A STUDY TO EVALUATE THE EFFECTIVENESS OF

PLANNED TEACHING PROGRAMME ON RENAL

CALCULI AND ITS MANAGEMENT AMONG

THE RENAL CALCULI PATIENTS

IN SELECTED HOSPITALS

IN MANGALORE TALUK.

by

CH. BABITA DEVI

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment

Of the requirements for the degree of

Master of Science in Nursing

2005

In

Medical-Surgical Nursing

Under the guidance of

Prof. B A Yathi kumara Swamy Gowda

Department of Medical Surgical Nursing

Alva’s College Of Nursing

Moodbidri

2005

Rajiv Gandhi University of Health Sciences, Karnataka

DECLARATION BY THE CANDIDATE

ii

I hereby declare that this dissertation/thesis entitled “A Study to evaluate the

effectiveness of Planned Teaching Programme on Renal Calculi and its

management among the renal calculi patients in selected hospitals in Mangalore

taluk” is a bonafide and genuine research work carried out by me under the guidance

of Prof. B A Yathikumara Swamy Gowda, Principal and Head of the Department of

Medical-Surgical Nursing, Alva’s College of Nursing, Moodbidri.

Date: Signature of the Candidate

Place: Ch. Babita Devi

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A study to evaluate the

effectiveness of Planned Teaching Programme on Renal Calculi and its

iii

management among the renal calculi patients in selected hospitals in Mangalore

taluk” is a bonafide research work done by Ms. Ch. Babita Devi in partial fulfillment

of the requirement for the degree of Master of Science in Nursing (Medical-Surgical

Nursing).

Date: Signature of the Guide

Place:

Prof. B A Yathikumara Swamy Gowda,

Head of the Department

Medical-Surgical Nursing,

Alva’s College of Nursing, Moodbidri.

ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE

INSTITUTION

iv

This is to certify that the dissertation entitled “A study to evaluate the

effectiveness of Planned Teaching Programme on Renal Calculi and its

management among the renal calculi patients in selected hospitals in Mangalore

taluk” is a bonafide research work done by Ms. Ch. Babita Devi under the guidance of

Prof. B A Yathikumara Swamy Gowda, Principal and Head of the Department of

Medical-Surgical Nursing, Alva’s College of Nursing, Moodbidri.

Seal & Signature of the Seal & Signature of the

HOD Principal

Prof.. B A Yathikumara Prof. B A Yathikumara

Swamy Gowda Swamy Gowda

Date: Date:

Place: Place:

COPY RIGHT

v

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka

shall have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

Date: Signature of the Candidate

Place: Ch. Babita Devi

© Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

I acknowledge my love and gratitude to all those loving hearts that has helped me

throughout my endeavor.

I acknowledge with gratitude and devotion, The ALMIGHTY GOD for HIS abiding

grace, love, compassion and immense shower of blessings on me, which gave me the

strength and courage to overcome all the difficulties and completing the study.

vi

I express my sincere thanks to Dr. M. Mohan Alva, Chairman of Alva’s Education

Foundation for the opportunity given to me to under take this course in this esteemed

college.

The present study could never have been successfully completed without the expert

guidance of research supervisors.

I acknowledge my deep sense of gratitude to my research guide Prof. B.A,Yathi

Kumara Swamy Gowda, Principal of the college for his patience, valuable guidance,

direction and advice given for the completion of this study. I find myself lucky for

having been under his guidance.

I owe a deepest sense of gratitude to Prof. Alice Salins, Vice Principal of this college

for her intellectual enlightenment, valuable suggestions and sustained patience for the

successful completion of the study.

I express my sincere and whole-hearted gratitude to Assist. Prof. (Mrs) Baby S Nayak

for her expert and valuable guidance in every step of my work and scrutinized my

progress, inspiration, sustained patience, constant encouragement, suggestions and

support from the inception till the completion of this study. Her analytical approach

helped me in giving final shape to the report.

My heartfelt gratitude to Mrs. Priya Neetha Monis. Lecturer of this college who has

guided me and helped me whenever I approached her.

I have lot of happy moments to cherish with my classmate friends Simple M and Jaya

Mathew who have helped me and co-operated me throughout the course. Many thanks

and wishes to them.

My grateful acknowledge to all the experts who contributed their valuable time and

efforts towards validating the tools and contents of the PTP.

vii

My sincere gratitude to Dr. Krishna Mohan Prabhu, Managing Director of Prabhu

General Hospital, for granting permission to conduct pretesting and reliability of the

tool, Dr.Harish Nayak, Medical Superintendent of Alva’s Health Centre to conduct

pilot study and Dr. Prashanth Marla, Medical Director of A..J Hospital and Research

Centre to conduct main study.

My special thanks to all the participants who enthusiastically participated in the study

and for being very co-operative and also for adding light to my studies with their

heartfelt expression.

I extend my sincere gratitude to the non-teaching staff of this college for their

approachability.

I am thankful to the Dean and librarians of KMC, Manipal and librarians of Alva’s

Education Foundation for allowing me to use the library facilities.

I am indebted to my mother and father who have moulded me to lead so far with their

blessing and kindness and who has silently borne every trouble for my sake. To them I

owe my every success.

I am extremely grateful to my brothers and sisters for their understanding and

immense support for my studies

It is my privilege to acknowledge Dr. Geetchandra Singh who has supported in every

trouble, has given hands in times of need and has encouraged me to carry out my work

sincerely. Special thanks to him.

Lastly I am grateful to all of them who have directly or indirectly helped in completion

of this study.

Date: Signature of the Candidate

Place

Ch. Babita Devi

viii

LIST OF ABBREVIATIONS

Ca Calcium

GLV Green Leafy Vegetables

Ox Oxalate

P Phosphorus

PH4 Phosphate

PTP Planned Teaching Programme

RC Renal Calculi

UA Uric Acid

USG Ultrasonography

ix

ABSTRACT

Renal stone is a painful condition that affects 1 – 2% of the general

population.Kidney stones are aggregates of crystals mixed with a protein matrix that

cause obstruction of urine flow in the renal collecting system, ureters, or urethra and

result in severe pain, bleeding, or local erosion of kidney tissues 1 .

STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of Planned Teaching Programme on Renal

Calculi and its management among the renal calculi patients in selected hospitals in

Mangalore taluk.

OBJECTIVES OF THE STUDY

The objectives of the study are to :-

1) determine the pre test knowledge of the renal calculi patients regarding renal

calculi and its management.

2) plan and validate the planned teaching programme on renal calculi and its

management for the patients with renal calculi.

3) evaluate the effectiveness of planned teaching programme on renal calculi and

its management in terms of gain in knowledge in post test.

An evaluative approach with one group pre-test post-test design (pre-

experimental) was adopted in order to evaluate effectiveness of Planned teaching

programme on renal calculi and its management among renal calculi patients in a

x

selected hospital in Mangalore Taluk. The conceptual framework adopted for the study

was based on modified Rosen Stock’s Health Belief Model (1966).

The Content validity of the tool and Planned Teaching Programme was

established in consultation with thirteen experts in the field of medicine, nursing and

Food, Nutrition and Dietetic Department. Reliability of the tool was tested by split half

method (r=0.80)

Convenience sampling was used to select the sample for the study. Pilot study

was conducted to find out the feasibility of the study. Data collected from the sample

were analyzed by descriptive and inferential statistics. The final sample size was 48.

Results of the study

Majority of the sample belonged to age group 21 – 35 years (33.34%), male

(79.17%), having primary school education (27.08%), married (83.33%), doing

business (25%), having family income of Rs 1501 – 3000 (25%), Hindu

background (68.75%), Non-vegetarian (85.42%), had no history of previous

hospital admission (87.5%), no family history of renal calculi (91.67%), no habit of

smoking, chewing betal leaves and taking alcohol (68.75%) and had average

knowledge (89.58%).

There was a significant difference between pre-test and post-test knowledge scores

( t(47) =32.81, P<0.05; Tabled value = 2.02 ).

There was significant association between pre-test knowledge scores and age ( χ2(2)

= 17.28, p<0.05 ).

xi

There was no significant association between pre-test knowledge score and the

selected variables gender ( χ2(1) = 0.07, P>0.05 ), per capita income of the family (

χ2(1) = 0.89, P>0.05 )and dietary pattern ( χ2

(1) = 0.03, P>0.05 ).

The findings of the study show that the planned teaching programme was

effective in all the areas in improving the knowledge of the patients with renal calculi.

Keywords

Urinary system; renal calculi; renal calculi and its management; renal calculi patients;

urinary excretion; minerals; stone formation; food habits; occupational exposure.

xii

TABLE OF CONTENTS

1. Introduction 1 – 11

2. Objectives 12

3. Review of Literature 13 – 26

4. Methodology 27 – 38

5. Results 39 – 59

6. Discussion 60 – 61

7. Conclusion 62 – 67

8. Summary 68 – 73

9. Bibliography 74 – 79

10. Annexures 80 - 169

xiii

TABLES

Sl. No.

Tables Pages

1. Frequency and percentage distribution of patients with renal calculi on basis of demographic data.

41 – 43

2. Percentage of agreement by experts on areas of planned teaching programme in percentage and frequency.

49

3. Frequency and percentage distribution of pretest and posttest knowledge scores of patients with renal calculi.

50

4. Range, Mean, Median, Mean percentage and Standard deviation (SD) of pretest and posttest knowledge scores.

51

5. Area-Wise pretest and posttest knowledge scores on renal calculi and its management.

53

6. Mean, Mean deviation (MD), Standard deviation (SD), ‘t’ value between pretest and posttest knowledge scores of patients with renal calculi.

55

7. Area-Wise paired ‘t’ test showing the significant difference between pretest and posttest knowledge scores.

56

8. Association between pretest knowledge scores and selected demographic factors.

58

xiv

LIST OF FIGURES

Sl.

No.

Figures Pages

1. Conceptual framework on effectiveness of PTP based on modified

Rosenstock’s Health Belief Model (1966).

10

2. Pre experimental one group pre test post test design. 28

3. Schematic representation of research design. 28

4. Schematic representation of study plan. 29

5. Bar diagram showing the distribution of renal calculi patients

according to their age group.

46

6. Pie diagram showing the distribution of renal calculi patients

according to their sex.

47

7. Pie diagram showing the distribution of renal calculi patients

according to their dietary pattern.

48

8. Frequency polygon showing the mean and median of knowledge

scores of renal calculi patients in pretest and posttest scores on renal

calculi and its management.

52

xv

xvi

1

1. INTRODUCTION

Renal stone is a painful condition that affects 1 – 2% of the general

population. Kidney stones are aggregates of crystals mixed with a protein matrix that

cause obstruction of urine flow in the renal collecting system, ureters, or urethra and

result in severe pain, bleeding, or local erosion of kidney tissues 1 .

There are several types of kidney stone. The most common type of

kidney stone is composed of calcium oxalate and is caused by metabolic disorders that

are often treatable. In general, the crystallization of stone-forming salts owes to an

abnormal urinary composition that is either higher in crystallization promoters e.g.

calcium, oxalate, uric acid or lower in inhibitors e.g. citrate, glycosaminoglycans,

kidney proteins such as nephrocalcin, Tamm-Horsfall mucoprotein. Uropontin, or

both2.

The formation of the 4 basic chemical types of renal calculi is associated

with more than 20 underlying etiologies. Stone analysis, together with serum and 24-

hour urine metabolic evaluation, can identify an etiology in over 95% of patients.

Specific therapy can result in a remission rate of over 80% and can decrease the

individual recurrence rate by 90%. Emergency physicians, therefore, should stress the

importance of urologic follow-up, especially in patients with recurrent stones, solitary

kidneys, or previous kidney or stone surgery and in all children.

• Calcium stones (75%): Calcium oxalate, calcium phosphate, and calcium urate.

• Struvite (magnesium ammonium phosphate) stones (15%)

• Uric acid stones (6%): These are associated with urine pH less than 5.5, high

purine intake (eg, organ meats, legumes, fish, meat extracts, gravies), or

2

malignancy (ie, rapid cell turnover). Approximately 25% of patients with uric

acid stone have gout.

• Cystine stones (2%)3

The causes of renal calculi can be classified as follows

Metabolic abnormalities (a patient may show more than one)

* Supersaturation of urine with stone-forming salts

Hypercalciuria (>300 mg/24hr): 40-60% of cases

Hyperuricosuria (>750 mg/24hr): 20-35% of cases

Hyperoxaluria (>40 mg/24hr): 10-20% of cases

Cystinuria (>250 mg/L): 1-2% of cases

* Reduced inhibitors of stone formation

Hypocitraturia (<320 mg/day): 10-40% of cases

Hypomagnesuria

Abnormal nephrocalcin, or other glycoprotein defects (Tamm-

Horsfall protein, glycosaminoglycan, uropontin, crystal matrix

protein)

Infection with urease-producing organisms (mostly Proteus): 10-20% of

cases

Alterations in urinary pH

* pH<5.5 leads to uric acid stones

* pH>7.5 seen with struvite stones4

3

Calculus size and location are important determinants for the resultant

degree of disease. The most important factor for passage of a calculus though the

genitourinary tract is its size. The critical size for spontaneous passage is <5 mm.

Approximately 90% of stones that are less than 5 mm and located in the lower ureter

pass spontaneously within 4 weeks. 15% for stones between 5 and 8 mm. 95% of

stones larger than 8 mm become impacted along the genitourinary tract, generally

requiring lithotripsy or surgical removal. Intervention can usually be performed in the

outpatient setting5.

An increase in fluid intake is common advice for patients with renal

stones. A higher intake leads to increased urinary volume and, in turn, decreased in

concentration of stone formation components, which will presumably decrease rate of

stone formation. Alternatively, the increased urinary volume could decrease the

concentration of inhibitors of stone formation6.

NEED FOR THE STUDY

The formation of stones in the urinary tract is a common and important

problem that must be considered in daily urological practice. With a prevalence of

>10% and an expected recurrence rate of =50%, stone disease has an important effect

on the health care system. The condition affects 5-10% of the population in Europe and

North America. An even higher frequency has been reported from other parts of the

world and there are only a few geographical areas in which stone disease is rare e.g. in

Greenland and in the coastal areas of Japan7.

The annual incidence of stone formation in the industrialized world is

generally considered to be 1500-2000 cases per million. Over the past two or three

4

decades there has been a dramatic development in the techniques for stone removal.

Although the vast majority of stones pass spontaneously, open surgery for stone

removal was previously a very common urological procedure. Currently almost all

stones can be removed by non-or slightly invasive methods. Despite these

achievements the problem of recurrent stone formation remains and despite

considerable progress in this field, efforts to stop stone formation have so far been

insufficient. This raised the question of how much has been accomplished in the field

of further formation of renal calculi7.

Incidence/Prevalence in USA8

• 1-4/1000 annual incidence

• 5-12% lifetime incidence

• Higher incidence in the "stone belt" (southeastern USA)

• Recurrence rate - 50% in five years

• Predominant age: 20 -40 years

• Predominant sex: Male : Female (&approx;3:1), except for struvite (infection)

stones which are more common in females.

It has been estimated that 7 to 10 of every 1,000 hospital admissions are

due to renal calculi. In the U.S. the prevalence is 7% in men and 3% in women, and

70% of all ureteral calculi occur between the ages of 20 and 50 years5.

Low levels of urinary crystallization inhibitors were reported in

hypercalciuric, normocalciuric, and hyperuricosuric stone formers. In general, the level

of crystallization inhibitors in urine of stone-forming patients is low when compared

with individuals without stone formation9.

5

Citrate, a key component of the uric acid cycle, has received increasing

and renewed interest as an important inhibitor of stone formation. Citrate retards

crystallization by two means: It complexes calcium and reduces ionic calcium

concentration in urine, and it directly inhibits the crystallization of calcium oxalate and

calcium phosphate. In addition, nephrocalcin, an acidic glycoprotein, inhibits calcium

oxalate nucleation, growth, and aggregation. Tam-Horsfall protein also inhibits

aggregation, and uroprotein inhibits the growth of calcium oxalate crystals9.

