"A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF DEEP VEIN THROMBOSIS AMONG IMMOBILIZED ORTHOPAEDIC PATIENTS IN SELECTED HOSPITALS AT TUMKUR"
PROFORMA FOR REGISTRATION OF SUBJECT FOR THE
DISSERTATION
SUBMITTED BY
SHERIN MARY KURIAN
MEDICAL SURGICAL NURSING
2010-2012
SRI SIDDHARTHA COLLEGE OF NURSING
AGALAKOTE, B.H. ROAD
TUMKUR
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT
FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / MISS SHERIN MARY KURIANI YEAR M.sc NURSING
SRI SIDDHARTHA COLLEGE
OF NURSING, AGALAKOTE,
TUMKUR
2. / NAME OF THE INSTITUTION / SRI SIDDHARTHA COLLEGE OF NURSING,B.H ROAD,TUMKUR
3. / COURSE OF THE STUDY & SUBJECT / MASTER DEGREE IN NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION / 20-05- 2010
5. / TITLE OF THE TOPIC / "A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF DEEP VEIN THROMBOSIS AMONG IMMOBILIZED ORTHOPAEDIC PATIENTS IN SELECTED HOSPITALS AT TUMKUR.”
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“Every human being is the author of his own health or illness”
-Buddha
Immobility refers to the inability to move about freely. The word immobility and orthopaedic patients were closely related. Orthopaedic patients will have impairment in mobility results from prescribed restriction of movement in the form of bed rest, physical restriction of movement or impairment of motor skeletal function .In a classic study Deitric and others found that even young healthy man put in bed rest had physiological problem. Periods of immobility or prolonged bed rest can cause major physiological, psychological and social effects.1,2
In orthopaedic patients the treatment of choice following surgery or injury are varying in rest & motion. The effect of immobilization leads to many complications related to different systems in our body. The patients with acute medical condition in hospital may be for few days but patients with orthopaedic condition may be for many days. When patients are immobilized following trauma there is high risk for deep vein thrombosis post operative stiffness due to limited range of motion2
The medical term for a blood clot in the blood vessel is a thrombus. Deep vein thrombosis is the formation of a blood clot in one of the deep veins of the body, particularly in the leg or pelvis. It is a problem that can be
asymptomatic, or in the worst case scenario, fatal. Death can occur if a blood clot which forms in the deep veins of the body breaks off and travels to the lungs, heart or brain and causes severe overload of the capacity to breathe or pump blood. Some doctors think that even a silent blood clot can cause chronic swelling or skin ulcerations, a difficulty called post-phlebitic syndrome. The risk of deep vein thrombosis is increased in a number of circumstances. Lower extremity surgery, and specifically total hip replacement surgery, increases the risk of deep vein thrombosis. The surgery heightens the body's tendency for coagulation or clotting. In addition, when the leg is manipulated during surgery there may be irritation to the walls of the major blood vessels in the leg. Finally, during and after surgery the lower extremity is not used as much and, therefore, the normal blood flow rate is decreased. The leg muscles usually help venous blood return to the heart when they are used 3,4
Prevention of deep vein thrombosis is very important among orthopaedic client. Many healthcare providers are under the false impression that this life-threatening illness is not a problem in their hospital or among their patients. While it is true that an individual doctor will normally see relatively few patients with this disease, it is clear that deep vein thrombosis is an important public health problem. The incidence of deep vein thrombosis in India as reported is one percent of the adult population after the age of fourty and is 15 to 20 % in hospitalized patient and the risk of deep vein thrombosis is 50% in patients undergoing orthopaedic surgery particularly involving the hip and knee. It is 40% in those patients undergoing abdominal or thoracic surgery. 1/100 who developed deep
vein thrombosis dies, usually from the blood clot travelled to the lungs which is called as pulmonary embolism.5,9
The tragedy is that most of these problems could be avoided by simple, cost-effective measures. Use of modern methods of deep vein thrombosis prophylaxis will reduce the incidence of deep vein thrombosis during the postoperative period by two-thirds and will prevent death from pulmonary embolism in one patient out of every 200 major operations. Methods to prevent blood clot after surgery may include early mobilization and activity, elevation of the feet, ankle exercises, elastic stockings, compression devices that passively help blood flow in the legs, and anti-coagulation medicines 5,7
Venous blood flow is assisted by respiration, which causes pressure changes in the thorax and abdomen, and by skeletal muscles and valve cusps. During mobilization the skeletal muscles of the lower limbs contract, causing the valves to open and forcing blood towards the heart .When the muscles relax, the valves close to prevent backflow.4,6
