RAJIVGANDHI UNIVERSITYOF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMAFOR REGISTRATION OFSUBJECTS
FOR DISSERTATION
1.Name of the candidate andaddress / Mrs. BINDU MATHEW
Florence college of nursing
Bangalore-43
2.Name of the institution / Florence college of nursing
3.Course of study and subject / I year M.Sc. Nursing
Psychiatric Nursing
4.Date of admission to course / 27 .06.2007.
5. Title of the topic / “A quasi experimental study to evaluate the effectiveness of a self instructional module on lithium therapy for nurses, working at selected psychiatry hospitals, Karnataka”
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Mental illness was always associated with ignorance, superstitions and fears. As a result, mentally ill patient went through a lot of torture and problems because of lack of knowledge and facilities. These affected the care of patients. The introduction of understanding of the human behavior during the later part of the 19thcentury, led to a change towards the mentally ill patients. Subsequently, in the third decade of the 20th century the physical form of treatment was introduced. By the fourth decade pharmacology for mentally ill was introduced.1
Lithium, the lightest of the alkali metals was discovered in 1817 by Johan August Arfvedson. During the past 25 years, the practice of psychiatry has been revolutionized by the introduction of psychoactive drug, and none has been potentially revolutionary as Lithium. It has firmly established that Lithium is a specific and effective antimanic agent, capable of controlling and preventing recurrent episodes of mania. In addition there is a growing body of evidence which indicates that Lithium may also control and prevent recurrent episodes of depression in both bipolar and unipolar illness. Although definitely as some supporters claim, Lithium has become established as the first psychiatric drug in psychiatric history .2
Now the psychopharmacology is the “gold standard” in the treatment of psychiatric disorders, but drugs alone do not treat the patient‘s personal, social, or environmental responses to these illnesses .The psychiatric nurse has a wealth of knowledge and competencies that makes nursing unique in the care of people with psychiatric disorders; hence psychopharmacological treatment has been integrated with principles of psychiatric nursing practice. The nurses play a significant role in the administration of medication, monitoring drug effects and in educating patient and family regarding compliance to the treatment regimen.3
Lithium is not only an antimanic drug, but also it is used to treat physical illness like uremia, renal calculi, gout rheumatism etc. The exact mechanism of action of lithium is not fully understood, many neurotransmitter functions are altered by this drug. Hence lithium toxicity is an emergency situation to manage; it’s a challenge for nurses to educate patient and family on lithium therapy.
6.1 NEED FOR THE STUDY
Bipolar disorders are chronic multidimensional conditions affectingabout 3–6% of the population. The onset ofaffective episodes usually occurs during adolescence or theearly adult years and follows an irregular course inwhich acute abnormal mood states alternate with periods of fullor partial remission.Bipolar disorder ranks as the sixth leading cause of disabilityworldwide and is associated with increased mortality. The excess mortality associated with bipolar disorder is notlimited to suicide. Mortality ratios comparing patients withbipolar disorders with the general population reveal elevateddeath rates due to a number of general medical conditions includingheart disease, stroke, and cancer. 4
Another study has found that lithium, one of psychiatry's oldest drugs, may be the most effective solution for preventing suicide in patients with manic-depressive disorder and other types of bipolar disorders. Nearly half of all suicide deaths each year are in patients with bipolar disorders, in whom the risk is more than 20 times that of the general population. The new prevalence estimate counts 4.3 percent of adults in the U.S. suffer from bipolar disorder or“sub-threshold" bipolar disorder, which includes those who don't fit the precise clinical criteria for bipolar disorder but whose symptoms still severely impair their ability to perform daily tasks of living. Previous studies have placed the prevalence at 1 percent. 5
