RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

Ms.SHINU JACOB1ST YEAR MSc NURSINGRAJIV GANDHI COLLEGE OF NURSINGIIT CAMPUSOPP.MEENAKSHI TEMPLEBANNERGHATTA ROADBANGALORE -76

2. NAME OF THE INSTITUTION

RAJIV GANDHI COLLEGE OF NURSING

3. COURSE OF STUDY AND SUBJECT

1ST YEAR MSc NURSINGMEDICAL SURGICAL NURSING

4. DATE OF ADMISSION TO COURSE

16-06-2012

5. TITLE OF THE TOPIC

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE AND ATTITUDE REGARDING PREVENTION OF PRESSURE ULCERS AMONG CARE GIVERS OF PATIENTS WITH NEUROLOGIC IMPAIRMENT IN SELECTED HOSPITALS, BANGALORE.

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6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

“Diseases can rarely be eliminated through early diagnosis or good treatment, but prevention can eliminate disease” Denis Burkitt An individual gives great importance for his health status and quality of life. It is increasingly recognized that health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society.

Research made a drastic change in the field of health science. Because now we live on average 10 years longer than in the 1960's and 20 years longer than in the 1930's. Without research, many diseases that can now be treated would cripple people or result in early death. The development of new medical treatments and cures would not happen without health research and the active role of research volunteers. Research is an important tool for the continual development of a relevant body of knowledge in nursing. It helps us in many other ways like to control the occurrence of undesired outcomes, to enhance client health, and to initiate activities to promote appropriate client behaviour.

Maintaining skin integrity is important. A few client populations are thought to be at greater risk of developing pressure sores because of immobility like paraplegic or quadriplegic patients, patients with decreased sensation due to neurologic disorders, patients with impaired mental capacity and seriously ill patients.

The term Decubitus ulcer, originates from the Latin word decumbere, means "to lie down."1 This is also known as Pressure ulcers, bedsores or pressure sores. Popularly known as pressure ulcer.

Pressure ulcers are a type of injury that affects areas of the skin and underlying tissue. They develop when a large amount of pressure is applied to an area of skin over a short period of time. Or, they can occur when less force is applied but over a longer period of time. The constant pressure against the skin reduces blood supply to that area and the affected tissue dies. The most common place for pressure ulcers are over bony prominence (bone close to the skin) like the elbow, heals, hips, ankles, shoulders, back and the occiput of the head.2

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Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg is considered the average. Thus, keeping the external pressure less than 32 mm Hg should be sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and co morbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients. Pressure ulcers can develop within 2 to 6 hours. Therefore, the key to preventing pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures may be implemented. 3

Pressure ulcers remain a major health problem affecting approximately 3 million adult’s.4 Mortality is also associated with pressure ulcers. In fact Florence Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing.’’ 5 Others view pressure ulcers as a “visible mark of caregiver sin.” 6 Nurses and care givers play a major role in prevention of pressure ulcer, as they are giving all the care for disabled. They should observe for the adequate integrity of the skin and should take all measurements to prevent ulcer.

Only few studies were conducted regarding the importance of frequent position change to prevent pressure ulcer. The first such nursing study was an observational one that divided older adults into three turning treatment groups (every 2 to 3 hours [n = 32], every 4 hours [n = 27], or turned two to four times/day [n = 41]).These researchers found that older adults turned every 2 to 3 hours had fewer ulcers. This landmark nursing study created the gold standard of turning patients at least every 2 hours.

Pressure sores can develop in unexpected place assess the whole client when determining pressure sore risk. Therefore in this case care giver part is very essential one and the nurse’s responsibility is giving health education to family members. The prevention of pressure ulcers represents a marker of quality of care. Pressure ulcers are a major nurse-sensitive outcome. Hence, good care has a major effect on pressure ulcer development and prevention.

