synopsis - rguhs.ac.in file · web viewa study to assess the effectiveness of self instructional...
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESKARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. Name of the candidate and address (in block letters)
ASHLY JOSEI YEAR M. Sc. NURSINGINDIRA NURSING COLLEGEFALNIRMANGALORE - 575002
2. Name of the Institution INDIRA NURSING COLLEGEFALNIRMANGALORE - 575002
3. Course of Study and Subject M. Sc. NURSINGOBSTETRICS AND GYNAECOLOGICAL NURSING
4. Date of Admission to the Course 28.06.2012
5. Title of the study
A STUDY TO ASSESS THE EFFECTIVENESS OF SELF
INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING
ASSESSMENT AND MANAGEMENT OF ECTOPIC
PREGNANCY AMONG STAFF NURSES IN SELECTED
HOSPITALS AT MANGALORE.
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6. Brief resume of the intended work
6.1 Introduction
“A mother’s joy begins when new life is stirring inside.....when a tiny heartbeat is heard for the very first time, and a playful kick reminds her that she is never alone”.1
It is believed that giving birth to an offspring is the most beautiful experience for a
women. Pregnancy is the fertilization and development of one or more offspring known as
an embryo or foetus, in a woman’s uterus.2
The word ectopic means “in the wrong place” and it is a pregnancy that develop
outside the uterus(womb).It is a potentially fatal condition and remains a leading cause of
pregnancy related death in the first trimester. It constitutes 2% births with recurrence in
more than 20%patients and permanent sterility in 20-60% of cases.3
The survival rate from ectopic pregnancies is improving even though the incidence of
ectopic pregnancies is also increasing. The developing embryo can’t survive, and the
growing placental tissue may destroy important maternal structures. The majority of women
diagnosed, will have to be operated or treated with medication.4
6.1 Need for the study
An ectopic pregnancy put very simply, means “an out of place pregnancy” .It
happens when a woman’s ovum (egg), which has been fertilised by a man’s sperm, becomes
stuck in the fallopian tube or sometimes in other places in the reproductive organs or
abdomen, instead of developing in uterus.5 The incidence of ectopic pregnancy ranges from
1 in every 40 to 1 in every 100 pregnancies. In India, the incidence of ectopic pregnancy
reported by the Indian council of medical research task force was 3.12 per 1000 pregnancies.
In India 75% of ectopic pregnancy occurred in the age group of 21-30 years.6
Ectopic pregnancy may be caused by birth defects in the fallopian tubes, endometriosis,
previous ectopic pregnancy, pregnant while having an intrauterine device, tubal sterilization,
tubal surgery, in-vitro fertilization etc. Women who experience a tubal pregnancy often
experience manifestation of abnormal vaginal bleeding, low back pain, mild cramping on
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one side of pelvis, pain in lower belly or pelvic area. If the area around the abnormal
pregnancy ruptures and bleeds, symptoms get worse. There will be fainting, intense pressure
in rectum, low blood pressure, pain in shoulder and severe sharp sudden pain in lower
abdomen. The nurse must be aware about the symptoms to recognize the ectopic pregnancy
from a normal pregnancy.7 Patient may also express feelings of self-blame and concern for
her child bearing capacity. In addition to providing high quality physical care to patient,
nurse must be sensitive to the sense of loss and grief.3
Because the ectopic pregnancy cannot be diagnosed in the community, the nurse
should be aware that all sexually active women with a history of lower abdominal pain and
vaginal bleeding should be referred to a hospital for early ultrasonography and if necessary,
measurement of serum concentrations of HCG should be done. Nurse should educate the
women with a history of ectopic pregnancy to have early ultrasonography to verify a viable
intrauterine pregnancy in their subsequent pregnancies. Diagnostic laparoscopy is necessary
if the clinical situation cannot be clarified or if the patient’s condition deteriorates.