Urinary oxalate is an important determinant of calcium-oxalate

supersaturation. Rather small increments in oxalate excretion markedly raise the

activity product of the ions contributing to stone formation by increasing the urinary

saturation of calcium oxalate. Dietary oxalate is responsible for only a minor fraction (≤

20%) of urinary oxalate. Endogenous oxalate production is a metabolic end product of

glycine and ascorbic acid metabolism. Hyperoxaluria (urinary levels > 40 mg/day) can

be either genetic or acquired. The genetic form, primary hyperoxaluria, is rare and can

be result from mutations in the gene for alanine: glyoxylate aminotransferase or in the

gene for glyoxalate reductase/D-glycerate dehydrogenase. Acquired hyperoxaluria is a

consequence of increased intestinal absorption of oxalate and is often found in patients

with malabsorption in the small bowel2.

Excessive urinary calcium excretion represents a major pathophysiologic

factor of kidney stones because many stone patients have idiopathic hypercalciuria, a

primary metabolic alteration. Hypercalciuria promotes calcium salt crystallization and

crystal growth. Theoretically, the risk of developing renal calcium stones increases as

urinary calcium excretion rises. The mechanism involved in hypercalciuria includes an

6

increase in the filtered calcium load and/or a decrease in the efficiency of tubular

reabsorption of calcium2.

The role of dietary sodium in the pathogenesis of hypercalciuria is

based on the close relationship between renal tubular calcium and sodium handling.

Reabsorption of calcium parallels the renal reabsorption of sodium in the proximal

tubule and Loop of Henle. High sodium intake may also influence renal reabsorption of

calcium in the distal tubule both directly or indirectly through its effects on parathyroid

hormone levels9.

The role of protein intake in calcium stone formation has been

investigated by several groups. The ingestion of a diet rich in animal protein (meat,

fish, poultry, eggs, and dairy products) increases the risk for calcium nephrolithiasis.

Conversely, the disorder is less common in populations who consume protein primarily

from plant sources. Protein feeding can lead to an increase in glomerular filtration rate,

an increase in serum ulfilterable calcium concentration, or both9.

The researcher takes interest in this study as she had come across a large

number of renal calculi in and out patients during her clinical postings so that she can

impart knowledge for such patients regarding the disease and make them aware to

prevent the recurrence of the disease.

STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of Planned Teaching Programme on

Renal Calculi and its management among the renal calculi patients in selected

hospitals in Mangalore taluk.

7

PURPOSE OF THE STUDY

The purpose of the study is to plan and validate the planned teaching

programme on renal calculi and its management for the patients who are suffering from

renal calculi that will help them to gain in their knowledge regarding renal calculi and

its management

OPERATIONAL DEFINITIONS

Effectiveness

It refers to the extent to which the planned teaching programme has achieved the

desired result in terms of patients’ gain in knowledge as evidence by higher mean post

test knowledge score than the mean pre test knowledge score.

Patients with renal calculi

It refers to patients who are clinically diagnosed to have renal calculi and are attending

the selected hospital for the treatment.

Planned Teaching Programme

It refers to the teaching given to the patients who are suffering from renal calculi on

renal calculi and its management using pamphlets, charts, and flash cards.

Management of renal calculi

It refers to the over all management of patients with renal calculi in respect of drugs,

diets and fluids.

8

Knowledge

It refers to correct response of the patients with renal calculi to knowledge items on

dietary modification and fluid therapy of renal calculi, expressed in terms of knowledge

score, which is graded arbitrarily as good, average and poor.

Variables

These are the selected factors, which are presumed to influence the subjects,

knowledge. The factors are age, gender, per capita income of the family and dietary

pattern.

ASSUMPTIONS

The study assumes that

the patients who are admitted to the hospital with the diagnosis of renal calculi

will have some knowledge regarding renal calculi, gained through mass media,

friends, relatives and other sources.

the patients who are attending the planned teaching programme will be able to

follow the instructions in their daily life.

Renal calculi are prone to get recurrence.

Health teaching can impart knowledge regarding renal calculi which make them

aware of their disease.

Creating health awareness will help in prevention of recurrence of renal calculi.

HYPOTHESES

H1 : The mean post test knowledge score of the patients with renal calculi on renal

calculi and its management will be significantly higher than the mean pre-test

knowledge scores, as measured by a structured knowledge questionnaire.

9

H2 : There will be significant association between the pre test knowledge scores

and the selected variables.

All the hypotheses will be tested at the 0.05 Levels of significance.

CONCEPTUAL FRAMEWORK

Conceptualization refers to the process of refining general or abstract ideas,

which are formulated by generalizing from particular manifestations of certain

behaviors or characteristics. These abstracts are referred to as concepts9.

The framework of the present study, as shown in figure 1, is adopted

from Rosenstock’s Health Belief Model. This model stresses the importance of

learner’s motivation in seeking preventive health behaviour.

In the present study, there are certain demographic variables, which will

lead to development of renal calculi. There are also certain modifiable and non

modifiable risk factors, which cause renal calculi. These risk factors are known or little

known to the normal patients. A planned teaching programme can be conducted, which

will be helpful for them in sustaining knowledge and apply it in their daily life. Other

cues are mass media, information from other sources such as family, friends, health

professionals will have beneficiary effects for the individuals to take necessary actions.

If this programme is effective, there can be gain in knowledge of the

participants and there is a likelihood of making recommended changes in their food

habit and lifestyle and this can be measured by knowledge questionnaire. If there is no

change in knowledge, there is no change in practice. Hence feedback can be obtained

and repeated awareness programmes may be conducted.

10

Fig: 1 CONCEPTUAL FRAMEWORK BASED ON MODIFIED ROSENSTOCK’S HEALTH BELIEF MODEL (1966)

Assessment of renal calculi patients’ knowledge regarding renal calculi and its management

Perceived threat of recurrence of renal calculi

Study Instrument Demographic Performa Knowledge Questionnaire

Cues to Action Planned Teaching Programme *Mass media (newspaper,magazines, articles) *Information from other sources (family, friends, health professionals)

Gain in Knowledge

Low or no change in knowledge

Feedback

Likelihood of making recommended changes in their food habit and lifestyle Demographic

Variables Modifiable Factors Dietary pattern *Occupation Non-modifiable Factors Age, Gender Socio-psychological Variables Family income *Type of family *Religion *Education

* not under study

Patients with renal calculi

11

DELIMITATIONS

The study is delimited to patients with renal calculi:

admitted in the hospitals

know to read and write Kannada or Hindi or English

willing to participate

SCOPE OF THE STUDY

1) The findings of the study would reveal the existing knowledge of the renal calculi

patients regarding renal calculi and its management.

2) Nurse educators, public health nurses and student nurses can utilize this

information in providing health education to the patients with renal calculi to

prevent the recurrence of renal calculi.

SUMMARY

This chapter dealt with the introduction, need for the study, statement of the problem,

objectives, operational definitions, assumptions, hypotheses, conceptual framework,

delimitations and scope of the study.

12

2. OBJECTIVES

The objectives of the study are to :

1) determine the pre test knowledge of the renal calculi patients regarding renal

calculi and its management.

2) plan and validate the planned teaching programme on renal calculi and its

management for the patients with renal calculi.

3) evaluate the effectiveness of planned teaching programme on renal calculi and

its management in terms of gain in knowledge in post test.

13

3. REVIEW OF LITERATURE

Literature review refers to the activities involved in searching for information

on a topic and developing a comprehensive picture of the state of knowledge in that

topic10.

An extensive review of literature relevant to the research study topic is

done to gain information and insight to build the foundation of the study. The literature

reviewed for the present study is organized and presented under the following headings.

Epidemiology and Socio Economical aspects of Renal Calculi

Urine and Serum Composition of Renal Calculi

Biochemical Evaluation of Renal Calculi

Risk Factors in Renal Calculi

Epidemiology and Socio Economical aspects of Renal Calculi

The following series of studies give empirical evidence of the etiology, risk

factors and factors influencing the type of calculi formed in different environment and

setting.

14

An epidemiological study was conducted on the occurrence of

urolithiasis in the 19th century population in Asia. For this study 250 quotations from 54

countries concerning 340,000 urinary stone were collected. The analogy was

demonstrated for age distributed, stone location, male-female ratio, and stone

composition. The distribution of urolithiasis is an underdeveloped country population is

defined by highest frequency in children, (>40%) bladder stone, 20% female patients,

40& calcium oxalate stone,(>30%) uric acid stone. Typical for a population in a

developed country the characteristic of urolithiasis are : highest frequency among adult,

(<10%) bladder stones, (>25%) female patients, (>60%) calcium oxalate stone, (<20%)

uric acid stone11.

The results of the above study showed that the distribution of calcium

oxalate stone in a low socioeconomical level population is less than that of high

socioeconomical status. The high protein is related with occurrence of uric acid stone.

On conclusion he said that increasing socioeconomical level was accompanied by the

following distribution of urolithiasis, decrease in bladder stone, decrease in phosphate

stone, decrease in uric acid stone, increase in female patients and increase in calcium

stone.

An exploratory study was conducted on epidemiological determinations

of urolithiasis in Germany. The study samples were 271 males and 160 females and the

age limits were 20-30 for males 30-40 for females. There was evidence of urolithiasis

in patients of 15.91% of the patients and in grandparents of 3.1% of patients. For

23.64% of patients, infection of the urinary system was determined and for 19.62%

hypertension. The gastrointestinal disturbances were found in 18.28% of the patients.

Salaried employees (24.41%), house wives, and manual workers formed the largest

15

group of samples (23.08%), as opposed to the public servants 10.9%, school children,

apprentices and students were 8.75%, pensioners 5.85%, and self employed 2.91%12.

A study conducted on epidemiology of urolithiasis in terms of seasonal

variation, occupation and lifestyle in Kuwait shows that a postal questionnaires were

sent out to 5,476 men (>18 yrs) selected at random from the electoral roll. Since all the

questions were not returned, a further random sample of 200 men was chosen from the

group and who did not reply to the questionnaire were interviewed by telephone. The

findings showed that twice the number of renal colic seemed to occur during the summer

months. Patients with a family history of urolithiasis were more likely to get a recurrence

than those without. A large population of stone patients was of sedentary occupation,

and there was a high incidence of urolithiasis seen among sailors than any other

people13.

A study reviewed the urolithiasis from the standpoint of analytical

epidemiology, which examined a statistical association between a given disease and a

hypothesized factor with an aim of interfering its causality. Factors included

epidemiologically for the stone formation included age, sex, occupation, social class,

season of the year, the climate, dietary and the fluid intake and the genetic

predisposition. Since some of the factors were interlinked they were broadly classified

into 5 categories and epidemiologically looked over. The environmental factors were

looked as more important than the genetic predisposition. A hot sunny climate was

considered to be influencing stone formation through inducing dehydration. With

increased perspiration increased solute consideration and decreased urine volume,

coupled with inadequate liquid intake and possibly through the exposure to the ultra

16

violet radiation, which eventually resulted in an increased vitamin D production. This

resulted in the excretion of calcium oxalate through urine. Excessive intake of coffee,

tea and alcoholic beverages seemingly increases the risk of calcium stone formation.

An increased level of animal protein and sugar intake and a decreased ingestion of

dietary fiber and green leafy vegetables were linked with the higher probability of

formation of renal stone14.

A study was conducted on Hyperoxaluria in patients with recurrent

calcium oxalate calculi: dietary and other risk factors. The aim of the study was to

identify recurrent stone formers with mild hyperoxaluria and to classify them further by

assessing their response to a low oxalaye diet. In addition, the prevalence of other risk

factors for stone formation in this group of patients was investigated. A total of 207

consecutive patients with recurrent renal calculi were screened and 40 (19%) were

found to have mild hyperoxaluria. Of these, 18(45%) responded to dietary oxalate

restriction by normalizing their urinary oxalate. The remaining 22 patients were

classified as having idiopathic hyperoxaluria and were subdivided into those in whom

urinary oxalate excretion was consistently elevated in all specimens measured and

those in whom the elevation was intermittent in nature. Dietary oxalate restriction had a

partially beneficial effect in lowering oxalate excretion in the patients with persistent

hyperoxaluria. No difference in urinary excretion was found after dietary restriction in

the patients with intermittent hyperoxaluria. Other risk factors, including dietary,

absorptive and renal hypercalciuria and hypo citraturia, were documented, the

prevalence of which (65%) was not significantly different from that (62.5%) found in

40 age- and sex-matched calcium stone formers without hyperoxaluria. The prevalence

17

of hyperuricosuria was significantly greater in patients with hyperoxaluria when

compared with stone controls15.

An exploratory survey study was conducted on prevalence of the

nephrolithiasis and its relation to the environmental risk factors including the nutrition,

a correlation had been demonstrated between activity of the renal stone disease and

excessive protein intake and the low fiber diet, and the cause and effect relationship had

been suggested between the prevalence of the disease and low urine volume due to

under hydration. Indeed too much meat and drinking alcohol even in a little amount

could cause the disease. Defective intestinal absorption of citrate and the modifications

in the protein substances, which inhibited the urinary crystallization, had also been

observed16.

An exploratory study was conducted to identify the epidemiology of

renal calculi and nutrition worldwide. In the prevalence and incidence it was found that

the majority of the patients with urolithiais were men and the prevalence was more

found in the industrialized countries (>10,000 patients). For identification of the

nutritional intake, 100 healthy subjects were fed two different standard diets, one being

a mixed diet and the other a ovo-lacto vegetarian diet, both the diet consisted of equal

amount of energy and fluid. The result showed that the consumption of the ovo-lacto

vegetarian diet resulted in a statistically significant increase in oxalate excretion (by

30% as compared to the mixed diet). The intake of vegetarian diet resulted in a

statistically significant 20.4% decrease in urinary calcium formation. The result of the

study also showed that a well balanced nutrition with consecutive high intake of fluid

leads to a significant decrease in the risk of urinary stone formation. The stone formers

18

showed no significant difference in magnesium and citrate excretion. The magnesium

excretion was <50mg/24hr. in 53.9% in both stone formers and normal subjects. The

citrate excretion was with in the normal range in all the persons. Sodium excretion was

very low in stone formers as compared to normal patients. The result suggests that

hyperuricosuria and hyperoxaluria with concomitant lower magnesium and sodium

excretion could be important determinants in the causation of the urinary calcium

disease, and the hyper calciuria appears to play a comparatively minor role in this17.

A study was conducted on Urine volume: stone risk factor and

preventive measure. Using the data available in literature and partly unpublished

personal research, they examine the role of urine volume as a stone risk factor, its

impact on calcium crystallization mechanisms and its real importance as means of

prevention. The most important findings of the study are (1) a low urine volume must

be considered as a real factor, both as regards the onset of renal calculi and stone

relapses; (2) an increase in urine volume induced by a high water intake produces

favorable effects on the crystallization of calcium oxalate and does not reduce the

activity of natural inhibitors; (3) a sufficiently high intake of water and probably other

fluids such as coffee, tea, beer and wine has a preventive effect on nephrolithiasis and

its recurrence, and (4) the role of fruit juice is still to be defined the study concluded

that a high intake of fluids, especially water, is still the most powerful and certainly the

most economical meansof prevention of nephrolithiasis, and it is often not used to

advantage by stone formers18.

Urine and Serum Composition of Renal Calculi

19

Renal calculi are generally composed of varieties of chemical

substances, bound together in intricate chemical bondage. This section of the reviewed

literature presents information about each type of renal calculi and the sources of those

chemicals, which contribute the formation of renal calculi.