Neurological impairments are a group of disorders that primarily relate to the central nervous system comprised of the brain and spinal cord. Among the more common diagnostic categories and conditions are cerebral palsy, epilepsy, brain injury, spinal cord injury, multiple sclerosis, brain tumours, Parkinson's disease, stroke and Tourette’s syndrome. A neurological,

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impairment or disability may affect an individual’s speech, motor skills, vision, memory, muscle actions and learning abilities.

Neurological ailments varying from migraines to Alzheimer's disease, and affect almost 1 billion people across the world," reports the World Health Organization in its Neurological disorders: Public health challenges publication. The report also states that 24 million people are affected by diseases such as Alzheimer's and other types of dementia, while 50 million are affected by epilepsy, which requires far-reaching care.

The loss of sensory perception or impaired level of consciousness prevents the patient from perceiving the pain of pressure and the need to relieve it. Similarly neurological conditions causing paralysis or motor weakness prevents change of posture when pressure is exerted. Surprisingly poliomyelitis affected patients are less prone to pressure ulceration indicating that sensory loss is a more important factor. The sensation of pain and pressure prevents prolonged pressure and hence, the ischemia.

Neurological disorders accounted for 4.2% of the global burden of disease in 1996 which has significantly increased to 6.29% in 2005 assessed by the disability adjusted life years (DALYs) for common neurological disorders. Further rise in burden is expected and by 2030 it is estimated to be 6.77%. An increase in mortality due to neurological disorders from 11.67% of the total mortality in 2005 to 12.22% in 2030 is also anticipated.7 Thus neurological disorders can be considered as a global epidemic.

A report on community survey as a component of Bangalore Urban Rural Neuro epidemiological survey (BURN), disability assessment done using modified Barthel's index showed that 20% of 3128 persons identified with neurological disorders.8

Caregivers are people who take care of other adults, often parents or spouses, or children with special medical needs. Some caregivers are family members; others are paid. They help with: Going to the toilet, bathing and dressing, Eating, Providing Company and emotional support, Food shopping and cooking, House cleaning, paying bills, and giving medicine.

In most countries, family care is the primary means of care giving rather than institutions and they responsible for caring their loved ones who are ill or aged. Patients are best managed by the nurses in hospital environment. But at home the care givers look after their dear ones. It is a truth that, the care givers are the ones who perform nursing tasks in home environment.

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6.1 NEED FOR THE STUDY

Among patients who are neurologically impaired, pressure sore occur with an annual incidence of 5-8%, with life time risk estimated to be 25-85%.moreover, pressure sores are listed as the direct cause of death in 7-8%of all paraplegics.

Pressure sores are common conditions among patients hospitalized in acute- and chronic-care facilities. Prevention of pressure ulcer is always better than treating the complication associated with it, with higher expenses. Pressure ulcer occurs almost exclusively in people with limited mobility, so it is a challenge to prevent the occurrence of pressure ulcer. When considering pressure ulcer prevalence defined as number of clients with at least one pressure ulcer who exist in a client population at a given point in time (WOCN, 2004).More that 1 million individuals develop pressure ulcer each year (WOCN, 2003).Where there is a risk for pressure ulcer development preventive interventions such as skin care practices, elimination of shear and positioning are high priorities.9

The reported incidence of pressure ulcer in acute care facilities ranges from 2.7% to 29.5% and approximately 5-8% annually and 25-85% of these patients develop a pressure sore at some time. The prevalence in acute care setting ranges from 3.5% to 29.5% and 2.4% to 23% in nursing homes and about 20% at home in people older than 65. Studies have suggested that, at any given time, 3-10% of hospitalized persons have pressure sores and 2.7% develop new pressure sores. Among a selected population, the incidence rate for the development of a new pressure sore has been demonstrated to be much higher, with a range of 7.7-26.9%. 10

Pressure ulcers remain a major health problem affecting approximately 3 million adults. In 2003, pressure ulcers were noted in 455,000 hospital stays, 11 years before it was 280,000.The Healthcare Cost and Utilization Project (HCUP) report found a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this time period increased by only 11 percent. It shows the importance of a study to prevent pressure ulcers. The incidence rates of pressure ulcers vary greatly with the health care settings. The National Pressure Ulcer Advisory Panel (NPUAP) says the incidence ranges from 0.4 percent to 38 percent in hospitals, from 2.2 percent to 23.9 percent in skilled nursing facilities, and from 0 percent to 17 percent for home health agencies. There is ample evidence that the majority of pressure ulcers occur relatively early in the admissions process. For patients in the hospital, they can occur within the first 2 weeks. With the increased acuity of

