RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BENGALURU, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

Mr. SHIVALINGESH HOKRANI

IST YEAR M.Sc. (N) NURSING

MEDICAL SURGICAL NURSING

2011-2013

SRI SHANTINI COLLEGE OF NURSING

#188/13, PARVATHI NAGAR, OPP: SUB REGISTRAR

OFFICE, LAGGERE MAIN ROAD, LAGGERE

BENGALURU-560058

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

1. / NAME OF THE CANDIDATE AND ADDRESS / MR.SHIVALINGESH HOKARANI
1st YEAR M.SC NURSING,
SRI SHANTHINI COLLEGE OF NURSING
#188/B,PARVATHI NAGAR, OPP:SUB REGISTRAR OFFICE,
LAGGEREMAINROAD,
LAGGERE,BANGALORE -560058
2. / NAME OF INSTITUTION / SRI SHANTHINI COLLEGE OF NURSING ,
#188/B,PARVATHI NAGAR,
OPP:SUB REGISTRAR OFFICE,LAGGERE MAIN ROAD, LAGGERE,
BANGALORE -560058.
3. / COURSE OF STUDY AND SUBJECT / I YEAR M.Sc. NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 30/06/2011
5. / TITLE OF THE STUDY / THE EFFECTIVENESSN OF STRUCTURED TEACHING PROGRAMME ON SEVERITY OF ORAL MUCOSITIS AND FATIGUE ON PATIENTS UNDERGOING RADIATION THERAPY SELECTED CANCER HOSPITAL

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

“Preparation through education is less costly than learning through the tragedy”

Chronic diseases (CDs) are the greatest public health problem, either in terms of direct cost to society and government, or in terms of disability lasting for years. They include cardiovascular diseases, diabetes, cancer, osteoporosis, obesity, etc. The burden of CDs is rapidly increasing worldwide. It has been calculated that in 2001 CDs contributed approximately 60% to the 56.5 million total reported deaths in the world and approximately 46% to the global burden of disease. The proportion of the burden of CDs is expected to increase to 57% by 2020 (Bezek et al., 2008).

Not so long ago, cancer was synonymous with death. But today, overall cancer death rates decreased in men by 19.2% and in women by 11.4% between 1990 and 2005. The reduction in the overall cancer death rates has resulted in the avoidance of about 650,000 deaths from cancer over the 15-year period (Jemal et al., 2009). As Hay lock (2006) caught the words of the director of the National Cancer Institute Klaussner (1998), “We are at an amazing time in science. The changes in science are as profound as any paradigm change in human history.” He was referring to the effects of several advances—the human genome project, the early phases of our understanding of molecular mechanisms of cancer, the evolution of therapies that target specific mechanisms, the application of computer-generated models, and the information technology—on the future of cancer care.

Radiation therapy (RT) has been in use as a cancer treatment for more than 100 years with its earliest roots is traced from the discovery of X-rays in 1895 which is used for diagnostic purposes. And with the discovery of radium in 1898, radiation was used in the treatment of cancer. This began a new era in medical treatment and research. Historically, workers exposed to radiation were noted to have a higher incidence of carcinomas of the fingers related to the handling of the radioactive substances and primitive X-ray equipment. This observation led the scientists in the early 20th century to explore the use of radiation to treat tumors. They hypothesized that, if radiation resulted in the destruction of the highly mitotic skin cells of the workers, it could be used in a controlled way to prevent the continued growth of highly mitotic cancer cells (Lichter, 1995).

Sindrasky (2005) stated that cancer is a complex genetic disease derived from the accumulation of various genetic changes. These genetic alterations include activation of proto-oncogenes and inactivation of tumors suppressor genes. Cancers can be named according to the region or area affected. Head and neck cancers are one among them which comprises a wide range of tumours that occurs in several anatomical areas of the head and neck region including the oral cavity, oropharynx, tongue, nasal cavity, sinuses, larynx, salivary gland, and so on (Vokes, Weichselbaum, Lippman, & Hong, 1993).

According to Connell, Martel, and Hellman (2005) many cancers of the head and neck can be cured especially if they are diagnosed early. Treatment varies according to the type, severity and location of cancer. It may include surgery, RT, or chemotherapy. In modern decades, RT has become a standard treatment option for a wide range of malignancies. It is estimated that up to 60% of all persons with cancer will receive RT at some point in the treatment of their disease.