Regular mobility and stretching exercises help maintain proper blood circulation. Stretching exercises are also excellent for circulation and deep vein thrombosis prevention. Taking frequent stretching breaks while doing office work prevents blood circulation from becoming sluggish. Using prophylaxis for deep vein thrombosis is neither complicated nor expensive. In fact, several studies show that preventing this disease is cheaper than treating its consequences.3, 5
6.1 NEED FOR THE STUDY
Deep leg veins are the larger veins that go through the muscles of the calf and thighs. Venous thrombi are IV deposits composed of cellular materials. They are not the veins that we can see just below the skin .A calf vein is the common site for a deep vein thrombosis. A thigh vein is less commonly affected. Rarely, other deep veins in the body can be blocked by blood clots. When a person has deep vein thrombosis, the blood flow in the vein is partially or completely blocked. An important complication of deep vein thrombosis is the dislodgement of the clot from the deep vein, which will travel along the circulation and reaches the pulmonary vasculature and causing pulmonary embolism 4.
A deep vein thrombosis is the part of a group of problems together known as venous thromboembolism .Blood normally flows quickly through veins, and does not usually clot. Blood flow in leg veins is helped along by leg movements, because muscle action squeezes the veins. Sometimes a deep vein thrombosis occurs for no apparent reason. Immobility causes blood flow in the veins to be slow. Slow-flowing blood is more likely to clot than normal-flowing blood5,
Venous thromboembolism (deep vein thrombosis and pulmonary embolism) is prevalent throughout the world. About 2 million new cases of deep vein thrombosis and 600 000 new cases of pulmonary embolism occur every year in the USA (population 300 million). In Asia certain centres revealed that deep vein thrombosis occurred in 41% of patients undergoing major joint surgery without
thrombo-prophylaxis. The incidence of symptomatic venous thromboembolism in another prospective epidemiological study of 2420 Asian patients undergoing major orthopaedic surgery without thrombo-prophylaxis was two point three percentage, as high as that in western patients. 32 of 53 patients who underwent major orthopaedic surgery without thrombo-prophylaxis had deep vein thrombosis which was proven on venography. In a recent global epidemiological study, 52% (38% medical and 62% surgical) of 68 183 inpatients in 358 hospitals across 32 countries were found to be at risk for developing venous thromboembolism8,9
An autopsy study on 1000 medical patients at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh revealed that pulmonary embolism was present in 159 (16%) of 1000 patients who died in the hospital—it was a fatal embolus in 36 and was a major contributor to death in 90 patients; in 30 patients, the embolus was an incidental finding at autopsy as death occurred due to some other cause. 7,9
Deep vein thrombosis may be clinically silent and hence usually not suspected. Even when symptomatic, the clinical features are non-specific; presence of pain, swelling and tenderness in the lower limbs are not always due to deep vein thrombosis.3,8
Deep vein thrombosis is an easily preventable complication of immobility. Prophylactic measures used for prevention of deep vein thrombosis are lifestyle modifications, mechanical and pharmacological methods. Patients needing
hospitalization should be encouraged to remain ambulant, as far as possible. Those waiting for elective surgery should be advised to discontinue smoking, oral contraceptive pills and hormone replacement therapy for at least 4–6 weeks in order to reduce the risk for venous thromboembolism.3,4,9
All patients who are admitted should be screened for their risk for deep vein thrombosis. Some common risk factors for deep vein thrombosis are orthpaedic surgery, pelvic surgery, prolonged surgery, immobilization, coagulation disorders, cancer, sepsis etc. Based on the presence or absence of these risk factors, which carry varying weight age, patients can be stratified into high, moderate and low risk for deep vein thrombosis. Those at high or very high risk should receive prophylaxis—both mechanical and pharmacological Mechanical measures such as elastic graduated compression stockings, intermittent pneumatic compression and venous foot pumps should be used in bed-ridden patients and those undergoing surgery .Pharmacological prophylaxis involves the use of heparin in low doses which are associated with no or little increase in the risk of clinically important bleeding and do not warrant monitoring the coagulation profile. Pharmacological prophylaxis may be started pre- or postoperatively. It should be continued for at least seven days or until the patient is ambulant. Patients at high risk of bleeding and those with contraindications to heparin should receive mechanical prophylaxis only. Deep vein thrombosis prophylaxis is effective—it reduces the risk of deep vein thrombosis by two-thirds. Deep vein thrombosis prophylaxis has been identified as the number one measure to improve the safety of hospitalized patients.9,11