Evidence has been presented that, the lithium intake in Indians appears to be higher than in the western population. Despite this higher intake of lithium, the serum levels of lithium are not high, but the 24-hour urinary excretion of sodium and lithium are both high. Total exchangeable sodium levels have been found to be higher in Indians as compared to subjects from temperate countries.It is possible that lithium can substitute for sodium in carrying the current of action potentials. Hence a greater amount of exchangeable sodium would provide a greater scope for the action of lithium. 6
A more recent Meta-analysis of 13 epidemiological studies in India, comprising 33,572 individuals, concluded that prevalence of mental diseases is 58.2 per 1000 population. Among the various problems, organic psychosis, schizophrenia; affective disorders, mental retardation, neurotic disorders, and alcoholic – related disorders are the major problems encountered in the community. Mental disorders were found to be higher in the urban areas, among women, in the age group of 35-44 years and in the lower socio-economic states. This study concluded stating that nearly 1.5 million people suffer from various psychiatric disorders and requiring immediate help at any given point of time. 7
Bipolar disorder is currently treated with mood stabilizing drugs as lithium or valproic acid. Some people have reported side effects because they act by blocking an enzyme, glycogen synthase-6(GSK-3). Lithium is the prototype mood stabilizer for treating adult bipolar disorder; it has proven to be effective in preventing future episodes of bipolar disorder and reducing suicidal thoughts in adults. Some studies determined that lithium may have similar protective effect in pediatric cases also.8
Lithium is used in the prevention and treatment of manic episodes associated with bipolar disorder. Lithium alters sodium metabolism within nerve and muscle cells and enhances the reuptake of biogenic amines, nor epinephrine and serotonin.It blocks sensitive dopamine receptors and become antimanic and ant depressive agent. There is narrow margin between the therapeutic and toxic levels of Lithium carbonate.9
A videotape lecture and written hand-out containing factual information about lithium were given to 30 attenders at a lithium clinic. A further 30 patients acted as a control group and were not given the programme until later in the study. The educational programme resulted in substantial and significant increase in patient knowledge about lithium, such that knowledge increased from a baseline level comparable with that of social workers to a level similar to that of community psychiatric nurses. Patient’s attitudes to lithium also became more favorable after education.10
A study to assess the nurse’s knowledge on selected psychotropic drugs in NIMHANS in Indiarevealed that nurse knowledge regarding psychotropic drugs were only 66.4% specifically in antimanic 66.3%. The deficiency in the knowledge among nurses can result in poor drug compliance and poor outcomes . She suggested that every nurse should be proficient and competent in the administration of psycho tropic drugs. The findings of this study can form basis for future research.This study recommended that the nurses can conduct research related to psycho pharmacology; that will be of significance to nursing practice and similar study can be conducted in general hospitals as most general hospitals have a separate psychiatric department.11
From the available literature reviewed, it was found that mood and affective disorders ranks among the major mental illness for which lithium is considered as the drug of choice. Literature also reveals that lithium therapy should be carefully monitored for side effects. Other wise it can bring life threatening complication.
As the studies related to lithium therapy were scanty in Karnataka, the investigator is interested in educating the nurses on lithium therapy with a self instructional module (SIM). This will help the nurses toimprove their knowledge about lithium therapy and provide care accordingly to their clients.