6.1 NEED FOR THE STUDY.

Head and neck cancer can develop sporadically, but people who use tobacco including cigarettes, cigars, pipes and smokeless tobacco, snuff, drink alcohol excessively, have genetic susceptibility or exposure to certain chemicals are much more likely than others to develop this disease . In India, oral cancer rate for males and females is 12.8 and 7.5 per 100,000, respectively, as compared to 6.3 and 3.7 per 100,000 in the United States. The disproportionately higher head and neck cancer in India as compared to other malignancies may be additionally due to low socio-economic conditions, poor oral hygiene and diet, and rampant viral infection. A total of 1,479,350 new cancer cases and 562,340 deaths from cancer are projected to occur in the United States in 2009 (Jamal et al., 2009).

Cancer treatment varies according to the type, severity, and location of the disease. It may include surgery, RT, or chemotherapy. RT is one of the principal treatment modality for head and neck cancers (Singh, et al. 2008).

As Haskell (1990) said “every effective therapeutic procedure has undesirable and at times dangerous side effects”, RT also has deleterious effects on the normal body cells. A study by Andrews and Griffith (2008) revealed that individuals undergoing RT for head and neck cancer are at risk for various deleterious side effects. Among these the two major ones are oral mucositis and fatigue.

Mock et al. (2000) defined cancer-related fatigue (CRF) as “an unusual, persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning”. A study conducted by Mock et al. (2001) found that exercises were effective in reducing the fatigue perceived by patients during treatment of cancer. Another study by Knols et al. (2005) demonstrated that physical activity reduces fatigue and improve physical functioning, health and quality of life during or immediately after cancer treatment.

According to Bennett et al. (2007), it is unable to maintain habitual physical activities in many of the patients. Thus an important public health goal is to develop strategies to help people to adopt physical activity habits and maintain activities in the long run. Motivational interview is one such strategy.

Oral mucositis is a common side effect of cancer therapies particularly RT for head and neck cancer and various forms of chemotherapy. Radiation induced mucositis can result in intense pain, which may substantially limit adequate hydration and nutrition, prevent proper oral hygiene, serve as a portal of infection, and affect speech (Redding, 2005).

The deleterious effects of RT can significantly interfere with the general well-being of the patient and may force the treating physician to interrupt the course of treatment to permit resolution of the acute symptoms. At times the treatment may be discontinued altogether before delivery of potentially curative dose of RT, which can compromise cure rates (Loprinzi, Gastineau & Foote, 1995).

According to Dickson (2004), meticulous oral hygiene must be maintained throughout the cancer treatment process in order to avoid severe complications. Patients often receive cancer treatment in an ambulatory setting and are responsible for their oral care at home, thus necessitating specific written instructions regarding appropriate use of oral care agents and instruments for effective daily plaque removal, use of prescribed fluoride treatment and reportable oral cavity observations and symptoms (Glajchen , 2004) .

There are no protocols developed in Indian set-up to teach the patients regarding management of RT side effects. Thus the researcher has taken up this study to test the effectiveness of a structured training programme which includes some simple, cost-effective measures to prevent and manage radiation induced mucositis and cancer-related fatigue. This structured training programme will help the nurses to teach the patients as well as help the patients to manage and prevent the oral mucositis, fatigue and associated long-term and short-term complications and to implement the findings through evidence-based practice.

6.2 REVIEW OF LITERATURE

A study conducted by Ahluwalia et al. (2001) in Allahabad found out that the new head and neck cancer cases reported in 20 years were 5386 with an average of 245 cases per annum. Out of total 5386 cases, 78.40% (4223 cases) were males and 21.60% (1163 cases) were females with a sex ratio of 3.6:1. The majority of cases were in the age group of 40-70 years with a peak in the sixth decade of life. Oral cavity lesion was the predominant cancer found in this population, followed by larynx and oropharyngeal malignancy.

Pernot (1994) conducted study on 448 patients treated with brachytherapy or combined with external beam RT. The time interval between brachytherapy and external beam RT significantly influenced by local control and survival for those who received both modalities. Shorter intervals were associated with better outcomes.

Erkal, etal conduct reported that among 107 patients treated with RT alone or radiation combined with a planned neck dissection at the University of Florida, the total control rates at 5 years after RT were 86% and 91%, respectively.