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elderly patients admitted and decreased lengths of stay in hospital, new data suggest that 15 percent of elderly patients will develop pressure ulcers within the first week of hospitalization. For those elderly residents admitted to long-term care, pressure ulcers are most likely to develop within the first 4 weeks of admission.

Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge. Most often, pressure ulcers do not cause death; rather the pressure ulcer develops after a sequential decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality .In the fourth annual Health Grades Patient Safety in American Hospitals Study, which reviewed records from about 5,000 hospitals from 2003 to 2005; pressure ulcers had one of the highest occurrence rates. In US acute care facilities alone, an estimated 2.5 million pressure ulcers are treated each year.11

In addition to these adverse health outcomes, the financial impact of treating pressure ulcers is substantial. A Dutch study found that costs associated with care of pressure ulcers were the third highest after those for cancer and cardiovascular diseases. The HCUP study reported an average cost of $37,800. Cost data vary greatly, depending on what factors are included or excluded from the economic models (e.g., nursing time, support surfaces). It has been estimated that the cost of treating pressure ulcers is 2.5 times the cost of preventing them. Thus, preventing pressure ulcers should be the goal of all nurses.

A study conducted on prevalence of pressure ulcers in hospitalised patients in India. A total of 445 patients hospitalised in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers. Haemoglobin, serum albumin and blood sugar levels of patients with pressure ulcers were recorded. The result was the prevalence of pressure ulcers was high (4.94%). Anaemia, malnutrition and diabetes were important risk factors, while morbidity due to pressure ulcers in long-stay wards, such as neurology, was exceptionally high (40.9%).

Pressure sores can develop in unexpected place assess the whole client when determining pressure sore risk. Care giver have a greater role in preventing pressure ulcer when the patient is at home and even at hospital by giving positioning, checking their nutrition, maintaining good skin care Research indicates that care giving is associated with biomarkers of chronic stress.

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A study conducted to assess the effectiveness of a brochure to prevent pressure ulcers in patient and caregivers. The study group consisted of 33 hospitalized patients and their 33 caregivers. Eighteen percent of patients had a previous history of pressure ulcer, but only 6.1% of the patients had received education regarding prevention of pressure ulcer. The group was provided with verbal educational intervention followed by educational brochure. The result showed that the knowledge level among patient and their relatives were markedly improved after the intervention According to expert patient company, a community interest company in UK, a patient with chronic neurological diseases spends roughly 3 hours/year with a health professional. The other 8757hours they spend with the family. This says the importance of a care giver in physically disabled patients especially with neurological impairments.

A study conducted in Polish, during a 4 month period, 62 caregivers (78% family members and 22% non-related) filled out the questionnaire enquiring about the issue related to pressure ulcer prevention and treatment. Only 11% of questioned person knew what the pressure ulcer was, 42% of caregivers were not aware of possible pressure ulcer causes, and 54.8% were not able to mention any pressure ulcer risk factor.12

Bedridden patients with neurological impairment can be treated only by prolonged care. It may leads to severe complications such as pressure sore. The length of hospitalizations with pressure ulcers is nearly three times longer than hospitalizations without pressure ulcers. This indicates, pressure ulcer is going to be a financial burden for the family. All these problems can be eliminated by a good care giver. The awareness about pressure ulcer is important to provide a good care. Couple of studies conducted among care givers of bedridden patients with neurological impairment states that there is a lack of knowledge. We can empower the care givers with proper education; ultimately, we can decrease the length of hospital stay and re-admissions. Hence, I felt there is a need to educate the care givers of patients with neurological impairment to prevent pressure sore with a consistent good care. This helps the care givers to provide an effective home based care.