Expectant and medical management of ectopic pregnancy are effective options in
selected women as long as adequate facilities for monitoring are available. If surgery is
necessary the laparoscopic route, result in shorter hospital stay. The decision should
therefore be made on individual basis. Methotrexate and laparoscopic salpingostomy are
equally successful in treating ectopic pregnancy.4
The nurse caring for a patient experiencing an ectopic pregnancy looks for changes
in the patient’s blood pressure and pulse, which could indicate hypovolaemic shock resulting
from haemorrhage. Regular assessment of vaginal bleeding is also essential. The nurses are
responsible for monitoring and controlling pain levels. If a linear salpingostomy or
salpingectomy is performed, the nurse monitors vital signs, oxygen saturation, intake and
output, and laboratory results according to institutional policies. As with all patients
experiencing a pregnancy loss, it is important for the nurse to recognize the loss and provide
resources to assist the patient in coping with the emotions that accompany experience of an
ectopic pregnancy. Nurses are responsible for ensuring that the patient is aware of signs and
symptoms that require a call to the healthcare provider or a return visit to the emergency
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room following hospital discharge. If methotrexate is used for the treatment of an ectopic
pregnancy, the patient should be educated about the unpleasant side effects (nausea and
vomiting) of methotrexate. The patient should have a clear understanding of the feelings of
anger, sadness or guilt that may arise following an ectopic pregnancy and that these feelings
are a normal part of the grieving process for someone experiencing the loss of pregnancy.8
An exploratory, qualitative, descriptive study was conducted in a Gauteng hospital,
South Africa to explore and describe the experience of midwives and doctors when caring
for mothers with pregnancy loss(miscarriage and ectopic pregnancy). Sample consisted of
doctors and midwives who worked in the maternity unit for a period of two years and was
selected by purposive sampling method. Data was collected by semi-structured individual
interviews. The study result showed that both midwives and doctors lack the knowledge to
support mothers with pregnancy loss and that they were overwhelmed by problems like
shortage of staff and overcrowding. The study concluded that a counselling programme
should be developed to help health professionals to deal with problems in ward situation.
The study also recommended that the institution should develop guidelines, policies and
procedures to help health professionals to cope when a life can no longer be saved.9
A longitudinal retrospective descriptive survey was conducted in Ghana, to find out
the reason for low detection of ectopic pregnancy before its rupture. Data was collected by
using interview method for 1492 patients. The study result showed that the incidence of
tubal ectopic pregnancy was 32.90 per 1000 deliveries and un-ruptured cases formed 5.43%.
It also found that lack of awareness of early pregnancy, late reporting by women to
healthcare facilities when aware of pregnancy and failure of healthcare providers to utilize
the diagnostic aids for detecting un-ruptured ectopic pregnancy were the main reason for low
detection rates. The study concluded that the health education should be provided to
encourage women to attend clinic early in pregnancy, especially when experiencing unusual
symptoms and judicious use of diagnostic aids for detecting un-ruptured ectopic pregnancy
by health care providers should be improved upon the detection rates.10
A case control study was conducted in France to analyse the risk factors of ectopic
pregnancy. Sample consisted of 2486 women (803 cases of ectopic pregnancy and 1683
deliveries). The study result showed that the main risk factors were infectious history
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(adjusted attributable risk=0.33; adjusted odds ratio for previous pelvic infectious
disease=3.4, 95% confidence interval (CI) : 2.4,5.0) and smoking (adjusted attributable
risk=0.35; adjusted odds ratio=3.9,95% CI:2.6,5.9 for >20 cigarettes/day Vs women who
had never smoked).It also showed that other risk factors were age, previous use of an
intrauterine device. Prior medical induced abortion was a risk of ectopic pregnancy (adjusted
odds ratio=2.8, 95% C I: 1.1, 7.2), but no such association was observed for surgical
abortion. The study concluded that increasing public health awareness about the risk factors
of ectopic pregnancy may be useful for its prevention.11
The investigator’s clinical experience revealed that most of the nurses lack
knowledge about assessment and management of ectopic pregnancy. Nurses are in a position
to educate the women regarding the signs and symptoms of ectopic pregnancy that require
an emergency admission to hospital. Nurses are also responsible to assist the patient in
coping with the emotions that arise following an ectopic pregnancy. The investigator
personally felt that there was a need to bring awareness among staff nurses regarding
assessment and management of ectopic pregnancy. Review of literature and discussion with
the experts also prompted the researcher to pursue the study.
