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A STUDY TO ASSESS THE KNOWLEDGE OF MOTHERS OF INFANTS
REGARDING ASPIRATION PNEUMONIA IN A SELECTED PEDIATRIC
HOSPITAL AT BANGALORE WITH A VIEW TO DEVELOP AN
INFORMATION BOOKLET.
M.Sc. Nursing Dissertation Protocol submitted to
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
By
Mr. DAYANAND .G.HIREMATH
M.Sc NURSING 1ST YEAR
2011-2013
Under the Guidance of
Mrs.THENMOZHI HOD, Department of Pediatric Nursing
National College of Nursing
Hegganahalli Cross
Vishwaneedam Post
Bangalore –91
RAJIVGANDHI UNIVERSITY OF THE HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. NAME OF THE CANDIDATE
AND ADDRESS
MR. DAYANAND .G.HIREMATH 1st YEAR M.Sc NURSING NATIONAL COLLEGE OF NURSING, BANGALORE
2 NAME OF THE INSTITUTION NATIONAL COLLEGE OF NURING GANDHADAKAVALHEGGANAHALLI CROSSVISHWANEEDAM POST, MAGADI ROADBANGALORE-91
3 COURSE OF THE STUDY AND
SUBJECT
M.Sc. NURSING PEDIATRIC NURSING
(CHILD HEALTH NURSING)
4 DATE OF ADMISSION TO
COURSE
05-09-2011
5TITLE OF THE STUDY
“A STUDY TO ASSESS THE KNOWLEDGE OF MOTHERS OF INFANTS
REGADING ASPIRATION PNEUMONIA IN SELECTED PEDIATRIC
HOSPITALS AT BANGALORE WITH A VIEW TO DEVELOP AN
INFORMATION BOOKLET.”
6 BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION
Aspiration pneumonia is bronchopneumonia that develops due to the
entrance of foreign materials that enter the bronchial tree, usually oral or gastric contents
(including food, saliva, or nasal secretions). Depending on the acidity of the aspirate, a
chemical pneumonitis can develop, and bacterial pathogens (particularly anaerobic
bacteria) may add to the inflammation. Aspiration pneumonia is often caused by an
incompetent swallowing mechanism, such as occurs in some forms of neurological
disease (a common cause being strokes) or while a person is intoxicated. An iatrogenic
cause is during general anesthesia for an operation and patients are therefore instructed to
be nil per os (NPO) for at least four hours before surgery Whether aspiration pneumonia
represents a true bacterial infection or a chemical inflammatory process remains the
subject of significant controversy. Both causes may present with similar symptoms. Initial
bacteriologic studies into the causative organisms revealed the anaerobic species to be the
predominant pathogens in community-acquired aspiration pneumonia. 1
However, subsequent studies revealed that Streptococcus
pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae are
the most common organisms. Hospital-acquired aspiration pneumonia, on the other hand,
is often caused by gram-negative organisms including Pseudomonas aeruginosa,
particularly in intubated patients.
This syndrome most commonly occurs in individuals with chronically
impaired airway defense mechanisms. This includes gag reflex, coughing, ciliary
movement, and immune mechanisms, all of which aid in removing infectious material
6.1
from the lower airways. Other risk factors include poor dentition and poor oral care,
which both increase the bacterial burden of oropharyngeal secretions. Clinicians must thus
surmise this diagnosis when a patient presents with risk factors and radiographic evidence
of an infiltrate suggestive of aspiration pneumonia. The location of the infiltrate on chest
radiograph depends on the position of the patient when the aspiration occurred.2
NEED FOR STUDY Aspiration pneumonia is defined as the development of an infiltrate in a
Patient at increased risk of oropharyngeal aspiration. It occurs when a patient inhales
Material from the oropharynx that is colonized by upper airway flora.. It affects
Individuals of all ages, but occurs most frequently in children. Among children
pneumonia is the most common cause of death worldwide. In developing world today
many deaths from bronco pneumonia are also preventable by immunization or access to
simple, effective treatments.1 Aspiration pneumonia is more common in males than in
females. Any condition that reduces a patient's gag reflex, ability to maintain an airway, or
both increases the risk of aspiration pneumonia or pneumonitis.CVA,Intracranial mass
lesion Head trauma Alcohol abuse Drug overdose Isolated alteration of the swallowing
reflex associated with pharyngeal disease.1
The mortality associated with aspiration pneumonia mimics that of
Community-acquired pneumonia: approximately 1% in the outpatient setting and up to
25% in those requiring hospitalization. This mortality range depends on complications of
the disease. The mortality rate for severe chemical pneumonitis (Mendelson syndrome)
can be up to 70%.Without treatment, aspiration pneumonia is associated with a high
incidence of cavitations and abscess formation in comparison to community-acquired
pneumonia. Other complications of both aspiration pneumonia and pneumonitis include
empyema, acute respiratory distress syndrome, and respiratory failure. Aspiration
pneumonitis can rapidly progress to respiratory failure. 3
Few studies have been designed that
distinguish between aspiration pneumonia and aspiration pneumonitis. Several studies
suggest that 5-15% of the 4.5 million cases of community-acquired pneumonia result from
aspiration pneumonia.2 Approximately 10% of patients who are hospitalized after drug
overdoses will have an aspiration pneumonitis.