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6.2. REVIEW OF LITERATURE

Review of literature provides a basis for evidence based practice, states current knowledge with relevant research literature, justifies need for replications, throws light on the feasibility of the study, indicates constraints of data collection, provides a context for a study and synthesizes evidence based information to gain knowledge and improves nursing practice. It might give a new interpretation of old material or combine new with old interpretations.

The literature reviewed related to the present study is categorized in to the following headings.

1. Literature related to prevalence of pressure ulcer.2. Literature related to neurological patients with pressure ulcer.3. Literature related to care givers knowledge on care of patients with

pressure ulcers.4. Literature related to effectiveness of structured teaching programme.

1. Literature related to prevalence of pressure ulcer.

A cross sectional study conducted to identify the national prevalence of pressure ulcer. National pressure ulcer advisory panel (NPUAP) staging was used and data were collected using two self-administered questionnaires. Results showed that a total of 37307 inpatients in 1170 wards in 1149 hospitals were assessed representing a response rate of 93.5%. Their mean age was 72.3 years and 62% were females. In all 3314(64%) patients had at least one pressure ulcer. The prevalence rate of 8.9% and a total of 4991 pressure ulcers were recorded. They suggested that studies should be encouraged in all health care settings as a means of improving the care provided.13

A study conducted to identify the pressure ulcers prevalence and incidence in intensive care patients. The incidence ranged from 38% to 54%. There was a wide variation in the prevalence and incidence of pressure ulcers in intensive care patients and there was also a gap between theory and practice in the prevention and treatment of pressure ulcers. They suggested that further research is needed regarding the effectiveness of nursing care on pressure ulcers development and into treatments that may successfully prevent their occurrence in intensive care patients.14

A descriptive study conducted to investigate the burden of pressure ulcer associated mortality and to examine racial/ethnic differences and associated morbidities. They concluded that pressure ulcers are associated with fatal septic infections and are reported as a cause of thousands of death each year in the United States. Incapacitating chronic and neurodegenerative

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conditions were common morbidities and mortality rates in blacks were higher than in other racial/ethnic groups.15

A study conducted on pressure ulcer prevalence and incidence of acute care hospital.116 acute care facilities from 34 states participated and the sample of 17,560 patients in hospital –based medical-surgical or intensive care unit. The average length of stay for the participating facilities was 5 days .The result was pressure ulcer in 7% of the subject (n-383)90% were stage I or II pressure ulcer and 73% occurred in patients older than 65yrs.The most sites based on both prevalence and incidence measurements were sacrum and coccyx at 26% and 31% respectively.16

A study done on “prevalence and incidence studies of pressure ulcer in long term care facilities in Canada”, with 95 resident and other with 92 residents were selected for study. Data were collected on demography, medication information and possible contributing factors. The result was pressure of pressure ulcer in the 2 long term facilities was 36.8% and 53.2% respectively. The incidence of pressure ulcer on the long term care facilities was 11.7% and 11.6% respectively. The pressure ulcer prevalence is higher than published figure for the long term care setting .The pressure ulcer incidence of less than 2% in each facility suggests an equal and acceptable level of nursing care in both facilities.17

A study done to “assess selected factors relation to pressure sores among immobilized patients of a selected hospital, with view of developing standard protocol for its prevention”. Data was obtained from 50 immobilized patients or their care givers who were admitted emergency ward ICU .The finding of the study revealed that a proportion of 6.75% patients developed pressure sores during the 40 days stay. 18

A study was conducted about the prevalence of pressure ulcers in a selected hospital in India. A total of 445 patients hospitalized in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers. Prevalence of pressure ulcers was high (4.94%). Anaemia, mal nutrition, and diabetes were important risk factors. In India identifying their associated risk factors at an early stage may go a long way in preventing their occurrence.19

A study conducted about the costs of management of pressure ulcer varies from 1,064 (Grade 1) to 10,551 dollars (Grade 4). Costs have increased as pressure ulcer grade due to the healing time is longer and complications developed due to pressure sore. In UK, the total cost is 1.4–2.1 billion dollars per year (4% of total NHS expenditure). Most of this cost is nurse’s time.