An exploratory study was conducted on composition of the calcium

oxalate stone. The purpose of the study was to compare the urine composition in the

stone formers and the normal subjects, and thereby providing a bio-chemical basis for

selective prophylactic treatment in calcium oxalate stone formers. For the study 483

male and 226 female calcium stone formers and 100 normal male and 40 normal female

were selected and their urine was collected on an out-patient basis with normal dietary

and drinking habits. 24 hrs urine compositions was analyzed with respect to calcium,

oxalate, magnesium, citrate, urate and the inhibition of calcium oxalate crystal growth

rate. In the result of the study stone formers had an increased excretion rate of both

calcium and oxalate, where as magnesium and the urates did not separate stone formers

from that of the normal subjects. A large number of both male and female had a low

citrate excretion. The inhibition of calcium oxalate crystal growth was lower in males

but not in female patients. As a conclusion he said that by means of the analytical

programme of this design, it was possible to evaluate the stone formers from a

biochemical point of view19.

A study was conducted to determine the relevance of urinary citrate

measurement in management of patients with idiopathic calcium urolithiasis. They

selected a group of 83 normal persons and 120 patients with idiopathic calcium

urolithiasis (ICU), in an ambulatory setting age 20 – 70 yrs with uninfected urine,

20

normal renal function, and on no medication that might interfere with the citrate

excretion. In the result of the study it was seen that there was a significant co relation of

urinary citrate excretion with age in normal persons (9p<0.001) and no significant

correlation of urinary citrate excretion and age among patients with renal calculi.

Hypocitraturia (29.2%) was demonstrated in stone formers. In 15 of those 22 patients

one normal urinary citrate measurement was obtained, among them three patients had

both hypercalciuria and hypocitraturia. 24 of 35 hupocitraturia patients had a proven

intact urinary acidification mechanism. In their study they could not find any

relationship between the 24 hr urinary excretion of citrate and the severity of the stone

disease, or the frequency of the stone growth or new stone formation in the patients at

their follow up. The design of the study was comparative descriptive20.

The study was done on the effect of the calcium restricted diet of

urolithiasis patients on risk of kidney stone and the osteopenia. For the study 25

patients were randomly selected from 6 hospitals to form the experimental group. This

group had calcium restriction to 500 mg/day, oxalate rich foods are discouraged and

normalization of the animal protein and sodium was done for 1 month. In the result of

the urinary calcium excretion did not decrease significantly. The calcium restricted diet,

which was low in calcium, animal protein and the table salt due to omission of the dairy

products; it might have been beneficial for absorptive calciuria type II patients without

enhancing the risk of osteopaenia21.

Bio chemical Evaluation of Renal Calculi

21

Health assessment is an integral part of health care. The following

research studies present information about the number of bio chemical evaluation to be

done for early identification of recurrence and early management.

A study was conducted on the metabolic evaluation of patients with

recurrent nephrolithiasis. In this study he said that the primary goal of a metabolic

diagnostic evaluation was to identify as efficiently and economically as possible. The

particular physiological and environmental defects present in a given patient with

nephrolithiasis to enabled rational therapy of the stone disease. A multi channel blood

screen as well as voided urinary specimens for urine analysis was necessary for all the

patients with recurrent episodes of renal stones as well as for the patients with only one

incident of renal stone formation. It has been suggested that the excretion of various

stone forming substances might be impaired in the presence of urinary tract obstruction

by a renal or ureteral calculus. In addition one might expect similar alteration of urinary

function to exist after various techniques of stone removal. Therefore it is advisable to

postpone a complete diagnostic evaluation for one month after removal of the ureteral

obstruction or infection or after undergoing a stone removal procedure. This delay

allowed recovery of normal renal function as well as reinstitution of regular dietary

habits22.

A study was conducted to determine the number of times the bio

chemical evaluation has to be done after stone surgery and or its excretion through

urinary passage. A total of 16 women and 13 men aged 15 – 75 yrs were selected over a

6 months period on out patients’ basis, for the study. Urine (24 hrs) and blood

specimens were obtained while the patients were on their customary diet. Biochemical

22

evaluations were done two times for 29 out patients with calcium stone disease, the first

time within one month after surgical extraction or excretion of stones and the second

time after two months23.

The data for constituents other than urinary calcium were generally in

agreement for the two trials, and there were no significant difference when the results

were compared statistically (Student’s t-test) Classification of the etiologic basis for the

stone disease was the same after both tests in 27 patients. In the other two patients the

diagnosis was changed from renal to absorptive hypercalciuria. Both of these patients

had creatinine clearance rates less than 60% of normal during the first test. One also

had multiple residual stone during both the evaluations, and the second had an urinary

tract infection during the first test that resolved with a normal creatinine clearance by

the second test period. As conclusion they had emphasized that almost all patients

could be evaluated and placed in the management programme within a few weeks after

the surgery. If the work up could be done earlier, it would allow to initiate medical

management earlier and most important, improve patients’ compliance.

Risk Factors in Renal Calculi

There are many factors which are responsible for the formation of renal calculi. The

following research studies describe about some of the risk factors which may cause the

formation or the recurrence of renal calculi.

A study was conducted on drinking water quality and urolithiasis. The

case reports analysed for 1240 surgeries done over 35 years in the Bitola Yugoslavia.

23

Of the 1240 operations in that area 496 (60%) were done on kidneys, 228 (18.40%) on

ureters 462(37.25%) on bladder and 54 (4.35%) on urethra. The highest percentages of

surgeries were on kidney, and the renal stone numbered 58.40%. The investigation

showed that the right side was more affected than the left side and the male to female

ratio was 1:1.07 which was practically equal. They came in to a conclusion that the

mineral content of the drinking water had an influence on the etiology of the etiology of

the calcium oxalate urolithiasis, and it confirmed the hypothesis about soft drinking

water poor in calcium and magnesium and the high incidence and prevalence of

urolithiasis24.

An experimental study was conducted on effect of protein intake record

and dietary history in renal stone patients. For this study 20 renal stone patients and 20

patients for control group where selected and asked to make a 1 week retrospective

dietary recall and a prospective 4 days dietary record. The control people were selected

by the renal stone patients on the basis of equality in age, sex, occupation and social

conditions, but without a history of renal stone. Two 24 hr urine collection were made

for measurement of potential risk factors. The result showed that 4 days record of

dietary intake of protein, sodium, potassium and phosphate were positively correlated

to the urinary excretion of nitrogen, sodium, potassium and phosphate respectively.

Whereas dietary recall was not correlated to the urinary output. There was no difference

between stone formers and control group in the dietary intake of protein, purine,

carbohydrates, fat, calcium, phosphate, potassium or iron according to the record. The

control group had a 50% higher consumption of vitamin C and 15% higher fiber intake

than the stone formers. Stone formers seemed to consume 45% more alcohol than the

controls. Despite a tendency to lower calcium intake, stone formers had a higher

24

amount of urinary calcium (p<0.005), as well as sodium, phosphate and urate, than the

controls. As a conclusion they emphasized that the diet registration seems to be more

accurate than the diet recall. No major differences in diets of stone formers and controls

could be found except regarding the alcohol and fiber intake25.

A study was conducted on Hyperoxaluria in patients with recurrent

calcium oxalate calculi: dietary and other risk factors. The aim of the study was to

identify recurrent stone formers with mild hyperoxaluria and to classify them further by

assessing their response to a low oxalate diet. In addition, the prevalence of other risk

factors for stone formation in this group of patients was investigated. A total of 207

consecutive patients with recurrent renal calculi were screened and 40 (19%) were

found to have mild hyperoxaluria. Of these, 18 (45%) responded to dietary oxalate

restriction by normalizing their urinary oxalate, the remaining 22 patients were

classified as having idiopathic hyperoxaluria and were subdivided into those in whom

urinary oxalate excretion was consistently elevated in all specimens measured and

those in whom the elevation was intermittent in nature. Dietary oxalate restriction had a

partially beneficial effect in lowering oxalate excretion in the patients with persistent

hyperoxaluria. No difference in urinary oxalate excretion was found after dietary

restriction in the patients with intermittent persistent hyperoxaluria. Other risk factors,

including dietary, absorptive and renal hypercalciuria and hypocitraturia, were

documented, the prevalence of which (65%) was not significantly different from that

(62.5%) found in 40 age- and sex-matched calcium stone formers without

hyperoxaluria. The prevalence of hyperuricosuria was significantly greater in patients

with hyperoxaluria when compared with stone controls26.

25

A study was conducted on High Excretion of Uric acid combined with

high excretion of Calcium Links Kidney Stone Disease to familial hypertension

revealed that 34% of the patients with the combined abnormalities of hyperuricosuria

and hypercalciuria had a positive family history of hypertension, defined as 2 or more

first degree relatives with treated hypertension, that are significantly higher than in

patients with either “pure” hyperuricosuria (15%, P<0.02), “pure” hypercalciuria (8%,

P<0.001), or patients with “other” abnormality (10%, P<0.001). the adjusted result for

positive family history of hypertension in the “combined” abnormality group compared

to the control Kidney Stone Disease patients group was 5.6 (2.39 – 13.30). The

prevalence of hypertension in siblings of patients with the combined abnormality (13%)

was significantly higher than in siblings of patients either “pure” hyperuricosuria (3%,

P<0.001), “pure” hypercalciuria (1%, P<0.001), or siblings of control patients with

“other” abnormality(4%, P<0.001). the adjusted result for hypertension in siblings of a

patient with “combined” abnormality compared to a control Kidney Stone Disease

patient was 3.4 (1.97 – 5.91). patients in the “combined” abnor,ality group were also

characterized by significantly elevated urinary sodium, phosphorus, citrate and

potassium excretions27.

A study was conducted on Effect of Ascorbic Acid and consumption on

Urinary stone Risk factor. In the study a total of 12 normal subjects and 12 CaOx stone

formers underwent 2, 6-day phase of study while maintained on a controlled metabolic

diet. In each phase subjects ingested 1 gm Ascorbic Acid or an identical appearing

placebo twice daily. On the last 2 days of each phase 2, 24- hour urine collections were

analyzed for pH and stone risk factors, and blood specimens were submitted for serum

chemistry studies. The study concluded ingestion of 2 gm Ascorbic Acid results in no

26

change in urinary pH but a moderate though statistically significant increase in urinary

oxalate in normal subjects (20%) and stone formers (33%). Stone formers respond no

differently to Ascorbic Acid than normal subjects28.

SUMMARY

This chapter dealt with related literature for the study under the following headings

such as Epidemiology and Socio Economical aspects of Renal Calculi, Urine and

Serum Composition of Renal Calculi, Biochemical Evaluation of Renal Calculi and

Risk Factors in Renal Calculi

27

4. METHODOLOGY

Methodology of the research indicates the general pattern for organizing

the procedure for empirical study together with the method of obtaining valid and

reliable data for problem under investigation.

The methodology adapted for the study including research approach,

research design, setting of the study, population, sample technique, development and

description of the instruments for data collected, development of teaching programme,

procedure for data collection and plan for data analysis.

RESEARCH APPROACH

In order to achieve the objectives of the study en Evaluative Approach

was found to be appropriate and selected for the study.

RESEARCH DESIGN

The research design is the overall plan for obtaining answers to the

questions being studied and for handling some of the difficulties encountered during the

research process29.

28

The research design adopted for the present study was one group pre test

post testing. This design was adopted to assess the knowledge gain on renal calculi and

its management of patients with renal calculi following the administration of planned

teaching programme.

One group pre test post test design

Fig: 2 Schematic representation of the research design

01 : Pre test

X : Intervention (Planned teaching programme)

02 : Post test

Day 1 - Pre test

Day 1 - Intervention

Day 4 - Post test

Structured questionnaire to

assess the knowledge

Planned teaching

programme

Same as Day1 except the

intervention i.e. Planned

teaching programme

01 02 x

29

Fig:3 Diagrammatic representation of the research design ( Study design for assessing

the knowledge of patients with renal calculi regarding renal calculi and its

management).

Sample and

sampling

techniques

Variables

Tool

Analysis

48 renal calculi

patients who are

admitted in hospital

Convenient

Sampling

Independent

Variables

Planned teaching

programme

Dependent Variable

- knowledge of

renal calculi and its

management

Structured

Knowledge

Questionnaire to

assess knowledge

regarding renal

calculi and its

management

Descriptive

Analysis

Frequency

Percentage

Mean

Mean Percentage

Standard

deviation

Inferential Analysis

‘t’ test

chi square

test

30

Interpretation of

data

Fig: 4 Schematic representation of the study design

VARIABLES

Variables are qualities, properties or characteristics of person, things or

situation that change or vary30.

Independent Variable: Planned Teaching Programme

Dependent Variables: Knowledge about renal calculi and its management.

RESEARCH SETTING

The physical location and conditions in which data collection takes place

in a study31.

The study was conducted in A.J Hospital and Research Centre,

Mangalore in Karnataka State. The hospital has a urology department where all the

invasive and non invasive procedures are carry out. An average of 15 to 20 patients

with renal calculi is usually attending the urology OPD weekly. A free urology camp

for 45 days was conducted at the time of data collection.

POPULATION

31

The population is all elements (individuals, objects, or substances) that

meet certain criteria for inclusion in a study32.

In the present study, population consists of 48 patients who were

diagnosed to have renal calculi, admitted in A.J Hospital and Research Centre at the

time of data collected.

SAMPLE

A sample is a subset of the population that is selected for a particular

study, and the members of a sample are the subject30.

The sample of the study was the patients who were diagnosed to have

renal calculi and admitted in hospital.

SAMPLING TECHNIQUES

Sampling is a process of selecting subjects who are representative of the

population being studied30.

Convenience sampling, also called accidental sampling uses participants

who are easily accessible to the research and who meet the criteria o the study33.

Convenience sampling technique was adopted for this study. For the

study a convenient sample of 60 subjects was drawn from the study population on the

basis of criteria. There was a sample mortality of 12 patients with renal calculi for the

post test. Therefore the final sample consisted of 48 patients.

32

SAMPLE CRITERIA

Inclusive Criteria: Patients with renal calculi

who are admitted in the hospital

who know to read and write Kannada or English

who are willing to participate

who are above 20 years of age

Exclusive Criteria: Patients

from medical and paramedical profession

with past history of renal calculi

DATA COLLECTION INSTRUMENT

Structured Knowledge Questionnaire about renal calculi and its

management was used to assess the knowledge of patient with renal calculi.

DEVELOPMENT OF THE TOOL

Data collection tools are the procedures or instruments used by the

researchers to observe or measure the key variables in the research problem34. The

present study aimed to evaluate the effect of planned teaching programme on renal

calculi and its management. So structured knowledge questionnaire was developed as

the tool to collect data.

33

PREPARATION OF BLUE PRINT

A blue print was prepared with the objectives keeping in mind. It

depicted the distribution of items according to knowledge, comprehension and

application. The domains were anatomy and physiology of urinary system, causes,

clinical manifestations, management and prevention of recurrence of urinary stone.

TESTING OF THE INSTURMENT

CONTENT VALIDITY OF THE TOOL

Content Validity concerns the degree to which an instrument has an

appropriate sample of items for the construct being measured.

The Structured Knowledge Questionnaire, along with objectives and

blueprint was submitted to thirteen experts, five from the field of Nursing, three from

Consultant Urologists, two from surgeons, two from General Medicine Physicians and

one from the field of Food, Nutrition and Dietetic Department. There were 35 items in

the tool. There were 100% agreement for 30 items, and 84.62% of the four items were

given suggestion to reframe the stem. One item (80.2%) had suggested to delete

because it was beyond the level of understanding of the lay people. As this was found

relevant and meaningful, the necessary modification was made and the total number of

item was reduced to 34. The tool was translated in kannada and translated back to

English.

PRETESTING OF THE TOOL

34

Pretesting is the process of measuring effectiveness of an instrument.