Every year 0.9 million infants die from
aspiration pneumonia. Indeed, it is the leading cause of child death in the world. The
millennium development goal target of reducing the infant mortality rate by two-third by
2015 has renewed interest in accurate assessment of the number of children affected and
underlying causes.. A paper in the world health organization (WHO) bulletin reviews the
history and current status of knowledge on pneumonia in infants. The 1993 world
development report estimated the proportion of childhood deaths caused by acute
respiratory infections at around 30%.4
WHO established child health epidemiology
reference group (CHERG) in2001 to review epidemiological data on the main causes of
death for the year 2000.Globally there were 88 million new episodes of childhood
aspiration pneumonia, occur 95% in developing countries. The incidence of clinical
aspiration pneumonia –the risk of developing it within a specified period of time –in
infants in developing countries is almost 29%.In developing countries 8.7% of childhood
aspiration pneumonia cases (13.1 million0 are life threatening and requires
hospitalization. Around 1 million children under five years die from aspiration
pneumonia each year, mostly in the African and South East Asia regions. Over half of the
new pneumonia cases occur in 6 countries – India (43 million),China (21
million),Pakistan (10 million).Bangladesh, Indonesia and Nigeria (6 million each).
In Karnataka, age distribution of prevalence rate of major killer disease
like aspiration pneumonia is 5 % among infants . Pneumonia ranks first among health
problems requiring attention in the health centers. The most vulnerable members of the
population are infants who live in developing countries. On average 2-3% of children each
year have pneumonia severe enough to require hospitalization and many of these disease
episodes are potentially fate. This suggest that of every thousand children’s born alive 12-
20 die from pneumonia before their fifth birthday.5
Recently WHO has decided to launch an annual
“World pneumonia day” on November 2nd, 2009.This day will mobilize effects to fight
pneumonia tightly called a ‘neglected’ or ‘forgotten’ disease that kills more than 2million
children under the age of five each year worldwide. World over pneumonia kills more
than any other illness – AIDS, Malaria and Measles. About 156 million new episodes
occur each year worldwide, of which 151 million episodes are in the developing countries.
Of all community cases,7-13% are severe enough to be life threatening and requires
hospitalization. In India also 25,000 infants die of aspiration pneumonia each year.
“Millennium development goals (MDG)”- to reduce under five mortality by two-third by
2015 are to be achieved.4
The recent studies and statistics throws the light that aspiration
pneumonia is an important problem in this contemporary epoch and more infants are
affected with aspiration pneumonia. This is mainly due to unhealthy environment and
poor knowledge among the parents regarding the disease condition. So it is evident that
children’s especially under fives are vulnerable to this disease condition and through
teaching programme the mortality and morbidity rate can be controlled and prevented to a
great extent. So the investigator is very much interested in doing this topic.
6.2 REVIEW OF LITERATURE
INTRODUCTION
Review of literature is a key step in the research process. The typical purpose
of analyzing a review of existing literature is to generate questions and to identify what is
known and what is unknown about the topic. The major goals of review of literature are
to develop a strong knowledge base to carry out research and non research scholalarly
activity.
The review has been divided under the following headings:
a) Studies related to incidence, riskfactors, and etiology of aspiration pneumonia. (b) Studies related to mortality of aspiration pneumonia. (c) Studies related to assess knowledge of mothers regarding aspiration pneumonia
STUDIES RELATED TO INCIDENCE, ETIOLOGY,RISKFACTORS OF
ASPIRATION PNEUMONIA.