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A cross sectional study conducted regarding the prevalence of pressure ulcers, in a university hospital at Varanasi, India. A total of 445 patients hospitalized in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers.. Results show that the prevalence of pressure ulcers was high (4.94%).

2. Literature related to neurological patients with pressure ulcer

A study conducted on “perception of pressure ulcer among young men with spinal injury” .About 1000 younger people each year suffer a traumatic spinal cord injuries that leaves them wholly or partly paralysed. The majority of these individuals are males. The results suggest that there men were knowledgeable about pressure management and highly motivated to look after themselves but there were an over reliance on the specialist unit for support. 20

A study reported that patients who suffer brain stroke are sat high risk of pressure ulcer after the post acute rehabilitation period from 2002 to 2004 number of subjects who participated in the study were 1100 and was selected randomly from 22 Italian home health agencies. Instructional questionnaire was distributed to know incidence and prevalence of pressure ulcer among brain stroke patients the result showed that 30% of brain stroke patients have pressure ulcer.21

A Study conducted to gather prevalence and risk factor data on pressure ulcers from persons living with spinal cord injury in a community setting. Participant data for 140 individuals, 100 men and 40 women was collected at a single point in time. Thirty-three percent of the participants presented with at least one pressure ulcer, 46% of those with an ulcer had more than one, and 27.6% of all the ulcers were of Stage III or IV severity. Of all ulcers, 69.4% were in the pelvic region and 29.9% were in the lower extremities. Those individuals with ulcers had less voluntary motor control than those without ulcers and were less independent in various activities of daily life. 22

A study Conducted to estimate the point prevalence of pressure sores in a community sample of spinal cord injured patients. Data were collected by questionnaire survey. 472 were eligible for analysis. Point prevalence of pressure sores was 23%. 23

A study was conducted on about quality of life of people with spinal cord injury in India, Identify any association between clinical variable and quality of life, and finally to see the input of remedial measures taken to the quality of life over time. Thirty six (72%) men and 14 (28%) women participated. Mean age and duration of injury were 37.7 and 3.7 years

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respectively. Bladder problems (44%), bed sores (36%), gastrointestinal problems (56%), naturopathic pain (42%) and spasticity (60%) were the most common medical problem. There are 32% reported about the bed sores .24

3. Literature related to care givers knowledge on care of patients with pressure ulcers.

In a study conducted among family caregivers demonstrated a marked lack of knowledge in the areas of the musculoskeletal, integumentary, and respiratory system processes, as well as in the prevention of pressure ulcers and foot drop. These family caregivers also mentioned the need to search for additional information in other sources such as the Internet, other professionals or other people with experience in caring for dependents.25

A study carried out on family caregivers of 44 bedridden patients, on effectiveness of STP on prevention of pressure sore. A closed ended questionnaire with 31 items was used to assess the knowledge regarding prevention of pressure sores and their leaning needs was assessed using open ended questionnaire. The findings showed that the mean post test knowledge score (22.73) and the SIM was effective in increasing the knowledge level of family care giver of bedridden patients.26

A study conducted on delivering pressure sore care in community mentions that lot of time and effort is devoted to prevention and management of pressure sores in hospital setting but little importance is given to continuity of care at home. This study reveals that the education of a care giver plays an important role in reducing the risk of pressure sores. 27

A study done on “knowledge of pressure ulcer by under graduate nursing students in Brazil”. Third and fourth year undergraduate baccalaureate students at a public university in a Brazil CN= 38 were asked to provide demographic information, identify extracurricular activities and complete the pressure ulcer knowledge test. Students correctly answered 67.71 of the pressure ulcer knowledge list items. The result was students who participated in extracurricular activities and used the internet had significant impact on knowledge test score. Generally the students were found to have low pressure ulcer knowledge.28

