To Assess the Knowledge of the Staff Nurses Regarding Care of the Comatose Patients
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / Mr.benson K.J
1st Year MSc Nursing
Rajiv Gandhi College of Nursing
IIT Campus
Near Meenakshi Temple
Bannerghatta Road
Bangalore - 76
2 / Name of the Instituition / RAJIVGANDHICOLLEGE OF NURSING
3 / Course of study and subject / degree of master ofNursing
Medical & Surgical Nursing
4 / Date of Admission to course / 30-06-2008
5 / Title of the Topic / A study to assess the EFFECTIVENESS OF PLANNED TEACHING PROGRAM ON KNOWLEDGE of staff nurses regarding CARE OF COMATOsE PATIENTS IN SELECTED HOSPITALS, Bangalore.
6. BRIEF RESUME OF THE INDENDED WORK:
INTROIDUCTION:
The term ‘conscious’ or ‘un consciousness’ originates from the Latin word ‘conscious’ to know. Chambers Twentieth Century dictionary (1977) defines ‘consciousness’ is the waking state of the mind, the knowledge or it is the state of awareness of the self and the environment. (Fred Plum 1990).
The tem ‘coma’ is originates from the Greek word ‘kome’ means ‘deep sleep’. Here the patient is deeply unconscious and there is no response evoked by external or internal stimuli. (Arup kumar kundu 1979).
Coma is a state of sustained unconscious in which the patient (a) does not respond to verbal stimuli. (b) may have varying responses to painful stimuli. (c) does not move voluntarily. (d) may have altered respiratory patterns. (e) may have altered papillary response to light. (f) does not blink for general the longer the coma lasts, the more likely it is irreversible and due to a permanent disorder in the brain structure. (Joyce M Black 1986).
The comatose victims are usually admitted to the medical or surgical wards in an acute stage in spite of major surgical problem the surgeon will not take the case for surgery till the patient comes out of the comatose stage. So during this stage the emphasis is an medical treatment, the goal being to presence the vital functions for a period ranging from a day to week, at the end of which the patient moves into the chronic phase that recovery is a long drawn out process.
The specific practice of neuroscience nursing dates only to the last portion of the 19th century prior to this time there were no resources to me in teaching and guiding nursing care to this complex patient group. Nursing skills were “taught on the job” by physicians in the hospital based, in nursing schools. Yet, from its earliest inception, nursing care of the patients with neurological disfunction was recognized as critically important improving patient outcomes. The nursing personal are front line health care provides working with individuals with comatose patients and their families.
The literature suggests that nursing care may minimize secondary injury and improve patient’s outcome. The patient’s care begins as service to God and sympathy for the suffering. The nursing profession is engaged in dealing with people as they struggle with the problem of life Nurses are the professionals who are in close contact with the patients. If nurses are made aware through a systematic study, they can asses the condition of the patients and provide care accordingly, in other words nursing care is the process of recognizing, understanding and meeting the health needs of any comatose patients in the society.
As the patient is unaware of himself and his environment there are more chances of complication like airway obstruction, aspiration and respiratory treat infections are common cause of death in comatose patients. These patients are potential for injury, pressure sores (Decubitus Ulcer )and fluid volume deficit. Alternation in urinary elimination can lead to urinary incontinence or retention. Alternation in bowel function can lead to constipation. Thus the comprehensive patients care starts at the time of admission and continuous until the regain of normal function by each individual patient has been achieved. (Siddarth, Brunner1988).
Perry, potter in fundamentals of nursing as the chapter regarding, community with comatose clients discuss even when person are in comatose condition or non responsive, they may be able to receive stimuli. Hearing is thought to be the last sensation lost with comatose and the first to be regained with consciousness. therefore, nurses need to be careful not to say anything to be comatose clients or with in their hearing range that they would not say to fully conscious clients, other, important nursing invention include talking to the clients while providing care, exp0laining, name, place, date and time of day avoiding bed side conversations with others about the client.
Patient and their families expect nurses to provide relief from suffering “the fundamental responsibility of the nurse….. is to promote health, to prevent illness, to restore health and to alleviate suffering -----” says the code for nurses, revised and adopted at the 15th quadrencial congress of ICN in Mexiocity. May 1973. Henderson (1960) quoted that the unique function of the nurse is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this on such a way as to help him gain independence as rapidly as possible.
Hospitalization is a major stress for the family members. Development of complication can prolong the hospital stay. So every effort should be made be the nurse for the prevention of complication and early recovery of comatose patients. Each service and discipline which in a hospital setting was an obligator to maintain safe environment.