6.2 REVIEW OF LITERATURE:
Review of relevant literature serves as an essential background for any research. Critical examination of previous studies will help researcher to formulate and delimit the problem, to minimize the possibility of research, to suggest theoretical framework for the study, to learn from the reported experience of others about its feasibility to critically evaluate the various methods used by others and choose the most appropriate design for the investigation. 12
Polyuria, thirst and polydipsia due to renal diabetes insipidus (RDI) are common side effects of long-term lithium treatment. Although Polyuria and polydipsia is generally mainly a nuisance, the condition may become life threatening when free access to fluids is impossible. This is demonstrated by the case of a 46-year-old man who was on chronic lithium treatment with probable RDI and who developed fatal severe dehydration and hypernatraemia after traumatic brain injury. Awareness of possibility of RDI in patients on chronic lithium treatment is therefore important. 13
SharmaSD, Iqbal M. (2005)Conducted a hematological, biochemical and histopathological study on lithium induced toxicity .The study evaluated the toxic effects of small doses of lithium nitrate. They cited that administration of lithium nitrate (20 mg Li/kg body wt) for seven weeks on every alternate day elicited significant alterations in gross hematological values owingto hypo chromic anemia and leucocytosis. The histopathological picture of the kidney tissues revealed many deformative alterations. Necrosis, binucleated cells and Kuffer’s cells are visible in renal tissues.14
Chan HH, Wing H,Su R, Van Krevel C, Lee S. (2002) conducted a study to assess the nature and prevalence of skin disorders among psychiatric patients on chronic lithium therapy and to compare them with patients on other psychotropic medications. About 51 patients on lithium and 57 patients on other psychotropic medication were recruited. They found, lithium treated patients developed significantly more secondary cutaneous reactions than the control group. This applied particularly to acne and psoriasis. Male patients on lithium were more likely to be affected than female patients.15
Jordan S (2002) Conducted an observational study using a quasi- experimental group design undertaken with clients receiving long –term antipsychotic medications. Twenty nurse-client interactions were observed. Problems auctioned by nurses, with and with out the check lists were compared. The findings of the study revealed that implementation of evaluation check lists increased the number of adverse effects detected and auctioned by the nurses. The study however strongly recommended the need to empower nurses with sound knowledge, needed to address the ‘care gaps’ in medication management.16
Stallone F, Mendlewicz J, Fieve RR (2000) conducted a double –blind study on lithium prophylaxis. The study sample consisted of fifty seven patients. The objective of the study was to assess whether the patients believed they were receiving lithium or placebo. Research nurses who were ‘blind’ to the patient’s medication and a close relative living with each patient were also questioned. Nearly allpatients (96%) said they believed they were receiving lithium, ascribing this belief in 63% of the cases to a perceived improvement in condition. In only 14% of the cases on lithium was the presence of side- effects implicated in the patients’ beliefs. One of the three nurses had a correct guess rate in excess of chance expectancy.17
Bailey B, McGuigan M (2000) conducted a study on comparison of patients hemodialyzed for lithium poisoning and those for whom dialysis was recommended by PCC (poison control centre) but not done. There were 174 acute on chronic overdoses; hemodialysis was recommended in nine patients but only six underwent hemodialysis; one patient died during hemodialysis. There were 19 chronic poisonings; hemodialysis was recommended in nine patients but only two had hemodialysis, one patient died with out hemodialysis and one other had sequel after hemodialysis. This study indicates in more severe lithium poison cases hemodialysis has to be considered. 18
Schou M. (1999)Investigated on the prophylactic action of lithium in bipolar disorder, and its effect in reducing suicidal behavior. A Meta analysis approach was used .The study results claimed that in treating typical bipolar disorder lithium is significantly found to be more effective. A significant association was also found between prophylactic lithium treatment in reducing mortality and suicidal behavior among patients with bipolar disorder. 19
Bonin JP (1999) A study based on Pender’s preventive health beliefs model, was intended to identify the psychosocial determination of lithium compliance A random sample 149 of outpatients at a large psychiatric hospital was used to measure lithium compliance on the basis of five criteria .The study findings reveal that being female, being elderly, living with a partner, perceived treatment benefits and obstacles are determining factors in lithium compliance. It also suggest that nurses will have to be increasingly vigilant with respect to new obstacles and will have to adjust their interventions accordingly.20
Nordt SP,Catrel FL (1999) presented case of a minimally symptomatic patient found to have elevated lithium level 5.6 mEq\L, 21 hours after ingestion . The Patient was noted to be slightly drowsy .but could easily arouse. No gastro intestinal symptoms or ECG observation. Only the blood sample elicited inadvertently elevated lithium. This case illustrates the wisdom of the old adage to ‘treat the patient; not the levels’. Caution should be used by physician, nurses, technicians and other personnel, when obtaining blood samples..21
A study was conducted by Maliyakal (1998) at NIMHANS Bangalore, to determine the effectiveness of in-service education program on psychotropic drugs among staff nurses working in the in patient psychiatric ward. Fourty nurses were randomly allocated to experimental and control groups (20 each). Both groups were given a pre –test and later only the experimental group were given interactive classes for eight hours. After six weeks post test was given using the same tool that was used for pre test. The study revealed that, nurses had deficit in knowledge regarding psychotropic drugs .The study strongly suggested the need to empower nurses with new developments in the field of psychiatric drugs. .22
6.3 STATEMENT OF THE PROBLEM
A quasi-experimental study to evaluate the effectiveness of a self instructional module on Lithium therapy amongnurses, working in selected psychiatry hospital, Karnataka.