A study analyzed the perception of information received by family caregivers during the hospitalization of the dependent person. In a sample of 40 family caregivers, she concluded that caregivers weren’t given information related to “activities the patient can do” (77.5%); “activities the patient should avoid,” as well as “food the patient can eat” (70%); “when to return to hospital if experiencing problems post-discharge” (75%); and “potential complications to watch for” (80%). In general, they received very little information from health care professionals concerning the patient’s care at home.29

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4. Literature related to effectiveness of structured teaching programme

A study conducted on “effectiveness of Individual Planned Teaching to the care givers on prevention of pressure sore in bed ridden patients admitted in a selected Hospital. A quasi experimental approach with one group pre-test and post-test adopted for study a sample of 30 care givers of 30 bedridden patients. They were selected by using convenience sampling technique. The result was most of the caregivers (63%) had no prior experience of staying with the patients in the hospital. Majority (90%) of caregivers had a very good knowledge scores (81-100%) in the post test. The mean difference between post-test and pre-test knowledge scores on prevention of pressure sores which was found to be significantly high (29) = (p<0.05)92.30

A study conducted to determine the effectiveness of a planned teaching programme on prevention of pressure ulcer for immobilized patients among care givers . A total of 55 caregivers were selected by stratified random sampling method. The study was adopted one-group pre-test- post-test design. Data were collected by using structured questionnaire method. Impact knowledge to care givers by using structured teaching programme. The study also revealed that care givers gained knowledge after the structured teaching programmed. Analysis data shows that the post test knowledge score has significantly higher than the pre-test knowledge score at P < 0.01 level significance. The investigators concluded that the structured teaching programme was a good method conveying information to clients or care givers and it is very effective in order to gain knowledge.31

A study conducted on effectiveness of structured teaching care givers in the family on prevention of pressure sore among spinal cord damaged patients. The study conducted that teaching plan are various aspects of pressure sores and its prevention for family care givers of patients with spinal cord damage was effective method for providing adequate knowledge.32

A study to assess the effectiveness of a brochure to prevent pressure ulcers in patient and caregivers. The study group consisted of 33 hospitalized patients and their 33 caregivers. Among the samples half of the subjects (54.5%) were women and 60.5% were more than 65 years of age. In the group, slightly more than 60% were diagnosed as moderate risk and 39.4% were diagnosed as high risk for getting pressure ulcer. The samples were categorized on the basis of Braden Scale scores. Eighteen percent of patients had a previous history of pressure ulcer, but only 6.1% of the patients had received education regarding prevention of pressure ulcer. The group was provided with verbal educational intervention followed by educational

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brochure. The result showed that the knowledge level among patient and their relatives were markedly improved after the intervention.

A study found that pressure ulcer prevention and management is beneficial not only to patients but also to the health care system so education for healthcare professionals is an important factor in the prevention and management of pressure ulcers; however, in the current climate releasing staff to attend study days is becoming difficult. In some locations, staff has to travel long distances in order to attend while locally based study days are poorly attended. Developing e-based learning system was seen as a realistic option for nurses working in Trust within a large geographical area.33 A study conducted for “evaluation of an evidenced based programme for pressure sore prevention”. The purpose of the study was to implement and evaluate a standardised workshop for and two levels of nursing staff. A quasi experimental design was used. The convenient sample included registered nurses (n=595) and licensed practitioner nurses (n=59) employed in there acute care hospital with a total bed capacity of 1760. The questionnaire was pilot test, before use pre-test post- test with three month duration. Data was analysed using descriptive statistics. The result was general knowledge course for the total groups were significantly higher. The evidence based pressure ulcer education was effective increasingly in registered nurses and licensed practical nurses knowledge.34

A study conducted on clients regarding effect of implementing clinical guidelines to prevent pressure ulcers in home care . The research designed to have the three stages of: 1) baseline data collection, 2) guideline implementation,3) repeat of baseline data collection. Pre-test data was collected in 2002, two years later, after administering guidelines Post-test data was collected. The prevalence of pressure ulcers decreased from 42% in 2002 to 19% in 2004.35