A study was conducted in unites state of America
in2010 to show the relation between Seizures and aspiration pneumonia The results were
33 seizures (5.6%) occurred while patients were eating or drinking, 14 with food in the
mouth at onset. 4 (0.6%) were followed by post-ictal emesis. Supplemental oxygen was
provided in 93% of GTC seizures, and oral suctioning in 85%. such as oral suctioning 6
A study was conducted to identify the causes and contributing
factors of persistent aspiration pneumonia in under five children comprising of 41 cases
out of 41 cases, 8 had pulmonary tuberculosis and 12 had Gram negative bacterial
infections, 12 had aspiration due to gastro esophageal reflux disease or oil instillation, 3
had immunodeficiency due to HIV infection, 2 had congenital lung malformation, 2 had
cardiac disorders and one had foreign body aspiration as causes of persistent aspiration
pneumonia. The most common underlying cause of persistent pneumonia were persistent
infection followed by aspiration and acquired immunodeficies.7
STUDIES RELATED TO MORTALITY OF ASPIRATION PNEUMONIA.
A study Was conducted to study the changing pattern of infant mortality
rate in china .The infant mortality rate in China dropped to, 20.6 per 1000 live
births in 2006, respectively, comparing to 39.7 per 1000 live births in 2000. In urban
areas, Infant Mortality Rate (IMR) dropped to 9.6 per 1000 live births in 2006,
respectively while they were and 13.8 per 1000 live births respectively in 2000. In rural
areas, infant mortality rate dropped to and 23.6 per 1000 live births in 2006, respectively
but they were 45.7 per 1000 live births respectively in 2000. During this period, the
mortality rates due to aspiration pneumonia had dropped sharply. The proportion of
deaths due to pneumonia, dropped from 19.5%, in 2000 to 15.6%, in 2006, respectively.
In urban areas, the proportion of deaths due to pneumonia dropped from 9.9% in 2000 to
9.8% in 2006, In rural areas, the proportion of d deaths due to aspiration pneumonia
dropped from 20.1% to 16.2%.8
A retrospective survey was conducted of all
patients with severe aspiration pneumonitis requiring artificial ventilation in our Intensive
Care Unit from 2002-2006 inclusive. Of 38 infants , 8 (21%) died. Five of these deaths
were due to severe primary intracranial pathology, and occurred after complete or almost
complete resolution of the pneumonitis. One death (2.5%) due to myocardial infarction
was possibly related to aspiration, and 2 deaths (5%) were definitely related to aspiration.
The 7.5% mortality related to aspiration is considerably lower than in previous clinical
studies of severe aspiration pneumonia..9
A study Was conducted Over a 9-yr period, among
505 patients exhibiting severe community-acquired pneumonia and admitted into a total of
six medical ICUs in the north of France. During the 9-yr period study, 505 patients were
retrospectively (n = 337) and prospectively (n = 168) collected. Among them,
116 patients (23%) were retrospectively (n = 73) and prospectively (n = 43) defined as
exhibiting an aspiration pneumonia. For them, main medical grounds of ICU admission
were respiratory distress in 54 patients (Group 1) and neurological disturbances in
62 patients (Group 2). For the remaining 389 patients (Group 3) no criteria for aspiration
was present. Using monovariate analysis, comparison between Group 1 and Group
2 revealed some significant differences: In Group 1, patients were older (5year versus 1 yr,
p < 0.0001), had a more severe underlying diseases (anticipated death within 5 yr, 50%
versus 16%, p = 0.001), suffered more frequently from chronic respiratory insufficiency
(30% versus 8%, p = 0.003) and exhibited, at presentation, a lower PaO2/ FIO2 (223 versus
280 mm Hg, p = 0.01). Respectively, in Group 1 and 2, underlying immunosuppression
(2 patients versus 1 patient) (15% versus 8%), mean SAPS and OSF score, presence of
initial shock, chest X-ray involvement, and biological data such as mean PaCO2
(35.9 versus 36.6 mm Hg), mean serum creatinine (17.4 versus 13.7 mg/l), mean total
serum protein (60.4 versus 64.7 g/l), mean platelets count (258,000versus 208,000/mm3)
and mean leukocytes count (15,000 versus 12,400/mm3) were not significantly different.
Significant differences in comparing characteristics of patients with(Groups 1 and 2) and
without (Group 3) aspiration pneumonia were as followed: In patients with aspiration
pneumonia mean age was lower (4 versus 1 year, p = 0.00001), underlying diseases were
less severe (anticipated death within 5 yr were, respectively, 32% versus 48%; p = 0.004),
chronic respiratory insufficiency was less frequent (18% versus 49%, p = 0.001), = 0.04)
and, on admission, mean PaCO2 (36.3 versus 43.7 mm Hg, p = 0.001) was lower.10
STUDIES RELATED TO ASSESS KNOWLEDGE OF MOTHERS REGARDING
ASPIRATION PNEUMONIA.