The purpose is to reveal the problem relating to answering, completing and returning

the instrument and to point out weakness in the administration, organization and

distribution of the instrument35.

For the pretesting, modified version of the tool in English, Kannada was

carried out in Prabhu Hospital, Moodbidri. Ten patients who met the criteria were

selected. The respondents found the language of the questionnaire simple and

understandable. The average time taken to complete the tool was 15 to 22 minutes and

was acceptable to the subjects.

RELIABILITY OF THE TOOL

Reliability of an instrument is concerned with how consistently the

measurement technique measures the concept of interest30.

For reliability, the tool was administered to 20 renal calculi patients who

fulfilled the sampling criteria. Respondents did not find any difficulty in understand

and answering the questions.

The reliability coefficient of the tool was calculated using split half

method by Spearman’s Brown Formula. The reliability of the tool was found to be 0.84

which was statistically significant. This indicates that the tool was reliable.

DESCRIPTION OF THE FINAL TOOL

Structured Knowledge Questionnaire was used to assess the knowledge

of renal calculi patients regarding renal calculi and its management.

35

There were two tools used for the study, which are follows.

TOOL 1: Background Variables, which included 16 items such as name, age,

sex, address, hospital number, educational background, marital

status, occupational status, per capita income in rupees, religion,

food habits, information regarding the medical help taken before,

number of hospital admission before, formation of having similar

disease in their family and sources of their health information

regarding their disease condition.

TOOL 2: consists of 34 close ended questions to assess the knowledge of

renal calculi patients regarding renal calculi and its management.

The maximum score of each item was 1 and the minimum score was 0

and the total score was 34. The score was categorized on arbitrary basis as follows.

0 – 11 = Poor

12 – 23 = Average

24 – 34 = Good

PLANNED TEACHING PROGRAMME

Teaching programme is a guide for the teacher because it helps to cover the

topics comprehensively with proper sequence of points and without missing anything36.

The steps to prepare the teaching plan are

1. framing the outline of the teaching plan

2. framing the outline of the content

36

3. deciding methods of instruction and audio-visual aids

4. evaluation of the teaching plan

1. Framing the outline of the teaching plan

The outline on the basis of the teaching plan was framed. This includes

setting of the general and the specific objectives, specifying the place,

learners, duration of the session.

2. Framing the outline of the content

The content of the teaching plan included topics on renal calculi and its

management. It was explained under various heading such as anatomy and

physiology of urinary system, causes of urinary stone, clinical features of

urinary stone, management of urinary stone and prevention of recurrence of

urinary stone.

3. Deciding methods of instruction and audio-visual aids

The methods of instruction adopted was lecture cum discussion, visual aids

like charts, pamphlets on renal calculi and its management, booklets were

also given to each subject.

4. Evaluation of the teaching plan

Evaluation of the teaching plan was done by content validity, which was

ascertained by consulting experts in the fields of nursing, medicine and

Food, Nutrition and Dietatic Department. Details of the content validity is

enclosed in page no. 32.

37

PILOT STUDY

A pilot study is a small preliminary investigation, which has the same

general character on the main study35.

The pilot study was carried out at Alva’s Health Centre, Moodbidri

from 12th – 25th November, 2004. Written permission was obtained from the authority

before conducting the pilot study. Based on the predetermined criteria set by the

investigator through convenient sampling, pilot study was conducted on ten renal

calculi patients after taking written content from them. The subjects were informed

about the purpose of the study and requested to complete the questionnaire.

After obtaining data from renal calculi patients related to renal calculi,

planned teaching was given to them. Visual aids were used to facilitate understanding.

The time spent for teaching was 50 – 60 minutes. Pamphlets on renal calculi and its

management were distributed to the subjects. On 4th day of the planned teaching, post

test was given by administering the same pretest questionnaire. Statistical analysis of

the pilot study reveals that there was significant difference between pretest knowledge

and posttest knowledge of renal calculi patients on renal calculi and its management.

Time taken for pretest was 15 – 22 minutes and for posttest were 13 – 20 minutes.

DATA COLLECTION PROCEDURE

The final data collection was done from A.J Hospital and Research Centre,

Mangalore. Formal written permission was obtained from the Medical Director of the

hospital.

38

The data was collected from 60 renal calculi patients who were admitted in the

hospital and met the study criteria. Subjects were asked to participate in the study after

self-introduction by the investigator. The patients were informed the purpose of the

study and the consent was taken from them. Pre test was administered to each patient

on various day followed by teaching programme. Charts, pamphlets and booklet were

used to facilitate understanding of the teaching. The teaching was carried out in their

ward of the patients and the duration of the teaching was 50 – 60 minutes.

The method of instruction adopted was lecture cum discussion. After the

teaching session, patients were asked about the doubt and clarified them.

Post test was conducted using the same questionnaire on the fourth day of

teaching. There were twelve subjects mortality and the final sample was forty eight.

PLAN FOR DATA ANALYSIS

The investigator planned to analyze data by using both descriptive and

inferential statistics.

SUMMARY

This chapter dealt with the research approach, research design, setting of the

study, population, sample, sampling technique, development of the tool, method of data

collection, development of lesson, evaluation of the effectiveness of planned teaching

programme, plan for analysis of data and presentation.

39

5. RESULTS

This part deals with analysis and interpretation of data collected from 48

renal calculi patients to find out the effectiveness of Planned Teaching Programme and

association with selected demographic variables.

Master data sheet was prepared and the data was analyzed based on the

objectives and hypothesis, using descriptive and inferential statistics.

OBJECTIVES OF THE STUDY

1. To determine the pre test knowledge of the renal calculi patients regarding renal

calculi and its management.

2. To plan and validate the planned teaching programme on renal calculi and its

management for the patients with renal calculi.

3. To evaluate the effectiveness of planned teaching programme on renal calculi

and its management in terms of gain in knowledge in post test.

HYPOTHESES

The following hypotheses will be tested at 0.05 level of significance.

H1: The mean post test knowledge score of the patients with renal calculi on renal

calculi and its management will be significantly higher than the mean pre-test

knowledge scores, as measured by a structured knowledge questionnaire.

40

H2: There will be significant association between the pre test knowledge scores

and the selected variables.

ORGANIZATION OF THE STUDY FINDINGS

The data was presented under the following headings.

Section I : Sample Characteristics

Section II : Validation of Planned Teaching Programme

Section III : Evaluation of Planned Teaching Programme in terms of gain in

knowledge scores.

Section IV : Significance of difference between the mean pretest and posttest

knowledge scores.

Section V : Association between the pretest knowledge and selected demographic

variables.

Section I : Sample characteristics

This section deals with the characteristics of the patients with renal calculi in

terms of frequency and percentage.

41

Table : 1 Frequency and percentage distribution of patients with renal calculi on

the basis of their demographic data

N = 48

Sl no

Variables

Frequency

Percentage

1

2

3

4

Age

21 – 35 years

36 – 50 years

51 – 65 years

> 66 years

Sex

Male

Female

Educational Background

Primary School Education

High School Education

Pre degree

Graduate

Post Graduate

Marital Status

Married

Unmarried

Divorced

16

14

13

5

38

10

13

12

9

10

4

40

7

1

33.34

29.16

27.08

10.42

79.17

20.83

27.08

25.00

18.75

20.83

8.33

83.33

14.58

2.08

42

5

6

7

8

Occupational Status

Coolie

Agriculture

Beedi Worker

House Wife

Business

Any other

Student

Teacher

Driver

Bank Employee

Government Employee

Per Capita Income in Rupees

1 – 1500

1501 – 3000

3001 – 4500

>4501

Religion

Hindu

Muslim

Christian

Dietary Pattern

Vegetarian

Non-vegetarian

3

9

1

5

12

5

4

2

3

4

7

16

12

13

33

9

6

7

41

6.25

18.75

2.08

10.42

25.00

10.42

8.33

4.17

6.25

8.33

14.58

33.34

25.00

27.08

68.75

18.75

12.5

14.58

85.42

43

9

10

11

12

13

Previous hospital Admission

Yes

No

Number of Previous Hospital Admission One time Two times Three times Any Family History of Renal

Calculi

Yes

No

Sources of health information

on the disease condition

Doctor

Relatives

Friends

Any other

Any following habit(s)

Smoking

Betal leaves chewing

Alcohol

None of the above

6

42

2

3

1

4

44

44

2

1

1

10

8

3

32

12.5

87.5

4.17

6.25

2.08

8.33

91.67

91.67

4.17

2.08

2.08

20.83

16.66

6.25

68.75

44

Data presented in Table 1 depict the distribution of sample according to

Age, Gender. Educational background, Marital status, Occupational status, Per capita

income in rupees, Religion, Dietary pattern, Previous hospital admission, Number of

hospital admission, Family history of renal calculi, Sources of health information and

Habit.

Age

Majority of the sample ( 33.34%) belonged to age group 21 – 35 years.

Gender

Majority of the sample (79.17%) were male. Shown in figure no.

Educational background

Maximum number of the sample (27.08%) was having Primary School

Education.

Marital status

Majority of the sample (83.33%) were married.

Occupational status

Majority of the sample (25%) were doing business.

Per capita income in rupees

Greater percentage of sample (25%) had family income of Rs 1501 – 3000.

45

Religion

Majority of the sample (68.75%) belonged to Hindu background.

Dietary pattern

Majority of the sample (85.42%) takes Non-vegetarian. Shown in figure no.

Previous hospital admission

Majority of the sample (87.5%) had no history of previous hospital admission.

Number of previous hospital admission

Out of 12.5% of sample with history of previous hospital admission, 4.17%

sample admitted for one time, 6.25% for two times and 2.08% for three times admitted

to the hospital before.

Any family history of renal calculi

Majority of the sample (91.67%) had no family history of renal calculi.

Sources of health information

Majority of the sample (91.67%) reported that they came to know about their

disease when doctor told them while consultation.

Habit

Majority of the sample (68.75%) did not have the habit of smoking, chewing

betal leaves and taking alcohol.

46

Fig: 5 Bar diagram showing the distribution of renal calculi patients according to their age

0

5

10

15

20

25

30

35

40

21-35 36-50 51-65 >66

AGE IN YEARS

PER

CEN

TAG

E O

F A

GE

10.42

27.08

29.16

33.34

47

Fig: 6 Pie diagram showing distribution of renal calculi patients according to gender

FemaleMale

79.17%

20.83%

48

Fig:7 Pie diagram showing distribution of renal calculi patients according to their dietary pattern

VegetarianNon-vegetarian

85.42%

14.58%

49

Section II Validation of Planned Teaching Programme

The Planned Teaching Programme on Renal Calculi and its Management

developed by the investigator was validated by thirteen experts. The percentage of

agreement and suggestions are given below.

Table 2: Percentage of agreement by experts on areas of planned teaching

programme in percentage and frequency

N = 48

Agree Disagree Sl

No

Area Frequency % Frequency %

Suggestion

Action

Taken

1 Objectives 13 100 ------ --- No

suggestion

No action

taken

2 Selection and

Organization

of Content

13 100 ------ --- Provides

adequate

information

No action

taken

3

Language

Used

13 100 ----- ---

No

suggestion

No action

taken

4 Feasibility 13 100 ----- --- Feasible No action

taken

5 Practicability 13 100 ----- --

-

No

suggestion

No action

taken

50

The data presented in Table 2 shows the percentage of agreement by

thirteen experts on areas of planned teaching programme. The content of planned

teaching programme was validated by thirteen experts. There was 100% agreement in

the content of the Planned Teaching Programme.

Section III: Evaluation of planned teaching programme in terms of

gain in knowledge scores.

Table 3: Frequency and percentage distribution of pretest and posttest knowledge

scores of subjects

N = 48

Pre test Post test Level of

Knowlegde Frequency % Frequency %

Poor ----- ----- ------ -----

Average 43 89.58 1 2.08

Good 5 10.42 47 97.92

The data presented in Table 3 shows that in the pretest majority of renal calculi

patients (89.58%) had average knowledge regarding renal calculi and its management.

But in the posttest majority of the patients (97.92%) had acquired good knowledge.

51

Table 4: Range, Mean, median, mean percentage and standard deviation (SD) of

pretest and posttest knowledge scores

N = 48

Range

Mean

Median

Mean %

SD

PRETEST

14

18.79

18

39.15

2.922

POSTTEST

13

28.98

29.5

60.38

2.375

The data presented in Table 4 shows that the mean of posttest (28.98)

knowledge scores was higher than the mean of pretest (18.79) knowledge scores.

Shown in Figure 8.

52

0123456789

10111213141516171819202122

14-16 16-18 18-20 20-22 22-24 24-26 26-28 28-30 30-32 32-34 34-36

KNOWLEDGE SCORES

FREQ

UEN

CY

18

18.79 28.98

29.9

PRETEST POSTTEST

12-1410-12

Fig: 8 Frequency polygon showing the mean and median of knowledge scores of

patients with renal calculi in pretest and posttest

----- Mean ----- Median

53

Table 5: Area wise pretest and posttest knowledge scores

N = 48

Mean %

Knowledge

Score

Sl

No

Area

Maximum

Score Pretest Posttest

Mean

%

Actual

Gain

score

(A)

Mean

%

Possible

Gain

score

(B)

Modified

gain

score

A ÷ B

1 Anatomy and

Physiology of

Urinary stone

5

64.17

87.92

23.75

35.85

0.663

2 Causes of

Urinary stone

7

42.86

69.64

26.78

57.14

0.469

3 Clinical

feature of

Urinary stone

3

65.97

88.89

22.29

34.03

0.674

4 Management

of Urinary

stone

3

90.97

97.92

6.95

9.03

0.769

5 Prevention of

recurrence of

Urinary stone

16

49.48

82.68

33.2

50.52

0.657

54

The data presented in Table 5 shows that maximum gain was in the

area of management of urinary stone (0.769), second highest in the area of clinical

feature of urinary stone (0.674), third highest in the area of anatomy and physiology of

urinary system (0.663), fourth highest in the area of prevention of recurrence of urinary

stone (0.657) and the last highest is in the area of causes of urinary stone (0.469) as

indicated by modified gain score. The data further indicate that the posttest mean

percentage knowledge score in all content areas were higher than the pretest mean

percentage knowledge scores. The maximum gain was in the area of management of

urinary stone (97.92%), followed by area of clinical feature of urinary stone (88.89%),

area of anatomy and physiology of urinary stone (87.92%), area of prevention of

recurrence of urinary stone (82.68%) and area of causes of urinary stone (69.64%).

Modified gain score is a ratio of the amount actually learnt to the

amount that could possibly have been learnt. The difference between the mean pretest

and posttest percentage score indicates the actual gain. The possible gain is obtained by

subtracting mean pretest percentage score from 100.

To calculate the modified gain scores the mean score on the pretest as

well as the posttest is calculated followed by dividing the actual gain with the possible

gain which indicates that the gain in knowledge relative to the possible gain. Modified

gain score was calculated to adjust the achievement variable for a effect which would

predict that areas having low pretest scores would demonstrate greater amount of gain

than areas having high pretest scores.

55

Section IV Significance of difference between the mean pretest and

mean posttest knowledge scores on renal calculi.

In order to find the significant difference between pretest and posttest

knowledge scores ‘t’ value was computed.

To test the significance, following null hypotheses was stated.

H01 : There will be no significant difference between the mean pretest and posttest

knowledge scores of renal calculi patients regarding renal calculi and its management.

Table 6: Mean, Mean deviation (MD), Standard deviation (SD), ‘t’ value between

pretest and posttest knowledge scores of renal calculi patients.