According to a study conducted, education of nurses, doctors ,care assistants, patients and their relatives is vital in dealing and prevention of pressure ulcers . In order to achieve this it is desirable to have a designated specialist nurse whose aims are to define, develop, implement and evaluate a pressure ulcer prevention policy. Patients with pressure ulcers suffer pain and distress from wounds that can require treatment for many months following discharge from hospital.36

6.3. STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of structured teaching programme on knowledge and attitude regarding prevention of pressure

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ulcers among care givers of patients with neurologic impairment in selected hospitals, Bangalore’’

6.4. OBJECTIVES OF THE STUDY

To assess the pre-test level of knowledge among care givers of patients with neurological impairment regarding prevention of pressure ulcer.

To assess the pre-test attitude level among care givers of patients with neurological impairment about prevention of pressure ulcer.

To develop a STP regarding pressure ulcer.

To determine the effectiveness of STP regarding prevention of pressure ulcer among caregivers of patients with neurological impairment.

To find out association between pre-test knowledge with selected demographic variables of care givers of patients with neurological impairment.

To find out association between pre-test attitude with selected demographic variables of care givers of patients with neurological impairment.

6.5. OPERATIONAL DEFINITIONS

1. Effectiveness: It refers the extent to which the planned teaching programme has achieved the desire effect as measured by gain in knowledge and change in attitude.

2. Structured teaching programme: It refers to information providing about pressure

ulcer which includes definition, causes, sign and symptoms, stages, treatment, prevention, complication and care givers responsibility in caring for bedridden patients.

3. Knowledge: It can refer the total understanding of a person about measures to prevent pressure ulcer.

4. Attitude: In this study it refers to the way of thinking, belief and feeling regarding prevention of pressure sore among caregivers of bedridden client

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5. Prevention: Includes measures adopted to protect patients from developing pressure ulcer.

6. Pressure ulcer: It is localized area of tissues necrosis caused by unrelieved pressure due to prolonged lying.

7. Care givers: Caregiver refers the individual who help the bed-ridden patient at home and hospital. It may be a husband, wife or an adult son or daughter, also be friend or even professional home health aid.

8. Neurologic impairment: It refers to the patients with disorders affecting the central nervous system which leads to physical disability and bedriddeness.

9. Hospital: It refers to a health care institution providing care for neurologically impaired patients by specialized staffs and equipment.

6.6. ASSUMPTIONS

Care givers of neurologically impaired patients have less knowledge regarding prevention of pressure sore.

The structured teaching programme will have an influence on knowledge regarding prevention of pressure sore.

Improvement of knowledge regarding pressure sore helps to prevent pressure ulcers.

6.7 HYPOTHESIS

H1: The mean post-test knowledge score will be significantly higher than pre-test knowledge score regarding prevention of pressure ulcer among care givers of patients with neurologic impairment.

H2: The mean post-test attitude score will be significantly higher than pre-test knowledge score regarding prevention of pressure ulcer among care givers of patients with neurologic impairment.

H3: There will be significant association between post test knowledge scores with selected demographic variables.

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H4: There will be significant association between post test attitude scores with selected demographic variables.

6.8. DELIMITATIONS

Study is limited to the caregivers of neurologically impaired patients admitted in a selected hospital

Study is limited in assessing the caregiver’s knowledge and attitude by using structured questionnaire.

Study limited to 50 samples

Study limited to care givers who can understand kannada or English.

7. MATERIALS AND METHOD

7.1. SOURCE OF DATAThe data will be collected from care givers of neurologically impaired patients in a selected hospital from Bangalore.

7.1.1. Research DesignOne group pre-test and post test research design is selected for this study.

7.1.2. SettingsThe study will be conducted in a selected neuro hospital at Bangalore

7.1.3. PopulationCare givers of neurologically impaired patients in selected hospital, Bangalore.

7.2. METHODS OF DATA COLLECTION

7.2.1. Sampling ProcedureConvenient sampling technique will be used for the study

7.2.2. Sample Size

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50 care givers of neurologically impaired patients

7.2.3. Inclusion Criteria Care givers of neurologically impaired patients Who are willing to participate in the study Those who can read and write English and Kannada Care givers of both male and female patients admitted in the

hospital.