A study was conducted to assess the Mothers' knowledge, attitudes and
practices regarding acute respiratory infections in children in Baringo District, Kenya.
A total of 309 mothers were interviewed. Their mean age was 31.5 years (range 16-51)
and 34% had no formal education. Only 18% of mothers described pneumonia
satisfactorily. 60.2% knew that measles is preventable by immunization. 87.1% of the
mothers said they would seek health center services for severe ARI. Formal education
had a positive influence on the KAP of the mothers: The study reveals that the mothers
had good knowledge of mild forms of ARI but not the severe forms like aspiration
pneumonia 11
6.3
A study was conducted to determine Maternal perception of pneumonia in
in Enugu, eastern Nigeria. 400 women were interviewed using a pre-
tested structured questionnaire. Sixty-one per cent of them would recognize pneumonia
by difficult breathing, 42% by fast breathing and 26.5% by severe cough. Few of the
mothers mentioned signs suggestive of 'chest in drawing' (8.5%) and 'central cyanosis'
(1%). The maternal knowledge score on pneumonia signs increased significantly with
educational status and social class (p < 0.05). 12
A study was conducted among mothers to assess the knowledge and
recognition of aspiration pneumonia. The study population consists of 501 mothers. The
findings show that about 84% of the mothers said that they knew what aspiration
pneumonia is.68.7% said that pneumonia is caused by lack of parenteral care.28.9%
believed that virus causes the disease. More than 80% correctly picked rapid breathing
and chest retractions from a list of possible signs and symptoms of pneumonia..13
STATEMENT OF PROBLEM:
“A STUDY TO ASSESS THE KNOWLEDGE OF MOTHERS OF INFANTS
REGARDING ASPIRATION PNEUMONIA IN SELECTED PEDIATRIC
HOSPITALS AT BANGALORE WITH A VIEW TO DEVELOP AN INFORMATION
BOOKLET.”
6.4
6.5
6.6
OBJECTIVES OF THE STUDY
The objectives of the study are:
To assess the knowledge of mothers of infants on aspiration pneumonia.
To associate the knowledge with selected demographic variables such as
age,religion,education of the parents, type of family, number of children, area of
Residence, income.
To develop an information booklet.
HYPOTHESIS
The hypothesis will be tested at 0.05 level of significance.
H 1: There will be significant association between knowledge of Mothers of
infant and selected demographic variables such as age,religion,education.of the
parents, type of family, number of children, area of residence, income.
OPERATIONAL DEFINITIONS:
ASSESS It refers to the process used to identify the level of knowledge of mothers
regarding Aspiration pneumonia.
KNOWLEDGE
In this study it refers to the correct responses of the mothers to the knowledge
part of the questionnaire of the interview schedule and expressed as knowledge scores
6.7
6.8
ASPIRATION PNEUMONIA
It is a type of pneumonia that develops due to the entrance of foreign materials
that enter the bronchial tree, usually oral or gastric contents (including food, saliva, or
nasal secretions). Depending on the acidity of the aspirate, a chemical pneumonitis can
develop, and bacterial pathogens (particularly anaerobic bacteria) may add to the
inflammation.
MOTHERS In this study the word refers to the mothers with infants suffering from aspiration
Pneumonia.
INFANTS In this study the term refers to the children between the age group one month to
one years of age.
ASSUMPTIONS
Mothers will improve the knowledge regarding causes, prevention and
management of aspiration pneumonia
Mothers are best conveyors of health information to other mothers and to family.
DELIMITATIONS:The study is delimited to :
mothers who are having children between the age group one month to one years
of age.
who knows kannada or English
Study period is 4 weeks.
6.9
7.0
PROJECTED OUTCOME:
The present study will help the mothers of infant to understand about the
causes, prevention and management of aspiration pneumonia and hence it will help to
bring mortality.
MATERIALS AND METHODS
7.1 SOURCE OF DATA
The data will be collected from mothers of infants who are
Admitted in the hospital.
7.1.1 RESEARCH DESIGN
The research design adopted for this study is descriptive design
.
RESEARCH APPROACH
Survey approach will be used for the study
7.1.2 SETTING:
The study will be conducted in K C G hospital. at Bangalore. It is 15 km away from
the College.
7.1.3 POPULATION
The populations selected are mothers of infants who are admitted in the hospital.
7.2 METHOD OF DATA COLLECTION
7.2.1 SAMPLING PROCEDURE
The Sampling Technique adopted for this study is Non-probability convenient
sampling.