6.2 Review of literature
A longitudinal study was conducted regarding incidence, trends and risk of ectopic
pregnancy in a defined population of women aged 15-39 years in Lund. Data was collected
by interview method. The study result showed that the rate of ectopic pregnancy per 1000
diagnosed conceptions increased from 5.8 to 11.1. The mean annual incidence of ectopic
pregnancy per 1000 women increased from 0.6 to 1.2 during this period. It also found that
the number of ectopic pregnancies per 1000 diagnosed conceptions increased with
increasing age of women. The incidence was 4.1 in the teenage group, 6.9 in women aged
20-29 years and 12.9 in women aged 30-39 years. The study result also showed that ectopic
pregnancy increased sevenfold after acute salpingitis. The study concluded that the ectopic
pregnancy increased after salpingitis and the increased incidence partly accounted for the use
of intrauterine copper devices.12
5
A retrospective study was conducted in Rajasthan to assess the frequency of ectopic
pregnancy and to evaluate the relevance of known risk factors. Data was collected from case
record of patients. The study result showed that incidence of ectopic pregnancy was 2.46 per
thousand deliveries. Maximum (72.5%) cases were in the age group of 21 to 30 years and
most of cases (40%) were nulliparous. About half ( 47.5 %) of cases were suffering from
pelvic inflammatory disease. The commonest site of ectopic pregnancy was in ampullo-
isthmic region(82.5%). It also showed that almost all patients underwent exploratory
laparotomy, majority (45%) underwent total salpingectomy, while fallopian tubes were
conserved in a few (7.5%) of cases. The study concluded that by identifying the risk factors
and catching the patient by ultrasonography examination at the earliest of 6 weeks, it is
possible to improve the prognosis to reduce the morbidity and mortality associated with
ectopic pregnancy.13
A case control study was conducted in university medical centre to evaluate the
association between ectopic pregnancy and clinical and historical factors among women
presenting with pain and or bleeding in early pregnancy. Sample consisted of women with
symptomatic early pregnancy of unknown location presenting for care. The study result
showed that the risk of ectopic pregnancy is: prior ectopic pregnancy (odds ratio, 2.98[95%
confidence interval, 1.88-4.73] for one prior ectopic pregnancy and 16.04[5.39-47.72] for
two or more), pelvic inflammatory disease history (1.5[1.11-2.05]),pain at presentation
(1.42[1.06-1.92]),vaginal bleeding at presentation (1.42[1.04-1.93]) and HCG value 501-
2000 ml u/ml (1.73[1.24-2.42]). It also showed that age younger than 25 years (0.59[0.41-
0.85]) and history of abortion were protective from ectopic pregnancy (0.58[0.38-0.90]).
Prior non-tubal pelvic surgery, past intrauterine device use, prior caesarean section and
current cervical infection demonstrated no association with ectopic pregnancy. The study
concluded that knowledge of historical and clinical factors associated with ectopic
pregnancy may aid in early diagnosis.14
A retrospective study was conducted in Tseung Kwano Hospital, Hong Kong to
evaluate the success rates of expectant and medical management of ectopic pregnancy.
Sample consisted of 121 women with ectopic pregnancy identified by computer database.
The result showed that the success rates of expectant and medical management were 63%
and 73% respectively. There were no significant differences in the clinical characteristics
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such as presence of abdominal pain, vaginal bleeding, size of adnexal mass, presence of free
fluid in the pelvis, pre-treatment levels of serum beta –human chorionic gonadotropin
between the responders and non responders in the expectant and medical management
group. The study concluded that both expectant and medical management are reasonable
options in selected women with ectopic pregnancy. It also concluded that the non surgical
management options allow the use of more conservative treatment especially for those
women who want to preserve their fertility or those who have high surgical risk.15
A study was conducted in Montreal QC to identify risk factors of ectopic pregnancy
after in-vitro fertilization treatment. Sample consisted of 365 women, who had undergone in-
vitro fertilization. The study result showed that, out of 365 women, 18 women had an
ectopic pregnancy and 347 others had an intrauterine pregnancy. The incidence of IVF
ectopic pregnancy was 4.9%. It also showed that the tubal factor infertility and previous
surgery for endometriosis were risk factors for IVF ectopic pregnancy. The study concluded
that tubal factor infertility and previous surgery for endometriosis appear to be risk factors
for ectopic pregnancy after IVF treatment.16
A cross sectional study was conducted in Pakistan Institute of medical sciences for a
period of 2 years to determine the modes of treatment of ectopic pregnancy and their
outcome. Sample consisted of 52 patients with ectopic pregnancy. The result showed that the
rate of ectopic pregnancy was 1in 100 deliveries. Emergency laparotomy was performed in
30(57.9%) women,15(28.8%) received methotrexate injection. Seven women(13.3%)were
managed conservatively. It also showed that twelve out of fifteen (80%) cases of medical
treatment were successful, while one(6.7%) proceeded to emergency laparotomy, one(6.7%)
to operative laparoscopy and one (6.7%) to laparoscopy preceding laparotomy. Five out of
seven patients(71.4%)on conservative treatment did not require any further intervention
while two(28.6%)of them resolved with methotrexate injection. Study concluded that more
than half of all women with ectopic pregnancy presented with acute abdomen and required
emergency laparotomy and about 40% of women could be managed with non surgical
modalities with 80% success for methotrexate injection and 71% for conservative
treatment.17
The above studies shows that there is a need for bringing an awareness among the
staff nurses about the assessment and management of ectopic pregnancy to facilitate an early
diagnosis and management for a good prognosis.
