physical, psychological and pharmacological .Physical: This would include the hot compresses mentioned above, transcutaneous electrical nerve stimulation (TENS) and massage. A warm bath would be included in this group as would acupuncture. There is limited evidence to support the efficacy of these treatments but many women find them useful These modalities activate the sensory modulation of pain for an explanation of the gate-control theory of pain - and are thought to 'close the gate' to pain impulses.6
Psychological: Soranus's three women provided psychological support for the woman in labor by trying to alleviate her fears. As well as having a partner for support, women in labor may make use of a number of approaches such as relaxation, guided imagery and hypnotherapy. There is less evidence available for the efficacy of these treatments but Melzack and Wall (1996) suggest that they work by activating the descending mechanisms to 'close the gate'. They also say that 'different psychological procedures may each have different predominant effects, so that several procedures together work better6'.
Pharmacological: Entonox (an inhaled agent) is frequently used in the control of pain in labor. Time has moved on since drops of opium were given but opiates are still often a mainstay of pain relief in labor. However opioids are not without side-effects, both for the mother and child . There is some research comparing opioids, but no particular opioid appears better than another. Opioid are often given intramuscularly (IM) or in combination with local anesthetics in a spinal or epidural injection. They can also be used intravenously via PCA equipment.6
Patient-controlled analgesia (PCA) is commonly assumed to imply on-demand, intermittent, IV administration of opioid under patient control (with or without a continuous background infusion). This technique is based on the use of a sophisticated microprocessor-controlled infusion pump that delivers a preprogrammed dose of opioid when the patient pushes a demand button. The broader concept of PCA is not restricted to a single class of analgesics or a single route or mode of administration. Nor should PCA imply the mandatory presence of a sophisticated and expensive infusion device. Any analgesic given by any route of delivery (i.e., oral, subcutaneous, epidural, peripheral nerve catheter, or transdermal) can be considered PCA if administered on immediate patient demand in sufficient quantities.7
Now days, Patient controlled analgesia is extensively used in developed countries owing to the high demand from the patients. But in our country this concept has not spread widely even among health professionals.However, due to the expectations of customers to the international level as well as it’s being an comforting alternative for the inevitable pain of labor.All these demand a speedy implementation of these concepts into the backbone of the health care delivery system,the midwives.
6.1 NEED FOR THE STUDY
The pain of labor has evoked many responses over the centuries. With the rise of Christianity in the Western world the Bible taught women that child-bearing meant pain: 'I shall give you intense pain in childbearing, you will give birth to your children in pain' (Genesis 3:16). Before Christianity it seems that the pains of labor were seen as the action of evil spirits. This acceptance that pain was inevitable and a normal part of labor was questioned by Dick-Read in 1933. His text was seminal in re-thinking the role of midwives in labor and in the 'natural childbirth'.9
Bonica (1990) suggests that the reasons for change in the concept of painful labor occurs West in the past 50 years include: A growing number of anesthetists with an interest in obstetrics, an increasing number of hospital birth, a growing interest by women in receiving effective pain relief, a recognition by obstetricians of the benefits to mother and child a decline in the influence of religion in such matters.9
McCaffery's statement that 'the 'gold standard' for assessing the existence and intensity of pain is the patient's self-report' holds true for labor pain as much as that of any other type. It is affected by previous experience and expectations, as well as the size of the baby and primiparity . Research by Melzack (1984) confirmed that first-time mothers reported higher pain scores than multiparae 10
Comparison using the McGill Pain Questionnaire showed that pain scores for labor pain in both primiparae and multiparae were greater than the scores given by patients with chronic back pain, post-herpatic neuralgia and phantom limb pain .10 This objective data confirms the subjective opinion that many women hold - that labor pain is one of the most painful experiences a woman may have. It is little surprise that over the centuries (and sometimes against the will of doctors and priests) people have searched for ways of alleviating labor pain. The objective of good pain relief in labor must be to provide the best relief possible to the mother with the least risk to mother and child.10