A study conducted on 148 subjects receiving chemotherapy by Shun, Beck, Pett, and Richardson (2007) to examine the responsiveness of Chinese version of the Cancer Fatigue Scale (C-CFS), the Schwartz Cancer Fatigue Scale-revised (SCFS-r) and the Fatigue Symptom Inventory (FSI) based on effect sizes and patient perception of change indicate that the three scales are sensitive to changes over two days.

The study conducted by Portenoy, and Itri (1999) reported that non-pharmacological interventions such as providing patients with preparatory knowledge about their disease and treatment. The non-pharmacological treatment for CRF includes patient education, exercise, modification of activity and rest patterns, stress management, cognitive therapies adequate nutrition and hydration.

Multiple studies have found the greatest amount of fatigue is during periods of less day time activity ( more day time sleep) and less night time rest (more night time activity) ( An coli-Israel, Moore, & Jones, 2001; Wells & Fedric, 2001). Bernadine O’Leary (2007) suggested that 5–6 hours of uninterrupted sleep at night is beneficial in fatigue management, the patient can be advised to take a longer nap earlier in the day or 2–3 shorter naps throughout the day and they should be given advices to conserve energy by prioritizing and delegating activities in order to manage fatigue.

In a study conducted by Tai and So (2005) to assess the fatigue and fatigue relieving strategies used by Hong Kong Chinese Cancer patients; among 157 participants 15% reported high level of fatigue and most of the participants perceived a moderate level of fatigue. The five most frequently used fatigue–relieving methods were related to rest (lie down, sit, sleep, nap etc.) and reduction activities (stop what you are doing), whereas the five most effective methods for fatigue relief were sleep, nap, lie down, massage, and stop what you are doing.

STATEMENT OF THE PROBLEM

Effectiveness of Structured Teaching Programme on Severity of Oral Mucositis and Fatigue among patients undergoing Radiation Therapy for Head and Neck Cancer in selected cancer hospital at Bangalore.

6.3 OBJECTIVES

1.  To assess the severity of oral mucositis and fatigue among patients undergoing radiation therapy in experimental and control group.

2.  To determine the effectiveness of structured training programme on severity of oral mucositis among patients undergoing radiation therapy.

3.  To determine the effectiveness of structured training programme on severity of fatigue among patients undergoing radiation therapy.

4.  Associate the selected demographic and clinical variables with the severity of oral mucositis and fatigue of patients undergoing radiation therapy.

6.4 HYPOTHESIS

H1- The structured training programme significantly reduces the severity of oral mucositis among the subjects undergoing RT for head and neck cancers than those in the control group who received routine instructions.

H2 – The structured training programme significantly reduces the severity of fatigue among the subjects undergoing RT for head and neck cancers than those in the control group who received routine instructions.

6.5 VARIABLES

INDEPENDENTVARIABLE:

In this study independent variable is structured training programme regarding self care practices on management of selected side effects of RT for head and neck cancers.

DEPENDENTVARIABLE:

Dependent variable is severity of oral mucositis and fatigue among subjects undergoing RT for head and neck cancers.

6.6 OPERATIONAL DEFINITIONS

EFFECTIVENESS:

It is the capacity of structured training programme to develop desired self care practices in managing side effects of RT in terms of severity of oral mucositis and fatigue.

STRUCTURED TRAINING PROGRAMME:

It is the systematic, planned training in the form of computer assisted teaching about oral hygiene, nutrition and demonstration of jaw muscle exercise.

ORAL MUCOSITIS:

A sequelae of RT characterized by painful erythematous, erosive and ulcerative lesions of the oral mucosa with reduced salivary production, altered taste sensation and food intake as measured by Patient Reported Oral Mucositis Symptom (PROMS) scale.

FATIGUE:

The subjective sense of physical and perceptual tiredness related to cancer or its treatment which affect patients on multiple levels of psychosocial and physical functioning as measured by Schwartz Cancer Fatigue Scale–revised (SCFS-r).

RADIATION THERAPY:

Therapeutic use of high energy ionizing radiation to destroy cancer cells, which is administered directly at the tumor site from outside the body through linear accelerator.

HEAD AND NECK CANCER:

Subjects with cancer of the lip, tongue, cheek, floor of the mouth, palate, vocal cord, oropharynx, larynx, salivary gland, nasal cavity, sinuses, and thyroid.

HOSPITALS:

It’s an institution for the care, diagnosis and treatment of the sick and injured.

6.7 ASSUMPTIONS

·  Learning is better with audio-visual aids integrated computer-assisted training.

·  Knowledge is the base for practice.

7 MATERIAL AND METHODS