N = 48

Mean Mean

Deviation

Standard

Deviation (d)

Standard

Error

‘t’ Value

PRETEST

18.78

POSTTEST

28.98

10.19

15.26

2.20

*

32.8147

(P<0.05)

Tabled t47 = 2.02 ( P<0.05 * - Significant )

The data presented in Table 6 shows that ‘t’ value computed between pretest

and posttest scores is statistically significant at 0.05 level of significant. The calculated

‘t’ value (32.81) is greater than the tabled value ( t47 = 2.02 ), hence the null hypothesis

is rejected and research hypothesis is accepted at 5% level of significance. This shows

that the Planned Teaching Programme was effective in improving the knowledge of

renal calculi patients regarding renal calculi and its management.

56

Table 7: Areawise paired ‘t’ test showing the significant difference between

pretest and posttest knowledge scores.

N = 48

Mean

Knowledge

Scores

Area

Pretest Posttest

Mean

deviation

Standard

deviation

(d)

Standard

error

Degree

of

freedom

‘t’

value

Anatomy and

Physiology of

Urinary

System

3.21

4.39

1.18

5.96

0.86

47

*

10.25

Causes of

Urinary

Stone

3.00

4.87

1.87

7.66

1.11

47

*

17.81

Clinical

features of

Urinary Stone

1.98

2.67

0.69

4.65

0.67

47

*

7.11

Management

of

Urinary Stone

2.73

2.91

0.18

2.55

0.37

47

*

3.96

Prevention &

recurrence of

Urinary Stone

7.92

13.29

5.37

10.06

1.45

47

*

25

Tabled t47 = 2.02 ( P<0.05 * - Significant )

57

The data presented in Table 7 shows that ‘t’ value computed between

pretest and posttest knowledge scores for each area is statistically significant ( t47 =

2.02, P<0.05 ). The maximum difference was in the area of prevention and recurrence

of urinary stone (20) followed by the area of Causes of urinary stone (17.81), Anatomy

and Physiology of urinary system (10.25), Clinical features (7.11) and Management of

urinary stone (3.96).

Section V: Association between pretest knowledge scores and

demographic variables – age, gender, per capita income of the family

and dietary pattern.

To test the association following hypothesis was stated and tested using chi-square.

H02 : There is no significant association between pretest knowledge scores and selected

demographic variables – age, gender, per capita income of the family and dietary

pattern.

Chi-square was computed in order to determine the significance of

association between Pretest Knowledge Scores with demographic variables – age,

gender, per capita income of the family and dietary pattern.

58

Table 8: Association between pretest knowledge scores and selected demographic

variables

N = 48

Sl No

Variables ≤ Median ≥ Median χ2(df)

1

2

3

4

Age

21 – 35 years

36 – 50 years

51 years and above

Gender

Male

Female

Per capita income in Rupees

< 3000

> 3001

Dietary Pattern

Vegetarian

Non-vegetarian

16

8

0

33

10

23

20

6

37

0

6

18

3

2

1

4

0

5

*

17.28(2)

0.07(1)

0.89(1)

0.03(1)

Tabled value at χ2(2) at 0.05 level is 5.99 P<0.05 * - Significant

Tabled value at χ2(1) at 0.05 level is 3.84 P>0.05 – not significant

59

The data presented in Table 8 shows that there is association between

pretest knowledge scores and the selected demographic variable age at 0.05 level of

significance (calculated χ2(2) = 17.28). Hence the null hypothesis is rejected and

research hypothesis is accepted. Whereas the data shows that there is no association

between pretest knowledge scores and the selected variables – gender, per capita

income of the family and dietary pattern at 0.05 level of significance. Hence the null

hypothesis is accepted and the research hypothesis is rejected in these groups.

SUMMARY

This chapter dealt with the analysis and interpretation of data using descriptive

and inferential statistics. The findings of the study revealed that there is significant

difference between pretest and posttest knowledge scores regarding renal calculi and its

management.

60

6. DISCUSSION

The findings of the study had been discussed with reference to the

objectives and hypothesis stated in chapter I and in relation with the findings of other

studies.

Demographic Data

The findings of the study demonstrated that among all the respondents,

majority of them belonged to hindu, non-vegetarian, male within the age group of 21 –

35 years.

Knowledge of renal calculi patients regarding renal calculi and its management.

Findings of the study shows that in the pretest most of the renal calculi

patients (89.58%) had average knowledge regarding renal calculi and its management.

This indicates that less number of patients had adequate knowledge regarding renal

calculi and its management. The study conducted by Thankachan A (2004) on the

effectiveness of planned teaching programme on prevention of anemia among

adolescent girls revealed that 70% of the sample in experimental group had average

knowledge and majority of the sample in control group (73.33%) had poor knowledge

regarding prevention of anemia (n = 60, 30 each for experimental and control groups).

61

Comparison between Pretest and Posttest knowledge scores

The findings of the study revealed that there was a significant difference

between pretest and posttest knowledge scores. The pretest mean percentage

knowledge scores regarding renal; calculi and its management was found to be less

than the posttest mean percentage knowledge scores.

A study conducted on the effectiveness of planned teaching

programme about home care of patients with chronic renal failure on chronic renal

failure patients and their attendants, showed a significant improvement in knowledge

level of patients as well as their family members after the administration of a planned

teaching programme56.

Association of pretest knowledge with selected demographic variables

The findings of the study showed that there was significant association

between pretest knowledge and the patient’s age, whereas there was no association

between pretest knowledge level and the gender, per capita income of the family and

dietary pattern.

A study was conducted to evaluate a planned teaching programme on

prevention of recurrence of renal calculi in terms of knowledge, dietary practices, and

selected biochemical components in serum and urine of patients with renal calculi. The

study revealed that there was significant association between the knowledge and the

patient’s level of education and occupation whereas there was no association between

the knowledge level and the age, gender, religion and exposure to mass media57.

62

7. CONCLUSION

The following conclusions were made on the basis of the findings of the study.

Most of the sample (89.58%) had average knowledge regarding renal calculi

and its management in the pretest. The mean percentage posttest scores and the

modified gain scores in all areas were found to be high.

There was significant difference between the pretest and posttest knowledge

scores ( t(47) =32.81, P<0.05).

There was significant association between pre-test knowledge scores and age (

χ2(2) = 17.28, p<0.05), whereas there was no significant association between

pre-test knowledge score and the selected variables gender ( χ2(1) = 0.07,

P>0.05), per capita income of the family ( χ2(1) = 0.89, P>0.05; ) and dietary

pattern ( χ2(1) = 0.03, P>0.05).

NURSING IMPLICATIONS

Health is wealth is a saying and it is truth. It is the responsibility and right of

every individual to attain a state of health. A large number of diseases could be

prevented with little or no medical intervention if people were adequately informed

about the likely complications and encourage to take timely and necessary precautions.

The findings of the study have implications for nursing practice; nursing

education; and research; and nursing administration.

63

Nursing Practice

The present study has several implications for nursing practice. Planned

teaching programme on renal calculi and its management is a practical strategy to make

the patients aware of their disease and to reduce the recurrence of the disease and thus

reduce complications and also help them to take self-responsibility for their own health.

Health promotion is one of the major roles a nurse has to play; hence its

accountability has to be stressed. Patient education is a process of assisting people to

learn and incorporate health related behaviour into every day like. The educative role of

the nurse has to be emphasized. Educative teaching may motivate clients to practice

self care.

The patients suffering with renal calculi are under severe psychological

stress as well as depression because of their severe pain and their hospitalization.

Providing teaching programme helps them better in their adjustment psychologically by

instilling confidence in them to prevent the complications.

Health information can be imparted through various methods like

lecture, mass media, pamphlet, self instructional module etc. Any teaching strategy

which is simple, clear and attractive makes interested learners to follow the instructions

easily. Nurses have to impose themselves in all the areas of community health

practices, so as to help people in leading healthy lifestyle by preventing health

problems.

64

Nursing Education

The present study has got nursing implication in nursing education since

today’s nursing students are tomorrow’s staff nurses, educators, administrators and

supervisors. Nursing teachers should emphasize the importance of health education and

the methods of imparting education in an effective way during students learning period.

Students should get opportunities to give health education in an appropriate way during

their clinical practice.

In the present era of primary health care more emphasize is given for

developing self care abilities of the individuals. Nursing education should emphasize

more on preparing prospective nurses to impart health information and assist the

community in developing their self care potentials. This can be best done by equipping

the nursing curriculum with the knowledge regarding dissemination of health

information used in various methods of education technology. The planned teaching

programme prepared and examined by this study for its effectiveness in improving the

knowledge of patients with renal calculi about renal calculi and its management is the

proof by itself. As the effectiveness of this teaching plan is well established, this may

be used in patients as well as students’ learning.

Nursing research

There is a great scope for nurses to conduct research in this area to find

the effectiveness of various strategies to educate the patients, their care givers, and the

public at large. Research should be done on preparation on innovative method of

65

teaching, better practice of nursing care and development of good and effective

teaching material.

Research can also focus in specific area of renal calculi’s management

and on specific area of prevention of recurrence of renal calculi, preparation of booklet

on renal calculi and its management, survey to find the incidence of renal calculi and

related complications, self instructional module on renal calculi and its management,

survey to assist the psychosocial problems of patients with renal calculi. In fact, this

study has helped to open avenue to a new area for nursing research.

Nursing administration

Nurses as administrators should take great interest formulating short and

long term policies in an organization or institution. The patients who are visiting the

hospital should gain some kind of health information according to their needs.

The nurse administrators should take initiative in organizing in service

education programme for nurses and motivate nurses to participate in such activities.

Nursing administrators will serve as a resource person for other nurses, students, clients

and relatives. The nurse administrators should see that enough support is provided in

terms of manpower, money, and materials for disseminating health information.

Periodical educational sessions by health personals should be conducted. Health camps

can be conducted and referrals should be cared adequately. The study findings have

shown clearly that the responsibility of nurse administrators in organizing in service

education on such topics is of importance.

66

LIMITATIONS

The limitations recognized in the study are:

1. The study did not use control group. Hence, the result of the study must be

generalized with caution as there is threat internal validity due to history.

2. Incidental teaching by the nurses, doctors, and other health team members could not

be controlled in between pretest and posttest because of ethical reason.

3. The sample being convenient one limits generalization to larger population with

similar characteristic.

4. The time gap between pretest and posttest was only 4 days.

SUGGESTIONS

1. Patients with renal calculi are encourage for check up for every three to four months

to rule out recurrence of renal calculi and to seek medical help on time.

2. The booklet on renal calculi and its management can be distributed to the renal

calculi patients right at the time of diagnosis.

3. Health education programmes should be organized in hospital and institutional

settings.

67

RECOMMENDATIONS

On the basis of the findings of the study, it is recommended that

1. A similar study be replicated on a larger sample with a control group.

2. A similar study be replicated for patients with specific type of renal calculi.

3. A longitudinal follow up study be conducted after three months to determine the

effectiveness of this planned teaching programme on renal calculi and its

management, in terms of gain in knowledge and change in dietary practices of

patients with renal calculi.

4. A comparative study be done to find the effectiveness the teaching programme and

other teaching strategy like self instructional module on renal calculi and its

management, in bringing gain in knowledge and change in dietary practices of

patients with renal calculi.

5. A survey study can be conducted to find the incidence of renal calculi and related

complications.

68

8. SUMMARY

Renal calculi is a common disorder and a significant problem because of

incidence, recurrence and severe complications. Stone disease is a surgical as well as a

medical problem. Major progress has been made recently in understanding the

pathophysiological disturbances responsible for stone formation as well as in the

techniques of stone removal. The introduction of extra corporeal shock wave lithotripsy

has considerably reduced the need for surgery.

The annual incidence of stone formation in the industrialized world is

generally considered to be 1500 – 2000 cases per million. With a prevalence of >10%

and an expected recurrence rate of = 50% stone disease has an important effect on the

health care system.

Dietary and drug treatment of renal calculi depend mainly on the

mineral composition of renal stone. However, a high intake of fluids, especially water,

is still the most powerful and certainly the most economical means of prevention of

renal calculi.

Health care providers take important role, in providing renal calculi

patients with accurate and upto date information. Well conducted education campaigns

can indeed change knowledge, attitude and behaviour and thereby dietary pattern.

69

The objectives of the study were

4) to determine the pre test knowledge of the renal calculi patients regarding renal

calculi and its management.

5) to plan and validate the planned teaching programme on renal calculi and its

management for the patients with renal calculi.

3) to evaluate the effectiveness of planned teaching programme on renal calculi

and its management in terms of gain in knowledge in post test.

The study attempted to examine the following hypotheses which were tested at 0.05

level of significance.

H1: The mean post test knowledge score of the patients with renal calculi on renal

calculi and its management will be significantly higher than the mean pre-test

knowledge scores, as measured by a structured knowledge questionnaire.

H2: There will be significant association between the pre test knowledge scores

and the selected variables.

The study assumed that

the patients who are admitted to the hospital with the diagnosis of renal calculi

will have some knowledge regarding renal calculi, gained through mass media,

friends, relatives and other sources.

70

the patients who are attending the planned teaching programme will be able to

follow the instructions in their daily life.

Renal calculi are prone to get recurrence.

Health teaching can impart knowledge regarding renal calculi which make them

aware of their disease.

Creating health awareness will help in prevention of recurrence of renal calculi.

The conceptual framework adopted for the study was based on

modified Rosen Stock’s Health Belief Model. This model stressed the importance of

learner’s motivation in seeking preventive health behaviour.

The study design was Pre experimental one group pre test post-test

design. The population of the study was patients with renal calculi aged above 20 years.

Convenient sampling technique was utilized to select sample (n = 48).

A structured knowledge questionnaire was prepared with 34 items on

knowledge regarding renal calculi and its management. The validation of the tool was

done by thirteen experts. Pretesting and reliability (Spearman’s Brown Prophecy

Formula) was established prior to the pilot study. After pilot study, main study was

conducted; data was collected from forty eight renal calculi patients. The data obtained

were analyzed in terms of the objectives and hypotheses using descriptive and

inferential statistics.

71

DEMOGRAPHIC DATA

Majority of the sample (33.34%) belonged to age group 21 – 35 years.

Most of the sample (79.17%) were male.

Maximum number of the sample (27.08%) was having Primary School Education.

Most of the sample (83.33%) were married.

Majority of the sample (25%) were doing business.

Greater percentage of sample (25%) had family income of Rs 1501 – 3000.

Most of the sample (68.75%) belonged to Hindu background.

Most of the sample (85.42%) takes Non-vegetarian.

Most of the sample (87.5%) had no history of previous hospital admission.

Out of 12.5% of sample with history of previous hospital admission, 4.17% sample

admitted for one time, 6.25% for two times and 2.08% for three times admitted to

the hospital before.

Most of the sample (91.67%) had no family history of renal calculi.

Most of the sample (91.67%) reported that they came to know about their disease

when doctor told them while consultation.

Most of the sample (68.75%) did not have the habit of smoking, chewing betal

leaves and taking alcohol.

72

MAJOR FINDINGS OF THE STUDY

Knowledge of renal calculi patients regarding renal calculi and its management.

Most of the renal calculi patients (89.58%) had average knowledge,

while the remaining (10.42%) had good knowledge.

Comparison between pre-test and post-test knowledge scores.

There was a significant difference between pre-test and post-test

knowledge scores ( t(47) =32.81, P<0.05; Tabled value = 2.02 ). Hence, it is inferred

that post-test knowledge scores was higher than the pre-test knowledge scores. This

showed that planned teaching programme was effective.

Areawise comparison of pre-test and post-test knowledge scores.

For the pretest, subjects had attained knowledge scores in the areas of

Anatomy and physiology of urinary system (64.17%), causes of urinary stone

(42.80%), clinical features of urinary stone (65.97%), management of urinary stone

(90.97%) and prevention and recurrence of urinary stone (49.48%). But after the

administration of planned teaching programme, the level of knowledge of the subjects

improved in each area such as Anatomy and physiology of urinary system (87.92%),

causes of urinary stone (69.64%), clinical features of urinary stone (88.89%),

management of urinary stone (97.92%) and prevention and recurrence of urinary stone

(82.68%).