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6.3 Statement of the problem
A study to assess the effectiveness of self instructional module on knowledge
regarding assessment and management of ectopic pregnancy among staff nurses in selected
hospitals at Mangalore.
6.4 Objectives of the study
The objectives of the study were:
To assess the existing knowledge of staff nurses regarding assessment and
management of ectopic pregnancy using structured knowledge questionnaire.
To evaluate the effectiveness of self instructional module on knowledge regarding
assessment and management of ectopic pregnancy in terms of gain in post test
knowledge score.
To find the association between mean pre-test knowledge score regarding assessment
and management of ectopic pregnancy among staff nurses and selected demographic
variables.
6.5 Operational definitions
Effectiveness: In the present study, it refers to enhancement of knowledge after
administration of self instructional module.
Self instructional module: In this study, it refers to written material regarding the
definition, incidence, types, aetiology, risk factors, diagnosis and management of
ectopic pregnancy.
Knowledge: In this study, it refers to the understanding and awareness of staff nurses
regarding assessment and management of ectopic pregnancy.
Assessment: In this study, it refers to identifying signs and symptoms of ectopic
pregnancy and utilising diagnostic measures to detect ectopic pregnancy.
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Management: In this study, it refers to treatment modalities for ectopic pregnancy.
Ectopic pregnancy: In this study it refers to a complication of pregnancy in which
the fertilized egg attaches itself outside the cavity of the uterus (womb).
Staff Nurses: In this study, it refers to the registered nurse either with B. Sc. nursing
or diploma certificate programme in nursing and midwifery, working in maternity
units of selected hospital, Mangalore.
Hospitals: In this study, hospital is an organised institution where maternity services
are available.
6.6 Assumptions
Staff nurses may have some knowledge regarding assessment and management of
ectopic pregnancy.
Self instructional module is an accepted strategy to improve knowledge.
Failure in early diagnosis and management of ectopic pregnancy may result in
rupture of surrounding structures and heavy bleeding which may be fatal.
6.7 Hypotheses
The hypothesis will be listed at 0.05 level of significance.
H1: The mean post-test knowledge score regarding assessment and management of
ectopic pregnancy among staff nurses will be significantly higher than mean pre-test
knowledge score regarding assessment and management of ectopic pregnancy among
staff nurses.
H2: There will be significant association between mean pre-test knowledge score
regarding assessment and management of ectopic pregnancy among staff nurses and
selected demographic variables.
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6.8 Delimitations
The study will be delimited to staff nurses who are working in selected maternity
hospitals in Mangalore.
7. Material and methods
7.1 Source of data
Data will be collected from staff nurses working in selected hospitals at Mangalore.
7.1.1 Research design
Pre-experimental design will be used for the study.
One group pre-test-post test will be selected for the study.
Subject Pre-test Treatment Post-test
Staff nurses working in selected maternity hospitals at Mangalore
O1 X O2
R = O1 X O2
R = Sample.
O1 Pre-test assessment of staff nurses knowledge regarding assessment and management
of ectopic pregnancy.
X Treatment (self-instructional module regarding assessment and management of
ectopic pregnancy).
O2 Post-test knowledge of staff nurses regarding assessment and management of ectopic
pregnancy.
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7.1.2 Setting
The study will be conducted in selected hospitals at Mangalore that provide
maternity services.
7.1.3 Population
Staff nurses in the age group of 22-49 years who are working in selected hospitals at
Mangalore.
7.2 Method of data collection
7.2.1 Sampling procedure
Purposive sampling technique will be used to collect the sample.
7.2.2 Sample size
Sample size consists of 50 staff nurses.
7.2.3 Inclusion criteria for sampling
Staff nurses who are willing to participate in the study.
Staff nurses in the age group of 22–49 years.
Staff nurses who are available at the time of data collection.
7.2.4 Exclusion criteria for samplings
The study excludes:
Nursing superintendents.
Staff nurses who are not available at the time of data collection.
Staff nurses who were not willing to participate in the study.
7.2.5 Instruments intended to be used
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Following tool will be prepared and used for data collection.
Section A: Demographic variables.
Section B: Structured knowledge questionnaire regarding assessment and management of
ectopic pregnancy.