6.4 OBJECTIVES OF THE STUDY
The objectives of the study are to:-
1. Assess the knowledge of staff nurses regarding Lithium Therapy.
2. Evaluate effectiveness of the self instructional module on Lithium Therapy.
3. Determine the association between the knowledge of staff nurses and selected demographic variables such as age, sex, marital status, level of professional education, years of experience in psychiatric setting and exposure to in-service education.
6.5 HYPOTHESES
H1: The mean post test knowledge score of the staff nurses regarding lithium therapy will be significantly higher than the mean pretest knowledge score.
H2: There will be a significant association between demographic variables and mean knowledge score of the nurses regarding the lithium therapy.
6.6 OPERATIONAL DEFINITIONS
Evaluation:
It refers to the finding of the value of self instructional module on knowledge of nurses regarding lithium therapy.
Effectiveness:
In this study effectiveness refers to desired changes brought about by the self instructional module and measured in terms of significant knowledge gain in the post test and graded as adequate knowledge, moderate knowledge and inadequate knowledge.
Self Instructional Module:
Refers to a booklet in English prepared by the investigator and validated, which contains information about various aspects of lithium therapy.
Lithium Therapy:
In this study refers to the treatment with lithium, an alkaline metallic element used mainly for bipolar disorders.
Nurses:
It refers the registered nurses, working as staff nurses in selected psychiatry hospitals, Karnataka.
Psychiatric Hospitals:
In this study refers to Government or private psychiatry settings, nursing homes or psychiatry departments in general hospitals.
6.7 ASSUMPTION
- Staff nurses taking care of psychiatry patient are unaware of the lithium toxicity and severe side effects of lithium.
- The self instructional module on lithium therapy will enhance the knowledge of the staff nurses.
- The self instructional module will have a positive impact on staff nurses
- Nurses will cooperate and participate in the study
- The tool prepared for the study would be sufficient for collecting information about actual knowledge about lithium therapy
6.8 DELIMITATION
The study is delimited to;
- Staff nurses those who are working at selected psychiatric setting
- Only lithium therapy among other psychotropic drugs.
7. MATERIALS AND METHODS:-
7.1 Source Of Data
Staff nurses those who working in psychiatry settings in Karnataka.
7.2 METHOD OF DATA COLLECTION; PROCEDURE:
Research Method : Quasi-Experimental Method
Research Design : One group pre test-post test design
Sampling technique : Convenience Sampling Technique
Sample Size : 50 Nurses
Setting of the study : Study will be conducted at NIMHANS,
Cadabam , Spandana psychiatric hospital and
Fr.Muller’s hospital.
7.2.1 SAMPLING CRITERIA
INCLUSIONCRITERIA
This study includes ‘Staff Nurses’
1 Working in selected psychiatry settings.
2. Willing to participate in the study.
3. Present during the period of data collection.
EXCLUSION CRITERIA
This study excludes ‘Staff Nurses’
- Working in other departments
- Not willing to participate in the study
- Absent during the period of data collection
7.2.2: DATA COLLECTION TOOL:
A Structured knowledge questionnaire will be prepared to assess the knowledge of the nurses regarding Lithium Therapy. A SIM will also prepare about lithium therapy. Content validity of the tool will be ascertained in consultation with guide and experts from various fields like nursing and psychiatry medicine. Reliability of the tool will be established by split half method.