73

Association between the pre-test knowledge with selected demographic variables.

There was significant association between pre-test knowledge scores and

age ( χ2(2) = 17.28, p<0.05; Tabled value = 5.99 ).

There was no significant association between pre-test knowledge score

and the selected variable gender ( χ2(1) = 0.07, P>0.05; Tabled value = 3.84 ).

There was no significant association between pre-test knowledge score

and the selected variable per capita income of the family ( χ2(1) = 0.89, P>0.05; Tabled

value = 3.84 ).

There was no significant association between pre-test knowledge score

and the selected variable dietary pattern ( χ2(1) = 0.03, P>0.05; Tabled value = 3.84 ).

SUMMARY OF THE CHAPTER

This chapter dealt with the discussions on the results obtained,

conclusions, implications for various nursing field of nursing practice, nursing

education, nursing research and nursing administration, limitations of the findings,

future suggestions, recommendations and a brief description of the study and the major

findings.

74

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and patients with calcium urolithiasis. Urological research 1988 Mar;12:26.

21. Fassen VA. The effect of calcium restricted diet of urolithiasis patients with

absorptive hypercalciuria type II on risk factors for kidney stone and the

osteopenia. Urological research 1998 Apr;26:65-69.

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22. Preminger GM. The metabolic evaluation of patients with recurrent nephrolithiasis:

A review of comprehensive and simplified approach. The journal of urology

1989;141:760-2.

23. Morton U, Rose R, Jerry W. Biochemical evaluation of calcium stone patients:

How soon it can be done afterstone surgery/passage. Urology 1990;34(5):410-4.

24. Peater ML, Sofijanka S. Drinking water quality and urolithiasis. Urological

research 1988;12:27.

25. Fellstrome BD, Calrlstome. Dietary history and dietary records in renal stone

patients and control. Urological research 1988;12:58.

26. Laminski, Meyers, Kruger, Morgolius. Hyperoxaluria in patients with recurrent

calcium oxalate calculi: dietary and other risk factors. British Journal Urology

1991 Nov;68(5):454-8.

27. Andras T. High excretion of uric acid combined with high excretion of calcium

links kidney stone disease. Nephrology Dialysis Transplantation 2002 Feb;

17(2):23-27.

28. Oliver, Beverley, Gargaret. Effect of Ascorbic Acid and consumption on urinary

stone risk factor. The journal of urology 2003 Aug;170:397-400.

29. Polit DF, Beck. Nursing research: Principles and methods. 3rd. Philadelphia: J.B

Lippincott Company; 2004.

30. Burns N, Grove SK. Understanding Nursing Research. 2nd ed. India: Harcourt

(India) Private Limited; 2002. p. 41,56.

31. Polit DF AND Hungler BP. Nursing research: Principles and methods. 3rd

ed. Philadelphia: J.B Lippincott Company; 2001.

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32. Kerlinger FN. Foundation of behavioural research. New york: Holt International

Edition; 1973. p. 134.

33. Talbot LA. Principlea ans Practice of Nursing Research. Philadelphia: A times

Mirror Company; 1995. p. 232.

34. Roberts CA, Burke SO. A Quantitative and Qualitative Approach. Boston: Jones

and Baredt Publishers; 1989.

35. Treece K, Treece JW. Elements of research in nursing. St. lous: C.V Mosby;1962.

36. Ramachandra L. health Education – A New Approach. New Delhi: Vikas

Publishing House; 1999.

37. Cockerham WC. Medical sociology. 6th ed. London: Prentice hall International

Ltd; 1995.

38. Fox DJ. Fundamentals of nursing. 2nd ed. Newyork: Appleton Century Crafts;

1979.

39. Gopalan C, Rama S, Balasubramaniam. Nutritive values of Indian foods.

Hyderabad: National institute of nutrition; 1973.

40. Kothari CR. Research Methodology, Methods and Techniques. 2nd ed. New Delhi:

Wishwa Prakasha; 2002.

41. Nieswiadomy RM. Nursing Research. 4th ed. New Jersy: Prentice Hall; 2002.

42. Valesieck EW. Nutrition history of recurrent calcium oxalate stone formers pre and

post diet. Urinary stone. New york: Churchill Livingston; 1984. p. 41-6.

43. Guigan FJ. Experimental psychology. New Delhi: Prentice Hall of India; 1969.

44. Patwarden VN. Nutrition in India. Indian journal of medical science 1954;4:113-5.

45. Suchman EA. Evaluative research. New york: Russell sage foundation; 1967. p.

75.

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46. Reen V. Idiopathic urinary bladder stones of childhood. American Journal of

Surgery 977;50:18-22.

47. Anita FP. Clinical dietetics and nutrition. 2nd ed. Delhi: Oxford University:1973.

48. Bailey, Love. Short Practice of Surgery. New York: International Students

Edition; 2000. p. 1143-56.

49. Atri SC. Handbook of Surgery. Patna: Scientific Book Company; 2001. p. 106-16.

50. Aronson MD, Rose B. Diagnosis and acute management of suspected

nephrolithiasis. UpToDate, 2002 May 28.

51. Brenner, Rector. The Kidney. 6th ed. W. B. Saunders Company, Copyright ©

2000.

52. Eisendrath, Rolnick. Childhood disorders and diseases. 4th ed. vol I, Philadelphia:

WB Saunders, 1978.

53. Erkonen, William E. Radiology 101: The basics and fundamentals if imaging.

Pliladelphia: Lippincott-Raven, 1998.

54. Tulasi TV. The effectiveness of Instructional Module on Self Care Practices of

Renal Transplant Patients. The Indian journal of Nursing and Midwifery

1999;2(1):21-6.

55. Garret HG. Statistics in psychology and education. Bombay: Vaklis, Feffer and

Simons Ltd; 1981.

56. Minnie. Effectiveness of planned teaching programme about home care of patients

with chronic renal failure patients and their attendants, in a selected hospital in

Udupi district, Manipal. Unpublished Master of Nursing Thesis, MAHE. Manipal;

1999.

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57. John R. A study to evaluate a planned diet counseling programme on prevention of

recurrence of renal calculi in terms of knowledge, dietary practices, and selected

biochemical components in serum and urine of patients with renal calculi, in a

selected hospital in Udupi district. Unpublished Master of Nursing Thesis, MAHE.

Manipal; 2000.

58. Thankachan A. A study to determine the effectiveness of planned teaching

programme on prevention of anemia among adolescents girls in selected colleges at

Moodbidri. Unpublished Master of Nursing Thesis. Rajiv Gandhi University of

Health Sciences, Bangalore; 2004.

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1a Letter seeking permission to do pretesting and reliability of the research tool

From Ms. Ch. Babita Devi II Year M.Sc Nursing Alva’s College of Nursing Moodbidri – 574227. To Dr. Krishna Mohan Prabhu Managing Director Prabhu General Hospital Moodbidri – 574227. Through the Research Advisor. Respected Sir, Subject: Permission to do pretesting and reliability of the research tool among the patients with renal calculi in Prabhu General Hospital. In partial fulfillment of M.Sc. Nursing degree, I have to undertake a research in the clinical speciality Medical Surgical Nursing. The topic selected for the study is “A study to evaluate the effectiveness of planned teaching programme on renal calculi and its management among renal calculi patients in selected hospitals in Mangalore taluk.” May I request you to kindly permit me to do pretesting and reliability of the research tool among the above mentioned patients in your hospital. Kindly do the needful for the above mentioned matter. Thanking you with anticipation. Place: Yours sincerely, Date: ( Ch. Babita Devi )

81

82

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2a Letter seeking permission to conduct pilot study

From Ms. Ch. Babita Devi II Year M.Sc Nursing Alva’s College of Nursing Moodbidri – 574227. To Dr. Harish Nayak Medical Superintendent Alva’s Health Centre Moodbidri – 574227. Through the Research Advisor. Respected Sir, Subject: Permission to conduct pilot study among the patients with renal calculi in Alva’s Health Centre. In partial fulfillment of M.Sc. Nursing degree, I have to undertake a research in the clinical speciality Medical Surgical Nursing. The topic selected for the study is “A study to evaluate the effectiveness of planned teaching programme on renal calculi and its management among renal calculi patients in selected hospitals in Mangalore taluk.” May I request you to kindly permit me to conduct pilot study among the above mentioned patients in your hospital. Kindly do the needful for the above mentioned matter. Thanking you with anticipation. Place: Yours sincerely, Date: ( Ch. Babita Devi )

84

85

86

3a Letter seeking permission to conduct research study

From Ms. Ch. Babita Devi II Year M.Sc Nursing Alva’s College of Nursing Moodbidri – 574227. To Dr. Prasanth Marla Medical Director A. J Hospital and Research Centre Mangalore – 575004. Through the Research Advisor. Respected Sir, Subject: Permission to conduct research study among the patients with renal calculi in your esteemed hospital. In partial fulfillment of M.Sc. Nursing degree, I have to undertake a research in the clinical speciality Medical Surgical Nursing. The topic selected for the study is “A study to evaluate the effectiveness of planned teaching programme on renal calculi and its management among renal calculi patients in selected hospitals in Mangalore taluk.” May I request you to kindly permit me to conduct pilot study among the above mentioned patients in your hospital. Kindly do the needful for the above mentioned matter. Thanking you with anticipation. Place: Yours sincerely, Date: ( Ch. Babita Devi )

87

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90

4 REQUISITION FOR CONTENT VALIDATION OF THE TOOL

From, Ch. Babita Devi I Yr. M.Sc Nursing Student Alva’s College Of Nursing, Moodbidri - 574227 To, --------------------------------- --------------------------------- --------------------------------- Respected Sir/Madam, Subject: Requisition for content validation of the tool I, Ms. Ch. Babita Devi, I Yr. M. Sc Nursing student of Medical – Surgical Nursing speciality at Alva’s College Of Nursing, Moodbidri kindly request you to give consent to validate my tool on “A study to evaluate the effectiveness of planned teaching programmed on renal calculi and its management among renal calculi patients in selected hospitals in mangalore taluk.” I would be highly obliged if you kindly give your acceptance and valuable suggestions. A self addressed envelope and acceptance form are enclosed herewith for your perusal. Thanking you with anticipation. Date: Yours faithfully,

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5 ACCEPTANCE FORM FOR TOOL VALIDATION

NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DESIGNATION: _ _ _ _ _ _ _ _ _ _ _ _ NAME OF THE COLLEGE / HOSPITAL: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ STATEMENT OF THE ACCEPTANCE: I give my acceptance / non – acceptance to validate the tool on “A study to evaluate the effectiveness of planned teaching programmed on renal calculi and its management among renal calculi patients in selected hospitals in mangalore taluk.” Date: ( Signature )

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6 CONTENT VALIDATION CERTIFICATE

I hereby certify that I have validated the tool of Ms. Ch. Babita Devi, I Yr. M.Sc Nursing student who is undertaking the study “A study to evaluate the effectiveness of planned teaching programmed on renal calculi and its management among renal calculi patients in selected hospitals in Mangalore taluk.” Signature of the Expert Date: Place: Designation and Address

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7a Criteria Checklist For Background Variables

Instructions Kindly review the items in the background variables for the patients with renal calculi and give your suggestions regarding appropriateness of the content. There are three response columns namely strongly agree, agree, and disagree. Kindly place a tick mark (√) against specific column. If there are any suggestions or comments please mention in the remarks column.

Items

Strongly agree Agree Disagree Remarks

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16

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7b Criteria checklist for validation of the tools

Instructions Kindly review the items in the structured knowledge questionnaire regarding renal calculi and its management and give your suggestions regarding accuracy, relevance and appropriate of the content. There are four response columns namely strongly agree, agree, disagree and strongly disagree. Kindly place a tick mark (√) against specific column. If there are any suggestions or comments please mention in the remarks column. Criteria checklist for structured knowledge questionnaire

Items

Strongly agree

Agree Disagree

Strongly disagree

Remarks

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

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7c CRITERIA CHECKLIST FOR EVALUATION OF PLANNED TEACHING

PROGRAMME ON RENAL CALCULI AND ITS MANAGEMENT Dear sir / Madam, Please go through the criteria listed below, which has been formulated for evaluating and validating the planned teaching programme for renal calculi and its management. There are four responses columns in checklist. COLUMN I ( Meets criteria ) Please place a tick mark (√) against this column if you think the contents and specific criteria have congruence / consistency. COLUMN II ( Partially meets criteria ) Please place a tick mark (√) against this column if you think the content is satisfactory. COLUMN III ( Does not meet criteria ) Please place a tick mark (√) against this column if you think the content is not relevant to the criteria. REMARK COLUMN When responses are made in column COLUMN I, COLUMN II, COLUMN III, the evaluator comments are required in this column

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COLUMN

SL NO.

CONTENT CRITERIA

I

II

III

REMARKS

1 a b

Formulation of objectives Comprehensive enough for renal calculi patient’s knowledge regarding renal calculi and its management. Objectives are in terms of learners behavioural outcome

II a b c

Selection and organization of the content. Content provides adequate information. Content is according to the level of understanding of renal calculi patients Logical sequence.

III

Language used is simple and clear.

IV

Feasibility

V

Practicability

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8a Letter seeking consent for participation in the study

Dear participant, I am Ms. Ch. Babita Devi, final year M.Sc. Nursing student of Alva’s College of Nursing, Moodbidri. I intent to do a study to determine the effectiveness of planned teaching programme on renal calculi and management among renal calculi patients in a selected hospital in Mangalore taluk. Therefore I request you to respond to the questions in the questionnaire without any hesitation and to co-operate whole heartedly in the study. I assure you that the information given by you will be kept confidential and used only for the purpose of this study. Your participant will helped me to complete my study and contribute to the field of health. Thanking you. Yours faithfully, Place: Ms. Ch. Babita Devi Date:

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8b Consent Form

I am voluntarily willing to participate in the study conducted by Ms. Ch. Babita Devi, entitled as “A study to determine the effectiveness of planned teaching programme on renal calculi and its management among renal calculi patients in a selected hospital in Mangalore taluk”, and to co-operate in providing information. I am informed that the information will be kept confidential and used only for the above mentioned study. Signature of the investigator Signature of the participant

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9 BLUE PRINT FOR STRUCTURED KNOWLEDGE QUESTIONNAIRE

SL NO

CONTENT Knowledge

Comprehension

Application

Total No. Of question

Percentage (%)

1

Anatomy and physiology of urinary system

1 2

3 4

5

5

14.29

2

Causes of urinary stone

9 11

7 8

10 12

6

7

20.00

3

Clinical features of urinary stone

13

14

15

3

8.57

4

Management of urinary stone

---

---

16 17

18

3

8.57

5

Prevention of recurrence of urinary stone

20 21

21 23

29 32

25

19 26

27 28

30 31

33 34

35

17

48.57

TOTAL

11

8

15

34

PERCENTAGE (%)

34.28

22.85

42.88

100

101

10(1a)

TOOL – 1

DEMOGRAPHIC DATA INSTRUCTION: The interviewee are asked to fill the space provided below or place a tick ( ) mark against the correct response of the following : 1. Name : ………………………….. 2. Age :

a) 21 – 35 years ( ) b) 36 – 50 years ( ) c) 51 – 65 years ( ) c) above 66 years ( )

3. Sex Male ( ) Female ( ) 4. Address : …………………………….. 5. Hospital Number : …………. 6. Educational Background

a) Uneducated ( ) b) Primary school Education ( )

c) High School Education ( ) d) Pre degree ( ) e) Graduate ( ) f) Post – graduate ( ) g) Others ( )

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7. Marital Status

a) Married ( ) b) Unmarried ( ) c) Widow / Widower ( )

d) Divorced ( ) 8. Occupational Status

a) Coolie ( )

b) Agriculture ( ) c) Beedi worker ( ) d) House wife ( )

e) Business ( ) f) Any others ( )