According to Health Day News If women are given control of the amount of epidural anesthesia they get during labor and delivery, they use about 30 percent less medication than when given a standard dose from a doctor, a new study shows."We looked at patient-controlled epidural anesthesia, and found the women were basically as comfortable as women on a continuous dose, and there was a 30 percent reduction in the amount of anesthesia used," said study author Dr. Michael Haydon, a perinatologist at Long Beach Memorial Medical Center in California.11
Generally, epidural anesthesia is given on a continuous basis, according to Haydon. But patient-controlled devices that can control delivery of the anesthesia are widely available. Patients are given a button to push when they feel they need more medication. The devices are programmed to only provide a specific amount of medication for specific time periods to ensure that people don't give themselves too much.11
Accoding to Dr. Peter Bernstein, a professor of clinical obstetrics and gynecology and women's health at Montefiore Medical Center and Albert Einstein College of Medicine in New York City, epidurals tend to slow labor down. So, if you can get away with less medication with patient-controlled analgesia it's a wonderful thing, .9
The International Association for the Study of Pain (IASP) declared 2007–2008 as the ’’Global Year against Pain in Women - Real Women, Real Pain." The focus was to study both acute pain and chronic pain in women. Labor pain was found to be a good study model for treating acute pain. Increasing knowledge of the physiology and pharmacotherapy of pain and the development of obstetric anesthesia as a subspecialty has improved the training in obstetric anesthesia, leading to an overall improvement in the quality of labor pain relief.11
In many countries today, the availability of regional analgesia for labor is considered a reflection of standard obstetric care. According to the 2001 survey, the epidural acceptance is up to 60% in the major maternity centres of the US. The National Health Services Maternity Statistics of 2005–2006 in the UK reported that one-third of the parturients chose epidural analgesia. In our country, the awareness is still lacking and, except few centres that run a comprehensive labor analgesia programme, the national awareness or acceptance of pain-relieving options for women in labor virtually does not exist.11
The increased availability of epidural analgesia and the favorable experiences of women who have had painless labor with epidural block have reshaped the expectations of pregnant women entering labor. As more parturients demand pain-free labor, it is important that physicians managing labor have a clear understanding of the benefits ofcontraindications to and risks of epidural analgesia
PCEA is an attractive concept concept with special benefits in the obstetric population.It provides a safe and valuable alternative to other approaches to labour analgesia,with demonstrable advantages when used appropriately by motivated women.It also appears to be useful for management of pain after caesarian section.It may occasionally be of benefit in other acute and chronic pain settings in the obstetric population.Despite promising initial results,the full potential of PCEA remains to be explored,and this may be encouraged by onging developments in PCA pump technology.Comprehensive comparative studies and large prospective clinical series,further defining its role and safety in various settings are awaited.7
The level of knowledge that nursing and medical staff have about PCA may also play a role in its safety and efficacy. The study by Coleman and Booker‐Milburnshowed that the introduction of an acute pain service (APS) nurse, whose role included staff and patient education, led to improvements in analgesia and patient satisfaction with PCA. The midwife is recognized as a responsible and accountable professional who works in partnership with pregnant woman to give the necessary support, care and advice during pregnancy, labor and the postpartum period. This care includes prevention of complications, promotion of normal birth, the detection of complications in mother and baby. 12
A study comparing PCA managed by an APS compared with surgeons in the same hospital but 1 yr later, revealed that patients whose PCA was supervized by the APS used significantly more opioid, were more likely to have adjustments made to the PCA dose in response to complaints about inadequate analgesia or side effects, were more likely to be ordered oral opioid analgesia after PCA rather than i.m. opioids, and had significantly fewer side effects.It would seem that the APS used PCA technology in a different manner to non‐APS physicians and was more likely to tailor the PCA ‘prescription’ to suit individual patients.12
Inadequate knowledge about the risks of PCA and prescribing by more than one team (e.g. surgical team as well as the APS), have led to inappropriate prescriptions of supplementary opioid (by other routes) and sedative drugs.This may lead to over sedation and respiratory depression.12
Operator error is a reasonably common type of safety problem related to PCA use .Operator errors have led to over sedation resulting from the programming of incorrect bolus dose size,incorrect drug concentrations (with fatal results), incorrect background infusions,and background infusions when none were ordered.It has been suggested that drug concentrations should be standardized within institutions to reduce the chance of program errors. 12