Most mechanical methods of thromboprophylaxis aim to reduce venous stasis and thus the propensity for clot formation. They found that mechanical methods can be used in patients at low risk of venous thromboembolism and in those with contraindication to pharmacologic therapy. The nurse has an active role in the implementation of mechanical prophylaxis methods. In the first instance, the nurse will encourage patients to ambulate as early as possible and avoid prolonged bed rest. Nurses are well positioned to educate the patient on their use and benefits, and thus improve compliance. It is recommended that the patient becomes an active partner in the prophylaxis decision-making process, and this is where the nurse can play a vital role. Not only must nurses be vigilant for signs and symptoms in their patients, but it is important to ensure the patient is aware of signs and symptoms to encourage self reporting .Nurses also discuss lifestyle modifications and preventable risk factors educating both the patients and their families,10,12
6.2REVIEW OF LITERATURE“Literature review is a critical summary of research on a topic of interest often prepared, to put a research problem in the context or as the basis for an implementation project”
Polit and Hungler
A quantitative cross sectional survey was conducted in Canada to investigate the patient’s awareness and knowledge of thromboprophylaxis as well as patients satisfaction with thromboprophylaxis. The researcher used 48
participants receiving pharmacological thromboprophylaxis as samples. Among them 81.2% reported hearing of either deep vein thrombosis, pulmonary embolism or both conditions. Of the patients who had heard of deep vein thrombosis and or pulmonary embolism, 74.2% knew immobility was a risk factor but had limited knowledge about symptoms & treatment modalities. The research findings suggest that patients require further information on deep vein thrombosis during their hospitalization to enhance their involvement in deep vein thrombosis prevention and recognition. The study also highlights the need to strengthen the nurses role in providing patient education regarding deep vein thrombosis 13
A study conducted in U K aimed to evaluate the effect of preparatory information on patients post operative outcome following total hip replacement. 82 healthy individuals were selected by using non random technique. The subjects in the experimental group were given written and oral information about the procedure and prevention of post operative complications. Subjects in the control group only received the advice and support that would routinely given to total hip replacement patients. The study measured the physical outcomes by using questionnaire and results showed that preparatory information given pre-operatively, post operatively and pre discharge had positive effects on the physical recovery and prevention of complications of the patient.14
A study was conducted in Scotland to determine the optimum type of exercise for promoting venous return. Studies of both active and passive movements were carried out on 40 limbs in 20 subjects (18 men
and two women) with a median age of 27 years (20-54).They assessed the ankle dorsiflexion and plantar flexion, subtalar inversion, eversion and a combination of all movements .The active combined movements produced the higher velocities with an increase of 38% mean and 58% in peak flow velocities, which were significantly greater than the peak and mean flow rates produced by passive movements. The active combined exercises would therefore be the most effective in eliminating stasis and could contribute to the prevention of deep vein thrombosis15
A prospective randomized controlled study conducted to compare on early mobilization in a removable cast with immobilization in a cast after operative treatment of ankle fracture. 62 consecutive patients with ankle fractures that required open reduction and internal fixation were assigned to one of two post operative regimens immobilization in a removable cast. The results showed that patients who had early mobilization in a removable cast had higher functional scores at 9 and 12 weeks post operatively. They also returned to work [67days] earlier compared with those treated in non weight bearing below knee cast (95 days).They concluded the study that early mobilization has an important role in prevention of complications.16
A multicentre study was conducted on deep venous thrombus prophylaxis among orthopaedic patients at New Delhi .The aim of the study was to determine the ideal prophylaxis for deep vein thrombosis. The researcher grouped 30 patients in group 1 were not given any thromboprophylaxis while 100 patients in group 2 were put on mechanical prophylaxis. The result