7.2.4. Exclusion Criteria Care givers who are health care professionals. Patients who are admitted except with neurological

problems. Care givers who are not cooperate. Care givers in other hospital

7.2.5. Instruments Intended To Be Used Demographic variables. Structured knowledge questionnaire on prevention of

pressure sore. Structured attitude scale on care of pressure sore among care

givers.

7.2.6. Data Collection MethodData will be collected by administering the structured knowledge questionnaire and attitude scale.

7.2.7. Plan For Data AnalysisThe data will be analysed using both descriptive and inferential statistics on the basis of objective and hypothesis of the study.

Descriptive statistics Mean, mode, median, percentage, and standard deviation will be used for assessing their demographic variable.

Inferential statistics Chi-square test will be used to find out relationship of the knowledge and attitude with demographic variables.’T’ test will be used to find out effectiveness of structured teaching programme on pressure ulcer prevention.

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7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMAL?

Yes, the study can be conducted among care givers of bedridden patients by administering the structured knowledge questionnaire and attitude scale in selected neuro hospital, Bangalore.

7.4. HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM VARIOUS INSTITUTIONS?

1. Permission will be obtained from the research committee of Rajiv Gandhi College of Nursing.

2. Informed consent will be obtained from the director or medical officer of selected hospital at Bangalore.

3. Informed consent will be obtained from the care givers of patients in selected hospital to participate in the study.

8. LIST OF REFFERENCES

1. Pressure ulcer, Wikipedia, the free encyclopaedia

2. Black.M.Joyce, “Medical Surgical Nursing. Clinical Management For Positive Outcomes”, 7th edition, 2005, Elsevier Missouri, pg: 1403.

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3. Landis EM, “Micro-injection studies of capillary blood pressure in human skin.”, Heart 1930,15:209.

4. Eckman KL, “The prevalence of dermal ulcers among persons in the U.S. who have died.”, Deceits 1989,2:36–40.

5. Nightingale Florence, “Notes on nursing: what it is, and what it is not”. New York, D Appleton and Company, 1860.

6. Bliss MR, Thomas JM, “A basis for future action: applying clinical findings of trials on pressure-relieving supports to practice: kinetic treatment table versus “normal” bed with two-hourly turning. Prof Nurse.”, 1993,8:726, 728, 730.

7. World Health Organisation, “Neurological disorders: public health challenges.” Geneva, 2006.

8. Organization of neurology services in India, “Unmet needs and the way forward”, 2008, volume 56, page 4-12.

9 Perry. Potter, “Fundamentals of Nursing”, 7th edition, 2009, Elsevier Missouri, pg: 1228-1231

10. Bradon J Wilhelmi, “Pressure Ulcers ,Surgical Treatment and Principles”Southern Illinois University School of Medicine, 2010

11. Oot-Giromini B, Bidwell FC, Heller NB, et al, “Pressure ulcer prevention versus treatment, comparative product cost study. Decubitus. 1989, 2(3):52–4.

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1 SIGNATURE OF THE CANDIDATE

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2 REMARKS OF THE GUIDETHIS STUDY IS ESSENTIAL TO PREVENT PRESSURE ULCER AMONG ALL NEUROLOGICALLY IMPAIRED BEDRIDDEN PATIENTS.

3 NAME AND DESIGNATION OF THE GUIDE

Mrs. RAFI UNNISA.PASSOCIATE PROFESSOR

4 SIGNATURE

5HEAD OF THE DEPARTMENT

Mrs. RAFI UNNISA.P

6 SIGNATURE

7REMARK OF THE CHAIRMAN AND PRINCIPAL

THIS STUDY IS ESSENTIAL TO CONDUCT AMOUNG CARE GIVERS FOR BETTER PROGNOSIS OF CLIENTS.

8 SIGNATURE OF THE PRINCIPAL

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