9. Per capita income in Rupees

a) 1 - 1500 ( ) b) 1501 – 3000 ( )

c) 3001 – 4500 ( ) d) > 4501 ( )

10. Religion

a) Hindu ( ) b) Muslim ( )

c) Christian ( ) d) Others ( Specify) ( ) 11. In which of the following group do you belong to?

a) Vegetarian ( )

103

b) Non-vegetarian ( ) 12. Have you been admitted to the hospital for allopathic treatment for any other problem in the past? Yes ( ) No ( ) 13. If yes, how many times you have been admitted to the hospital so far?

a) One time ( ) b) Two times ( )

c) Three times ( ) d) If more, specify ( )

14. Did any of your family members have the similar type of disease? Yes ( ) No ( ) 15. What is the source of health information on your disease condition?

a) Doctor ( ) b) Nurse ( )

c) Relatives ( ) d) Friends ( )

e) Mass media ( ) f) Any other, specify ( )

16. Do you have any following habit? a) Smoking ( ) b) Betal leaves ( ) c) Alcohol ( ) d) All the above ( ) e) None of the above ( )

104

10(1b)

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10(2a) TOOL – 2

107

STRUCTURED KNOWLEDGE QUESTIONNAIRE

INSTRUCTIONS: Here is a list of questions in relation to Urinary stone and its management. Please read the questions carefully and select the correct answer from the responses given. 1. Which of the following organ is responsible for the formation and elimination of urine?

a) Lung ( ) b) Kidney ( ) c) Liver ( )

2. What is the main function of Kidney?

a) Digestion of food ( ) b) Stores waste products ( ) c) Remove the waste products from the body ( )

3. What is the capacity of urinary bladder?

a) 201 – 300 ml ( ) b) 301 – 400 ml ( ) c) 401 – 500 ml ( )

4. Which of the following substance form the urinary stone?

a) Vitamins ( ) b) Minerals ( ) c) Blood clot ( )

5. How does hot climate contribute to stone formation?

a) Due to increase absorption of solutes during high temperature ( ) b) Due to excessive sweating leading to thick blood concentration ( )

c) Due to loss of appetite during hot season ( )

6. Which of the following liquid foods helps in urinary stone formation? a) Coconut water ( )

108

b) Weak tea ( ) c) Pepsi ( ) 7. Who are the people more prone to form urinary stone?

a) People with sedentary lifestyle ( ) b) People who work in the direct sun almost everyday ( )

c) People who work in factory ( )

8. Why do you need to drink excess amount of water when you consume excess green leaf vegetables? a) Water helps in digestion ( ) b) Water helps in absorption of minerals ( ) c) Water helps in the excretion of excess minerals ( ) 9. Which of the following minerals is rich in green leafy vegetables?

a) Calcium ( ) b) Phosphate ( ) c) Uric acid ( )

10. How does deficiency of Vitamin A result in urinary stone development?

a) By causing the smoothness of urinary pathway wall ( ) b) By causing the roughness of the urinary pathway wall ( )

c) By causing absorption of minerals from the contents of urinary pathway ( )

11. Which of the following disease predispose to the formation of urinary stone?

a) Hypertension ( ) b) Hepatitis ( ) c) Hyperparathyroidism ( )

12. What will happen if there is infection of the urinary tract?

a) Obstruction in the urinary pathway ( )

109

b) Erosion of the urinary wall ( )

c) Excessive secretion of urine ( )

13. Which of the following is the warning sign for urinary stone?

a) Sudden, sharp, severe pain in flank ( ) b) Gradual, mild pain in abdomen ( ) c) Severe, fluctuating pain pelvic region ( )

14. Which of the following signs and symptoms is not seen in urinary stone?

a) Excessive urine output ( ) b) Difficulty in passing urine ( ) c) Feeling of fullness of urinary bladder ( )

15. Which of the following condition is indicated by presence of fever, chills, shivering and vomiting?

a) Disease causing micro-organisms in the urinary pathway ( ) b) Increase concentration of urine ( )

c) Mass in the urinary pathway ( )

16. What measure you will take when you suspect stone in the urinary pathway?

a) Take self medication ( ) b) Rely on friends / relatives ( )

c) Seek medical care ( ) 17. Within what time you will seek medical help after the onset of pain?

a) Immediately after the pain ( ) b) After the second attack of pain ( )

c) After one week of onset of pain ( ) 18. When do we need the operation in case of urinary stone?

a) Presence of blood in the urine ( )

110

b) Presence of pus in the urine ( ) c) Presence of large stone in the urinary pathway ( )

19. What is the means to prevent recurrence of urinary stone?

a) Drinking little water ( ) b) Drinking liberal water ( ) c) Eating little food ( )

20. How much water should be taken daily by the patient with urinary stone approximately?

a) 1000 – 2000 ml ( ) b) 2001 – 3000 ml ( ) c) 3001 – 4000 ml ( )

21. Which of the following is contained in excess amount in fruit juices?

a) Sodium ( ) b) Potassium ( ) c) Calcium ( )

22. Which of the following is rich in raw vegetables?

a) Carbohydrate ( ) b) Fats ( ) c) Fiber ( )

23. Which of the following fruit is rich in calcium?

a) Guava ( ) b) Apple ( ) c) Lime ( )

24. Which of the following food items helps in the excretion of urinary stone?

a) Black pepper ( )

111

b) Tamarind ( ) c) Jaggery ( )

25. Which of the following measure should be taken to prevent urinary stone formation for the patients who are bed ridden?

a) Reducing food intake ( ) b) Reducing fluid intake ( )

c) Changed position frequently ( ) 26. Why do you need to avoid animal protein if you are diagnosed as having urinary stone?

a) Accumulation of minerals in the urinary pathway ( ) b) Increase production of urine ( ) c) Causes stagnation of urine ( )

27. What will happen if we consume excess salt in our food?

a) Increase body weight ( ) b) Increases the calcium absorption ( ) c) Decreases blood pressure ( )

28. Which of the following is the richest source of calcium?

a) Potato ( ) b) Tomato ( ) c) Cabbage ( )

29. Which of the following drinks will you avoid if you are diagnosed to have calcium stone?

a) Watermelon ( ) b) Barley water ( ) c) Milk ( )

112

30. What is the problem if you consume foods rich in sugar?

a) Decreases the production of urine ( ) b) Increases the concentration of urine ( ) c) Obstruct the flow of urine ( )

31. Which of the following types of fish is rich in calcium?

a) Small fish with bone ( ) b) Big fleshy fish ( ) c) Medium size fish ( )

32. Why do you need to avoid eating betel leaves with lime?

a) It increases the chances of dental caries. ( ) b) It increases the calcium content of the body ( ) c) It increases the chances of mouth ulcer ( )

33. Why should a person with urinary stone need to avoid drinking alcohol?

a) Alcohol causes excessive excretion of urine ( ) b) Alcohol decreases the excretion of minerals. ( ) c) Alcohol may deposit minerals in urinary pathway. ( )

34. Which one of the following should you need to drink more if you had taken the foodstuff that are supposed to restrict?

a) Commercial drinks ( ) b) Clear water ( ) c) Tea ( )

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ANSWER KEY

1. (b) 2 (c) 3 (b)

4 (b) 5 (b) 6 (c)

7 (b) 8 (c) 9 (a)

10 (b) 11 (c) 12 (a)

13 (a) 14 (a) 15 (a)

16 (c) 17 (a) 18 (c)

19 (b) 20 (c) 21 (b)

22 (c) 23 (c) 24 (b)

25 (c) 26 (a) 27 (b)

28 (b) 29 (c) 30 (b)

31 (a) 32 (b) 33 (c)

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34 (b) Arbitrary Classification Total score - 34 Good - 0-11 Average - 12-23 Poor - 24-34

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CONTENT OF TEACHING OUTLINE

1. TOPIC : Planned teaching programme on Renal calculi and its management

2. GROUP : Patients with Renal calculi

3. PLACE : Selected hospitals in Mangalore Taluk, KARNATAKA.

4. DURATION : 1 hour

5. METHOD OF TEACHING : Lecture cum discussion and demonstration

6. TEACHING AIDS : Charts, booklet on Planned teaching programme on Renal calculi and its management

7. CENTRAL OBJECTIVES : On completion of the education programme, the patients with renal calculi will acquire knowledge on renal calculi and its management, and will be able to change their dietary practices.

8. SPECIFIC OBJECTIVES : On completion of the sessions, the client will

list the organs involved in the formation and excretion of urine.

explain the meaning of urinary stone

explain the causes for the development of urinary stone

explain the problem caused by urinary stone explain the methods of confirming the presence of urinary stone

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list the types of urinary stone

manage the problem without surgery

list the indication for surgery in urinary stone

explain the measures to prevent the recurrence of urinary stone

list some of the foods rich in calcium, uric acid, phosphorus and oxalate Time Objectives Content Teaching

Activity Learning Activity

A V Aids

I INTRODUCTION Urinary system is one of the important system which has the role of

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4 min 3 min

on completion of this session the participant will be able to contribute in the discussion on recurrence of urinary stone. list the structures involved in the formation and excretion of urine.

excreting waste material from the body. This function may be impaired by many reasons. Important one among them is the presence of stone in the urinary system, which is referred to as urinary stone or renal calculi. Let us see how the disease presents. Mr. John, 40 years came to the hospital with the complaints of severe, agonizing pain passing from loin to groin, vomiting and profuse sweating. He was diagnosed to have urinary stone. Ultrasonography report showed that the stone was large enough and needed to remove only by surgical method. When asked about his disease, he said that he had attacks for three times before. The pain relieved by taking pain killers as per the advice given by his relative. This time the pain was so severe that the pain killer did not help to relieve pain. So he came to the hospital. And he is in need of surgery which might not be required if had sought medical help in time. There are so many such conditions of Mr. John among us that signify the importance of planned teaching programme regarding renal calculi and its management in order to minimize the further progression of stone thereby reducing further complications and morbidity. II THE STRUCTURES INVOLVED IN THE FORMATION AND EXCRETION OF THE URINE. The structures involved in the formation and excretion of the urine are Kidney, Ureter, Bladder and Urethra. Whatever we eat and drinks gets mixed with the enzymes present in the mouth, stomach and small intestine, and get broken down into very small pieces. Some of these small particles get mixed with blood. Blood also gets mixed with oxygen present in the air we breathe. This blood gets circulated throughout our body and supplies food and oxygen to all the body parts for their proper functioning. Thus the kidneys also get their share of blood. Kidneys retain the substance which are useful and the substances which are waste products and harmful for the body are removed along with extra water. III WHAT DO YOU MEAN BY URINARY STONE? Urinary stone is a hard stone like substance which is formed by deposition of certain chemical substances in the structures involved in formation and excretion of

Narration and discussion on urinary stone Lecture cum discussion

Listening and participating in the discussion Listening and asking questions

Charts

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2 min 14 min

explain the meaning of urinary stone explain the cause for the development of urinary stone.

urine. These chemical substances are mainly calcium, uric acid and phosphorus. These are also known as minerals. IV CAUSES OF DEVELOPMENT OF URINARY STONE a) Fluid intake

This include water and other liquid food stuffs our body need about 2 – 3 liters of water/fluid intake per day and lost nearly the same amount in the form of urine, sweat, feces and through breaths. If we do not drink adequate water to compensate the loss, our urine becomes thick with minerals like calcium, oxalate and phosphorus. Deposition of these minerals in urine may lead to formation of stones. b) Food Habits

The food stuff which we eat daily contains all the nutrients including minerals. For example, Green leafy vegetables are the rich sources of calcium and oxalates. Likewise, milk and milk products are the rich source of calcium and phosphates. And such foodstuff is very good for health and we need to eat in plenty. At the same time we should also drink more amount of water so that more amounts of oxalate and calcium will be excreted from our body. If we do not drink adequate amount of water, the calcium or the oxalate or the phosphate will get deposited and give rise to stone formation. Similarly, if we eat food stuff which are rich in uric acid or magnesium or cystine without drinking adequate water, it will cause formation of urinary stones. Other habits include alcohol, chewing betal leaves, smoking. c) Climate

During hot weather, we sweat profusely and pass less urine. We know that the metabolic waste products from the body are excreted through urine. When we pass less urine, these waste products are retained in the urine, that is why urine becomes thick and look dark in color and it has a very strong smell. In addition, we expose ourselves to the sun, so more vitamin D is formed in our body. This vitamin D helps to absorb more calcium from the food we eat and send it to the blood stream. Therefore calcium level increases in our blood and contribute formation of calcium stone.

Questioning what is urinary stone? Lecturing, discussion, questioning Lecturing, discussing, questioning List the causes of development

Answering Listening Answering Listening Taking part in the discussion Answering

Charts

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d) Occupation People who have to work in the direct sun almost everyday for a long time have more chance of getting urinary stone. Because they sweat too much and generally pass concentrated urine. Such people are coolie workers, farmers etc. e) Vitamin A

Cement is necessary for the construction of a smooth wall. Solid dirt cannot attach easily on a smooth wall. Similarly, if the wall of our urinary pathway is smooth, these minerals cannot get deposited easily on it and form the stone. Vitamin A, which is richly found in yellow foods like carrot, helps to maintain the smoothness of the urinary pathway wall. Hence, if our daily food is lacking in vitamin A, the smooth wall of the urinary pathway becomes rough, the minerals gets deposited on it and cause stone formation. f) Hyperparathyroidism Our bones are made up of mainly calcium. In patient with hyperparathyroidism, much of calcium is removed from the bones, which gets absorbed in the blood and from blood it goes to the kidney. The excess amount of calcium gets deposited in the urinary pathway and helps in the formation of urinary stone. g) Infection of the urinary tract Some disease causing micro-organisms (which cannot be seen by our naked eye) can get into the urinary pathway through blood. They can also enter directly from outside if out private parts are not cleaned properly. Also when there is an obstruction in the pathway of urine flow, the micro-organisms can grow in the stagnated urine causing infections. Such infections may lead to the formation of urinary stone. h) Prolonged illness and restricted movement i) Prolonged illness, particularly when a patient is immobilized, as in the case of paralysis (weakness) of hands and/or legs or treatment of features, the small calcium particles get loosened from the bones and deposited in the urinary pathway walls. If the condition continues for a long period of time, gradually

of urinary stone

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the calcium stones are formed in our urinary pathway. ii) Dependency (position of the kidney): urine cannot come out freely increasing stagnation of urine leading to stone formation. Some urine always retained in the renal pelvis in supine position. i) Drugs Certain drugs which we take to relieve stomach pain like antacid also cause urinary calcium (stone). Other common drugs are Diamox, vitamin D, high dose of aspirin, laxatives etc. j) Congenital malformations and stasis Any defect by birth in any of the organs involved in urine formation and excretion (may be in renal pelvis; ureter or bladder), stasis due to stricture (narrowing) or prostatic enlargement, may predispose to the formation of urinary stone. k) Hereditary Urinary stones are found to occur among blood relatives. It can transfer from one generation to other, like parents to children. But the chances of recurrence of urinary stone is more in males than females. V Signs and symptoms of urinary stone a) Sometimes there may be no symptom i.e silent type.

b) Sharp, severe pain: there will be a sudden, sharp severe pain in the mid lateral abdomen, flanks or groin which radiates toward genitalia and thigh. It is the natural warning signal for going for a medical check up. c) Fever, chills, shivering and vomiting shows that there are disease-causing micro-organisms in the urinary pathway d) Pain in the flanks even on mild touch e) Frequent loose stools f) Feeling of vomiting or vomiting g) Decreased amount of urine h) Difficulty in passing urine i) Presence of blood in the urine j) Feeling of fullness in the urinary bladder k) Increased frequency of urination

126

4 min 3 min 3 min

explain the problems caused by urinary stone. explain the methods of confirming the presence of urinary stone. list the types of urinary

l) Cold moist skin m) Guarding and rigidity of the back and abdominal muscles during severe attack of pain VI How will you confirm the presence of urinary stone You need to collect urine in a small pot and check for the presence of any hard sand like particles and the presence of blood. If blood is present in urine you need to seek immediate medical help in any clinic/hospital where the urine will be sent for laboratory test to confirm the presence of stone. There are some other tests which may be done to confirm the presence of urinary stone. They are blood tests, special X – rays, ultrasonography, etc. VII Types of urinary stone Depending on the minerals that form stone, there are different types of stone. They are calcium, oxalate, phosphorus or mixed stones which contains little of all these minerals. Stones which are made up of calcium is known as calcium stones; stones which are made up of oxalate is known as oxalate stones and stones which are made up of phosphorus is known as phosphorus stones. Other types are uric acid which are common for the people who consume red meat and also in patients with gout (a disease condition due to deposition of large amount of uric acid in the cartilage and joints), cystine, xanthine and struvite stones. VIII How to mange when stone is present in urinary pathway If the size of the stone is small (< 0.5 cm in diameter) to pass through the urinary pathway, you need to drink large amount of water or infuse large amount of fluids into the veins. This will help to remove stone from the urinary pathway. IX When do we need an operation When

• the stone is too large to pass with urine • the stone is formed because of chronic infections • the stone is causing persistent pain and severe vomiting • the signs and symptoms are not relieved only with medicine

Lecture cum

Listening

Charts

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2 min 3 min 8 min

stone. explain the management without surgery list the indications for surgery in urinary stone explain the measures to prevent the recurrence of urinary stone

X Prevention of recurrence of urinary stones There are many things that we need to consider to prevent the recurrence of urinary stone. Here we shall talk about some common activities which we should do and some which we should not do for the prevention of recurrence of urinary stone. DO’S

• Increase the fluid intake At least 3 – 4 liters of water per day (15 – 16 glass of water, 1 glass = 200 ml water). Plain water, coconut water, barley water, sherbet, weak tea, fruit juice can be taken to dilute the urine. Diluted urine prevents the concentration of the solids in it and thus prevents the stone formation. A heavy manual worker in a hot humid climate should drink more fluids than a sedentary office worker in a cooler climate, to compensate for the fluid loss through perspiration.