Patient’s stay in the hospital is reduced by assessing the patient’s condition periodically and planning the nursing care accordingly, so that complications can be avoided. Awareness of the patients needs and planning appropriate treatment in an function of nursing & of staff nurses working with there patients.
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6.1 NEED FOR THE STUDY
Karnataka is the state which reports majority of RTA (Road Traffic Accidents) cases for the past couple of years, Bangalore is the centre of the state and as with the accidents. Most of the RTA (Road Traffic Accidents) cases ultimate in either coma or stupor conditions. However the nurse who care for these patients known little about the comprehensive management of comatose patients evidenced by more incidence of infection, decubitus ulcer and thrombo embolism etc.
A number of patients are admitted to the medical surgical cardiac and neurology wards and ICU who were comatose may be varied with expose to foreign substances, metabolic derangements, cardiac male functions, CVA (encephalitis, meningitis, cerebral malaria etc), respiratory compromise, peripheral vascular abnormalities, infection whatever may be the cause for the comatose patient presents with numerous nursing problems and complications. These problems offer a challenge to the nurses to take care of these patients.
According to “Luckmann Sorensen” (1987) the comatose patients loose the functions of the whole body, unaware of self as well as environment and thus his physical independence in profoundly affected he is helpless and is unable to carry his day to day activities. Which patients require long term care depending up on causes for coma.
A study conducted by Mapoure (2008 May) based on survival of comatose victims in a neurological department in Dakar. He conducted the study in neurology intensive care unit (NICU), were all coma patients confirmed or equal to 8/15. He evaluated a total of 105 patients. The mean duration of hospital study in the NICU was 10.82+ / -11 days with an estimated mortality of 82.9%. the three months survival was 7+ / -1 days (CI (95%):5-9). This study reveals that the comatose stroke patients have a
Poor prognosis, emphasizing the critical importance of primary prevention.
The researcher found that the comatose patients are completely dependent on others because their body systems are impaired. Coma is often life threatening and nurses are responsible for meeting their basic human needs and preventing the complication associated with coma.
Here, coma the role of the nurse to assess the comatose patients and to protect them from various complications. This prompted the researcher to find out the causes for this problem associated with the complications of comatose patients.
Hence the present study is planned to assess the knowledge of the staff nurses regarding the care of comatose patients.
6.2 REVIEW OF LITERATURE
Yeung J H (2002) conducted a study on high risk trauma in older adults in Hongkong. Trauma is the eight leading cause of death in Hongkong. The increasing older population in Hongkong presents a challenge to the health care system yet there is little local data can older trauma patients. The method was retrospective analysis of prosperity collected data from a centralized trauma database. The result shows that common cause of injury were falls (50.0%, 405/810) and motor vehicle crashes (33.6%, 272/810), head injury contributed to 80.3% (159/198) of deaths 38.4 (311/810) of trauma in older patients.
Boyle M Green M (2002) conducted a study based on pressure sores in intensive care unit. A prospective multisite observational study was conducted to define the incidence of pressure sores. They assured the 534 patients with pressure sores. The result shows that the factors, coma / Un responsiveness / paralyzed and redacted and cardiovascular instability were significantly associated with pressure sores with relative risks of 4.2 and 2.5 respectively.
Heron R, Davie A, Gilles R (2004) conducted a study that interrater reliability of the Glasgow coma scale among nurses in sub-specialties of critical care GCS is used as an assignment tool to measure the levels of consciousness and coma in patients. The research nurse (RNs) working in 5 different sub-specialty clinical areas of critical care, general intensive care, neurological intensive care, coronary care, emergency room and post anesthetic recovery room. The result shows the education qualifications and previous neurological experience were statistically significant with regard to the nurse accuracy of GCS assessment with p values of 0.004 and 0.043 respectively.
Callahan C (2004) was conducted of 1132 non coalition trauma patients who were admitted to a combat a support hospital. Data on age severity of injury indices, and in hospital morality rates were analyzed. All variables that were associated with death an univariate analysis were analyzed by multivariate logic regression to determine independent associates with morality. Those were 38 young pediatric patients (aged <or = 8 years) 1094 older patients had increased severity of injury indicated by decreased Glasgow coma scale score. This study shows that young children who present to a combat support hospital have increased severity of injury compared with older children and adults. In a population with primarily penetrating injuries after adjustments for severity of injury young children may also have an independent increased risk for death compared with older children and adults.