7.2.2 SAMPLE SIZE
The sample size is 60.
7.2.3 INCLUSION CRITERIA
The criteria for sample selection are mothers of under five who
Have children aged less than 1 year
willing to participate in the study
know kannada or English language
7.2.4 EXCLUSION CRITERIA
Children above 1yearsof age
Infants who are affected with diseases other than aspiration pneumonia
7.2.5 INSTRUMENT INTENDED TO BE USED
SELECTION OF TOOL
This consist of three parts :
PART 1 :consist of demographic variables such as age,religion,education of the parents,
type of family, number of children, area of residence, income
PART 2: Questionnaire will be used to assess the knowledge.25 Questions will be used.
SCORING PROCEDURE
For knowledge assessment
For Answers. If answer is yes 1
If answer is no 0
SCORING INTERPRETATION Good :- 75-100%
Average :- 50-75%
Poor: - Below 50%
7.2.6 DATA COLLECTION METHOD
Prior permission will be obtained from the Nursing Superintendent and Ward In-
charge before conducting the study. Interview will be conducted between 10 am to 3
pm. Data will be collected from 5 samples per day. The duration will be 4 weeks. The
duration of study will be 30 minutes will be spent per each subject.
7.2.7 PILOT STUDY
6 samples will be selected and study will be conducted to find out the feasibility.
7.2.8 DATA ANALYSIS PLAN
The data obtained will be analyzed in view of the objectives of the study
using descriptive and inferential statistics.
The plan for data analysis was as follows: -
Frequencies and percentage of distribution will be used to analyze
the demographic data.
Mean, Median and Mode, Standard deviation is used for accessing
the knowledge scores.
Chi-square test to find out the association between knowledge
with selected demographic variables. The significant findings will
be experienced in tables, figures and graph.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER
7.4
HUMANS OR ANIMALS?
- No-
HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?
YES, Ethical clearance will be been obtained from the research committee
of National college of nursing.
Consent will be taken from the hospital and permission will be taken from
the study subjects before the collection of data.
8.0 LIST OF REFERENCES
1.A.Parthasarathy ,P.S.N Menon ,Piyush Gupta, M.K.C Nayar .”Text book of Pediatrics”
4th edition.New Delhi:Jaypee brother’s Publishers;2009;pno 578.
2. Cotran, Ramzi S,Kumar, Vinay, Nelso Fausto, Robbins.” Pathologic basis of disease”
6th edition . St. Louis: Elsevier Saunders; (2005) ; pno 749.
3.International child disease and developmental research.” Health and Science Bulletin”;
4(2); June 2006.
4 WHO Bulletin”Global estimate of clinical incidence of clinical pneumonia among
children under five years of age”;2004.
5.Agnihotrao, V.Ramana kumar, etal.”Respiratory disease burden in rural India”:2005.
6. Noe KH, Tapsell LM, Drazkowski JF,”Epilepsy and Pneumonia “The American
Journal on Pediatrics 2010 Nov 29 11;4(11):pg 77-76.
7. Kumar M, Biswal N, Bhuvaneswari V, Srinivasan S. “Persistent pneumonia:
Underlying cause and outcome”.Indian Journal of Pediatrics: 2009 Nov 26.
8. Wang YP, Zhu J, Et al. “Analysis on under-5 mortality rate and the leading kinds of
diseases”. 2009 May;30(5):466-70.
9. Hickling KG, Howard R, “Aspiration pneumonia Mortality”. Intensive Care Medical journal . 2008;june 14(6):617-22.
10. Ye Y,Zulu E,et al.” pattern of pneumonia mortality among infants
”.Journal on tropical medicine and hygiene:Nov;81(5):770-5.
11 .Simyu D.E,Wafula E.M,Nduati R.W.”Mothers knowledge,attitudes and practices
regarding acute respiratory infections in children”.East African medical
journal:2003;June;80(6):303-7.
12 .Uwaezuoke SN, Emodi IJ, Ibe BC.” Maternal perception of pneumonia in children”.
Annals of Tropical Paediatrics:2002 Sep;22(3):281-5.
13 .S.fuchg, etal.”The burden of pneumonia in children in Latin America”. Paediatric
respiratory review: vol 6; 2000.
9. SIGNATURE OF THE CANDIDATE
10. REMARKS OF THE GUIDE
11. NAME AND DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3CO-GUIDE
11.4SIGNATURE
11.5 HEAD OF DEPARTMENT
11.6 SIGNATURE
12 12.1 REMARKS OF THE PRINCIPAL
12.2 SIGNATURE