7.2.6 Data collection method
Prior permission will be obtained from the higher authorities of the selected
hospitals. The purpose and need for the study will be explained to the women.
Confidentiality of the collected data will be assured to the women and written consent will
be obtained. A structured knowledge questionnaire regarding assessment and management
of ectopic pregnancy will be distributed and requested to be filled by the respondents. The
filled tool will be collected and self instructional module will be given to the respondents.
After 7 days, post test will be conducted to the same subjects using the same structured
knowledge questionnaire.
7.2.7 Plan for data analysis
The data will be analysed using both descriptive (mean, median, mean percentage
and standard deviation) and inferential statistics (chi-square test, paired ‘t’ test).
7.3 Does the study require any investigations or interventions to be conducted on patients, or other animals? If so please describe briefly.
Yes. In the present study, the investigator plan to use structured knowledge
questionnaire to evaluate the effectiveness of self instructional module regarding assessment
and management of ectopic pregnancy.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes. Ethical clearance is obtained from the ethical committee of the institution.
8. References
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1. http://www.finestquotes.com/select-category-pregnancy-page-o.htm.
2. http://en.wikipedia.org/wiki/pregnancy.
3. Swarna, Padmavathy K. Ectopic pregnancy. The Nursing Journal of India 2004
Aug;XCV(8):174-5.
4. Subhashini P, Nimisha RK, Kavimani S, Balu V. Ectopic pregnancy. Nightingale
Nursing Times 2009 Jan;4(10).
5. http://www.ectopic.org.uk/index.php/patients/frequently-asked-questions-faqs/
6. http://www.gulfmd.com/parenting_pregnency/ectopic%20pregnancy.asp?id=27
7. http://www.whattoexpect.com/pregnancy/pregnancy-health/complications/ectopic-
pregnancy.aspx
8. http://www.nursingceu.com/courses/curriculum_all.html
9. Experiences and perceptions of midwives and doctors when caring for patients with
ectopic pregnancy. [online]. Available from: URL:http://www.thefreelibrary.com/
10. Bed SA. Diagnosis of unruptured ectopic pregnancy is still uncommon in Korle Bu
Teaching Hospital. Ghana Medical Journal 2006 Mar;40(1).
11. Bouyer J, Coste J, Shojaei T, Pouly JL, Fernandez H, Gerbaud L, Job-Spira N. Risk
factors for ectopic pregnancy. American Journal of Epidemiology 2000;157(3).
12. Westrom L, Bengtsson LP, Mardh PA. Incidence, trends, and risks of ectopic
pregnancy in a population of women. Br Med J 1981 Jan;282(15).
13. Gupta R, Porwal S, Swarnkar M, Sharma N, Maheshwari P. Incidence, trends and
risk factors for ectopic pregnancies in a tertiary care hospital, Rajasthan. Journal of
Pharmaceutical and Biomedical Sciences 2012;16(16).
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14. Barnhart KT, Sammel MD, Gracia CR, Chittams J, Hummel AC, Shaunik A. Risk
factors for ectopic pregnancies. Fertility and Sterility 2006 Jul;86(1):36-43.
15. Cheng EOL, To WWK, Tsang SW, Mok KM, Sit CY. Success rates of expectant and
medical management of ectopic pregnancy. Hong Kong J Gynaecol Obstet
Midwifery 2008;8(1):35.
16. Malak M, Tawfeeq, Holzer H, Tulandi T. Risk factors for ectopic pregnancy after in-
vitro fertilization treatment. J Obstet Gynaecol Can 2011 Jun;33(6):617.
17. Mahaboob U, Mazhar SB. Ectopic pregnancy. [online]. Available from:
URL:http://www.ayubmed.edu.pk/JAMC/
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9. Signature of the candidate
10. Remarks of the guide
11. Name and designation of (in block letters)
11.2 Guide MRS. LIZZIE D’COSTAPROFESSOR AND HODOBSTETRICS AND GYNAECOLOGICAL
NURSINGINDIRA NURSING COLLEGEFALNIR, MANGALORE – 575 002.
11.2 Signature
11.3 Co-guide (if any)
11.4 Signature
12 12.1 Head of the department MRS. LIZZIE D’COSTAPROFESSOR AND HODOBSTETRICS AND GYNAECOLOGICAL
NURSINGINDIRA NURSING COLLEGEFALNIR, MANGALORE – 575 002.
12.2 Signature
13. 13.1 Remarks of the Chairman and Principal
13.2 Signature
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