Mohindra.S, Mukherjee K K (2005) conducted a study on continuation of poor surgical outcome after elderly brain injury. Inspite of the decline in mortality among trauma patient’s remains poor, both operative and non operative outcome for elderly patients after head trauma has resisted improvement. Road-traffic accidents caused most of the head injuries. The result shows, contusions were the commonest CT sum finding 27/70. For which surgery was indicated and the elderly patients experienced higher mortality and poorer functional outcome.
Goncalves F, Bento M J, (2006) conducted the study was to validate conscious scale for palliative care. The scale was named consciousness scale foe palliative care (CSPC). The validation had two phases. 1) Face validity- the scale was assessed by seven health care professionals, both doctors and nurses, experienced in palliative care. 2) Reliability and construct validity – performed by four investigators, two nurses and two doctors. In this study all four observes completed 44 periods of observation relative to 38 patients resulting in total of 176 observations. As a measure of very high (099). The inter-rater reliability was also very high with an interclass correlation co-efficient of 0.99.
Fishcher .C, Luaute J (2007) conducted a study an evoked potentials for the prediction of vegetative state in the acute stage of coma. For coma patients in intensive care units, it is important to anticipate their functional outcome as soon as reliable as possible among clinical variable the Glasgow coma score (GCS) and the patients pupil reactivity are the strongest predictive variables. Evoked potentials help to assess objectively brain function. In anoxic coma the abolition of somatosensory evoked potentials (SEPs) in related to a poor outcome, defined as death or survival in a vegetative state, with a 100% specificity following traumatic brain injury, the predictive value for unfavorable outcome is 98.5% when there are no focal injuries likely to abolish SEP cortical components. In contract, the pressure of event related evoked potentials and strong particularly mismatched negatively (MMN), is a string predictor of awakening and comatose patients from moving to a vegetative state (PVS).
Tomicic V, Espinoza M, Molina J (2008 August) conducted a study on the characterizing of patients receiving mechanical ventilation (MV) in children critical care units. The sample included prospective cohort of consecutive adult patients admitted to 19 intensive care units (RCM) from 9 children cities who received Foe more than 12 between September 1st 2003 and September 28th 2003. The result shows that of 588 patients admitted, 156(26.5%) received MV (57% male). The most common indicates for MV, were acute
respiratory failure (71.1%) and coma (22.4%). Assist –control made (71.16%) and synchronized intermittent mandatory ventilation (SIMV) (14.2%) were the most frequently used mean creation of MV and length of stay in ICU were 7.8+ / -8.7 and 11.1+ / -14 days respectively.
Rodling Wahlstrom M Olivecrona M (2008 October), conducted a study on fluid therapy and the use of albumin in the treatment of severe traumatic brain injury (TBI). The protocol used in this study includes albumin administration to maintain normal colloid cosmetic pressure and advocates a neutral to slightly negative fluid balance. The sample included 93 patients with severe TBI and Glasgow coma score (</= 8). The mortality was assessed after 10 and 28 days, 6 and 18 months. The result was total fluid balance was positive4 on days 1to 3, and negative on days 4 to 10. the crystalloid balance was negative from day 2.
6.3 STATEMENT OF THE PROBLEM
“A study to assess the Effectiveness of Planned Teaching Program On knowledge of the
staff nurses regarding care of comatose patients in selected hospitals, Bangalore”.
6.4 OBJECTIVES OF THE STUDY:
- To assess the knowledge of the staff nurses regarding care of the comatose patients.
- To assess the effectiveness of Planned Teaching Program on the care of comatose patients.
- To determine the association between knowledge on the care of comatose patients and selected demographic variables (age, sex, professional qualification, experience etc).
- ASSESS: To find out the staff nurses knowledge regarding the care of comatose patients.
- KNOWLEDGE: Gathering of information from staff nurses in a written form towards a given tool.
- NURSE: “A nurse is a person who has completed a program of basic nursing education and is qualified and authorized in her country to supply the most responsible service of nursing, nature for the promotion of health, prevention of illness and the care of the sick”.
- CARE: Refers to fulfilling the essential needs of a comatose patient by the nurses like patent airway, prevention of pressure ulcer, nutrition, prevention of injury and promotion of health.
- COMATOSE PATIENT: It is a state of sustained unconsciousness in which the patient cannot be aroused even by powerful stimulation.
- Nurses with higher professional qualification will have better knowledge about care of comatose patients.
- Nurses with more experience will have better knowledge about care of comatose patients.
- Nurses exposed to different educational programme (in-service education) will improve their knowledge about care of comatose patients.
- Nurses constantly working with comatose patients will have better knowledge about care of these patients.
H1- Mean post test knowledge score regarding care of comatose patients among staff
nurses will be significantly higher than their mean pre test knowledge score in selected hospitals, Bangalore.
H2- There is a significant association between the knowledge and selected demographic variables (age, sex, professional qualification, experience etc).
6.8DELIMITATIONS:
- This study is limited to those who are trained and qualified in recognized institution and are working in selected hospitals, Bangalore.
- In this study assessment of knowledge is done only through Questionnaire method.
7.1SOURCE OF DATA:
The data will be collected from staff nurses at selected hospitals in Bangalore.
7.1.1RESEARCH DESIGN:
Quasi-experimental design is used to find the effectiveness of planned teaching program on care of comatose patients among staff nurses.
7.1.2SETTING:
The study will be conducted in the selected hospitals in Bangalore.
7.1.3POPULATION:
All registered nurses working in selected hospitals, Bangalore.
7.2 Methods of Data Collection:
7.2.1SAMPLING PROCEDURE:
Purposive sampling techniques will be used to select the sample for the study.
7.2.2SAMPLE SIZE:
50 registered staff nurses.
7.2.3INCLUSION CRITERIA:
- Staff nurses who are willing to participate in the study.
- Staff nurses who are on duty during the period of data collection.
- Both male & female staff nurses
- Staff nurses with GNM, Bsc (N), Msc (N), and M.Phil & Ph.D (N) qualification
- Nurses working in all settings in the hospital.
- Staff nurses who are not willing to participate in the study.
- Staff nurses who are absent during the period of data collection.
- Nurses who are trained but not qualified in recognized institution.
- INSTRUMENT INTENDED TO BE USED:
7.2.6DATA COLLECTION METHOD:
Data regarding staff nurses knowledge on care of comatose patients will be collected by administering the structured knowledge questionnaire.
7.2.7 PLAN FOR DATA ANALYSIS:
The data will be analyzed using both descriptive and inferential statistics on the basis of objectives and hypothesis of the study.
DESCRIPTIVE STATISTICS:
Mean, mode, median, percentage, and standard deviation will be used for assessing their demographic variable and level of knowledge.
INFERENTIAL STATISTICS:
Chi-Square test will be used to find out relationship of the knowledge with demographic variables, ‘t’ test will be used to find out effectiveness of planned teaching program on care of comatose patients .
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS?
-YES, study will be conducted among staff nurses regarding knowledge of care of comatose patients.
7.3HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM VARIOUS INSTITUTIONS.
- Permission will be obtained from the research committee of the Rajiv Gandhi College of Nursing.
- Informed consent will be obtained from the staff nurses of selected hospitals to participate in the study.
- Permission will be obtained from the concerned authority of selected hospitals.
- Joyce M Black, Jane Hokanson Hawks, Medical Surgical Nursing, Lippincott publishers, 6th edition, 1992, page no. 20051.
- Fred Plum and Jerome B, the Diagnosis of stupor and coma, London, page no. 5.
- Perrry, Potter, Fundamentals of Nursing, Philadelphia, Mosbyear Book, page no. 339
- Sorenson Luck Mann, Medical Surgical Nursing, Philadelphia, Saudis Company, 1987, page no. 408.
- John M, Clochesy, Critical Care Nursing, Philadelphia, page no. 684.
- Barker Ellan, Neuroscience Nursing, Philadelphia, Mosbey company, 1995, page no. 169.
- Hickey J, Clinical Practice of Neurosurgical and Neurosurgical Nursing, Philadelphia, J B Lippincott Company, 1992, page no. 361.
- Kumar parveen, Michael clerk , clinical medicine “a text book for medical students and doctors , London 1995, page No. 901-904
- Abdulla FG Levine E 1965 better nursing care through nursing research page No 69
- Alexander F , Margaret, Nursing practice hospital and home, the adult , New York and Tokyo, Lipincot company 1994, page No. 839-857
- Dutt L Diane, Donna L, 1997 “Post comatose unawareness / vegetative state following severe brain injury,” a content methodology, Journal of Neuroscience Nursing, page no. 22-29.
- Kunkel J, 1981, “Nursing management of head injured patient, critical care update 8(3), page no. 22-23.
- Comatose patients – Wikipedia, the free encyclopedia.
- Ciffar C.L 1988, controversies in medical management of head injury clinical neurosurg 34, page No. 68-73
- Tomic v, Espinoza M, characteristics and factors associated with mortality
from URL; www. Pubmed .com
- Suddarth ,Brunner,Text Book of Medical Surgical Nursing,Philadalohia,JP Lippincott publishers ,1988,page no.1292-1295.
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