Remember clear water is better than artificial sweetened drinks e.g. Pepsi, cola etc.

Increase the intake of fruit juice, because fruit juice help in the breaking down of the stone into small pieces and thus gets excreted easily with the urine

Eat plenty of fruits and raw vegetables, which are rich in fiber. The fiber causes break down of the minerals and facilitates its elimination from the blood.

Add more tamarind in your food it helps in the excretion of urinary stone. Seek prompt and proper treatment for any type of discomfort in excretion of

urine. For example, burning sensation and pain while passing urine. For the patients who are bed ridden position should be changed frequently

and body and private parts should be cleaned thoroughly several times a day.

DON’TS Avoid excessive consumption of strong tea and coffee because the mineral oxalate is present in more quantity in it.

discussion Lecturing Lecture cum discussion Asking questions

And taking part in the discussion Listening and taking part in discussion Answering the questions and asking doubts

charts

128

Cut down the animal protein (e.g. Milk, Egg, Meat, etc). Because proteins will increase the amount of calcium, oxalate, minerals in our blood and excess minerals will get accumulated in the urinary pathway and cause formation of urinary stone.

Do not include more than one of the following items in your daily meals. o Egg – 1 o Meat – One portion ( 25 grams) o Fish – One portion ( 25 grams) o Milk – 200 ml o Cheese – 20 grams

Avoid too much of refined food e.g. white sugar. Cut down sugar in the drinks because white sugar increases the

concentration of the urine. Avoid sweets, chocolates, soft drinks, tinned fruits, sweet cakes, and

biscuits as these contains high amount of white sugar. Avoid drinking alcohol because alcohol increases the excretion of the uric

acid, calcium and phosphate in urine which may get deposited and form urinary stone

Avoid eating pan (betel leaves) with lime because it increases the calcium consumption and calcium amount in the body. Lime contains high amount of calcium.

Avoid adding extra salt to your food because salt increases the calcium absorption from the blood and there by increases the chance of development of urinary stone.

Avoid smoking. If not possible try to reduce the number of cigarettes and increase the internal between two smokes, because it increases the elimination of more minerals.

Avoid spending more time under direct sun. If unavoidable and you sweat more, drink plenty of water (10 – 15 glass of water daily). Use sun shade like hats while working under the direct sun.

Avoid stressful situations do relaxation, yoga, meditation, etc.

Lecture / discussion Lecture / discussion Lecture cum discussion Asking discussion

listening Taking part in discussion Taking part in discussion And Asking doubts

Charts

129

4 min

list some of the foods rich in calcium,

XI Foods to be restricted i) FOR PATIENTS WHO HAVE CALCIUM STONES The patients with calcium stones should restrict the intake of calcium. The following are some of the food stuffs rich in calcium, increase the amount of water intake if you are taking these foods. a) VEGETABLES: Green leafy vegetables (beans, spinach, carrot leaves, agathy, pumpkin leaves), potatoes, cauliflower, soya beans. The spinach is having more amount of calcium than oxalate and phosphorus. b) CEREALS: Ragi is one of the richest source of calcium. c) FRUITS: Dried fruits (grapes), nuts, peanuts. The citrus fruits like lime and lemon are richest source of calcium. d) FOODE CONTAINING FLOURS: Bread. Oat meal. e) BEVERAGES: Tea, Cocoa, Pepsi, Cola, Bear, Milkshakes, Ice creams, Milk and milk products (butter, ghee, cheese, milk powder etc.) f) FISH: Small fishes with bones and dried fishes. g) OTHERS: Ragi, excess salt, cake, pickle, cheese, egg yolk. h) VITAMIN D RICH FOODS: Fish liver oil (cod liver oil, shark liver oil), fatty fish, egg (hen). i) CHEWING BETAL LEAVES J) HARD WATER (water which does not make lather)

ii) FOR PATIENTS WHO HAVE URIC ACID STONES The patients having uric acid stones should restrict the foods rich in uric acid. The following are some of the foods rich in uric acid, you have to drink extra amount of water if you consume the following foods. a) VEGETABLES: Beans (dried, baked, green), Fenu green leaves. b) CEREALS: Bengal gram, black gram, green gram, horse gram, lentils whole, peas dry, red gram. c) NUTS: Groundnut, mustard seed. d) OTHERS: Sweet breads is one of the commonest source of uric acid. e) ALL TYPES OF MEAT f) ALL TYPES OF FISH

130

4 min 4 min

list some of the foods rich in uric acid list some of the foods rich in phosphorus

iii) FOR PATIENTS WHO HAVE PHOSPHATE STONES Patients who diagnosed to have phosphate stone should restrict the intake of excess amount of phosphorus. The following are some foods rich in phosphorus, you have to drink extra amount of water if you consume the following foods. a) VEGETABLES: Green leafy vegetables (carrot leaves, amaranth, agathi), Carrot, Potato, Cauliflower, beans. b) FRUITS: Banana, Custard apple. c) Whole cereals: Bagra, Maize, Oat meal, Little millet, Wheat flour> d) PULSES: Beans, Lentils, Peas, Bengal gram dhal, Soya bean. e) NUTS AND OIL SEEDS f) FISH: Small g) MEAT: Beef, Liver. h) EGG: Hen i) MILK AND MILK PRODUCTS j) FOODS CONTAINING FLOURS: Sweet breads. iv) FOR PATIENTS WHO HAVE OXALATE STONES Patients who diagnosed to have oxalate stone should restrict the intake of excess amount of oxalate. The following are some foods phosphorus. You have to drink extra amount of water if you consume the following foods. a) VEGETABLES: Spinach, tomato b) FRUITS: Chickoo, strawberries c) BEVERAGES: Cocoa, Tea, Chocolates d) NUTS: Cashew nuts, groundnuts e) MEAT: Beef

SUMMARY Teaching points

• Meaning of urinary stone

Demonstration

Taking part in discussion Taking part in discussion

Real models

131

2 min

list some of the foods rich in oxalate

• Causes of urinary stone • Signs and symptoms • Diagnostic tests • Management and indications for surgery • Measures to prevent the recurrence of urinary stone.

EVALUATION QUESTIONS

1. What are the structures involved in the formation and excretion of urine? 2. What is the function of kidney? 3. What do you mean by urinary stone? 4. List the causes of urinary stone. 5. What are the problems that develop due to urinary stone? 6. How will you confirm the presence of urinary stone? 7. What are the types of urinary stone? 8. What is the management of urinary stone? 9. When does a person need surgery for urinary stone? 10. Why do you need to take large amount of fluid for prevention of urinary

stone? 11. How does hot weather increases the chances of the urinary stone? 12. How does hyperparathyroidism lead to urinary stone? 13. Mention some of the foods rich in - calcium, uric acid, phosphorus and

oxalate. CONCLUSION Today we have discuss about urinary stone and its management and how few changes in our daily food practice can help in prevention of recurrence of urinary stone.

Demonstration Demonstration Demonstration

Taking part in discussion Taking part in discussion Taking part in discussion

Real Models Real Models Real models

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INFORMATONAL BOOKLET

ON

URINARY STONE

CONTENTS

I. Structured involved in the formation and excretion of urine II. Description about urinary stone 1. What do you mean by urinary stone? 2. What are the causes of urinary stone? 3. How can we identify the presence of urinary stone? 4. How will we confirm the presence of urinary stone? 5. Types of urinary stone? 6. Management / treatment of urinary stone? III. FOODS TO BE RESTRICTED

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INTRODCUTION The booklet is for the patient with urinary stone. Our food is as important a medicine or operation for treating any disease. Eating the right kind of food can help us feel better and stay strong. The information in it will be useful to prevent the recurrence of urinary stone. Some of the problems which are described in the booklet may not be experienced to a person but may be experienced to another person as person reacts differently to a disease. But it is better to be aware of them. A few modifications in our food will help to prevent the recurrence of urinary stone. We all know that prevention is better than the long suffering and temporary cure. Babita

I. THE STRUCTURES INVOLVED IN THE FORMATION AND EXCRETION OF THE URINE. The structures involved in the formation and excretion of the urine are twoKidneys, twoUreters, one Bladder and one Urethra. Whatever we eat and drinks gets mixed with the enzymes present in the mouth, stomach and small intestine, and get broken down into very small pieces. Some of these small particles get mixed with blood. Blood also gets mixed with oxygen present in the air we breathe. This blood gets circulated throughout our body and supplies food and oxygen to all the body parts for their proper functioning. Thus the kidneys also get their share of blood. Kidneys retain the substance which are useful and the substances which are waste products and harmful for the body are removed along with extra water

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II. DESCRIPTION ABOUT URINARY STONE 1. What do you mean by urinary stone? Urinary stone is a hard stone like substance which is formed by deposition of certain chemical substances in the structures involved in formation and excretion of urine. These chemical substances are mainly calcium, oxalate, uric acid and phosphorus. These are also known as minerals.

2. What are the causes of urinary stone?

LIQUIDS: Inadequate intake of water, inadequate intake of Vit A containing foods. DIETARY HABITS: More salt, excessive green leafy vegetables, excessive animal protein Eg. Egg, meat, fish etc.

OCCUPATION: More among people who work directly under sunlight. Eg. Coolie worker, Traffic police etc.

CLIMATE: More in summer season due to excessive sweating.

RARE CONDITION:

* Hereditary * Diseases of the parathyroid gland, Cushing’s disease, Paget’s disease, sarcoidosis etc * Growth and multiplication of the disease causing micro- organisms in the urinary pathway. * Prolonged illness and restricted movement * Certain drugs such as antacid, diamox, vitamin D, high dose of aspirin, laxatives etc. * Birth defects in the structure of urinary organs.

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3. How we can identify the presence of urinary stone?

# SHARP, SEVERE RADIATING PAIN in the flanks # PAIN IN THE FLANKS EVEN WITH MILD TOUCH # FEELING OF VOMITING AND / VOMITING

#FEVER, CHILLS, VOMITING AND SHIVERING - shows growth of disease causing micro-organisms in the urinary pathway

# URINARY PROBLEMS Decreased urinary output Burning sensation while passing urine Difficulty in passing urine Presence of blood in the urine Increased frequency of urination Feeling of fullness of bladder Frequent loose stools

4. How we will confirm the presence of urinary stone?

The presence of urinary stone can be confirmed by special X-ray, Ultra sound and other blood and urine studies. 5. Types of urinary stone?

a. STONE RICH IN CALCIUM b. STONE RICH IN OXALATE c. STONE RICH IN PHOSPHORUS d. STONE RICH IN URIC ACID e. MIXED STONE. f. CYSTINE STONE g. STRUVITE STONE h. XANTHINE STONE

6. Management / Treatment of urinary stone? DIETARY CHANGES: To prevent further stone formation CRUSHING OF STONE: which get eliminated through urine OPERATION: to remove stone from the urinary pathway

III. FOOD RELATED FACTORS IN URINARY STONE Diet plays an important role in recurrence of urinary stone

and one can prevent the risk through appropriate changes in the dietary practices.

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DO’S • DRINK MORE WATER [15-16 glasses of water daily,

1 glass = 200ml]

• EAT PLENTY OF FRESH FRUITS /FRUIT JUICE, RAW VEGETABLES RICH IN FIBER DAILY

• ADD MORE TAMARIND IN YOUR FOOD • SEEK PROMPT MEDICAL TREATMENT FOR ANY

DISCOMFORT IN PASSING URINE • CHANGES THE POSITION OF THE BED RIDDEN

PATIENTS EVERY SECOND HOURLY.

DONT’S • DO NOT EAT EXCESS AMOUNT OF ANIMAL PROTEIN

• AVOID TOO MUCH OF REFINED FOOD

• REDUCE SUGAR IN DRINKS • AVOID SWEETS, CHOCOLATES, SOFT DRINKS, TINNED

FRUITS, SWEET BREAD, CAKES AND BISCUITS.

• AVOID SWEETENED WATER LIKE PEPSI, COLA ETC.

• AVOID EXCESS AMOUNT OF TEA AND COFFEE.

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• STOP THE FOLLOWING

o Smoking

o Drinking alcohol

o Eating pan o Adding extra salt to your food o Spending too much time under the sun o Stressful situation which causes anger, frustration,

worry, etc III. FOODS TO BE RESTRICTED 1. FOR PATIENTS WHO HAVE CALCIUM STONES The patients with calcium stones should restrict the intake of calcium. The following are some of the food stuffs rich in calcium. Increase the amount of water intake if you are taking these foods.

a. VEGETABLES: Green leafy vegetables (spinach, carrot leaves, agathy, pumpkin leaves), cauliflower, soya beans. The colacassia is having amount of calcium than uric acid and phosphorus.

b. CEREALS: Ragi is one of the riches source of calcium c. FRUITS: Dried fruits (grapes), nut, peanuts. The citrus fruits

like lime and lemon are riches sources of calcium. d. BEVERAGES: Tea, Coffee, Cola, Bear, Milk shake, Milk

products. e. FOODS CONTAINING FLOURS: Bread, Oat meal. f. MEAT: Beef, Mutton. g. OTHER: Jaggery, excess salt, cake, pickle, cheese. h. VITAMIN D RICH FOODS: Fish liver oil, fatty fish. i. CHEWING BEETLES LEAVES. j. HARD WATER.

2. FOR PATIENT WHO HAVE URIC ACID STONES. The patients who have uric acid stone restrict the following foods rich in uric acid. The following are some of the foods rich in uric acid. You have to drink extra amount of water if you consumed the following foods. a. VEGETABLES: Beans (dried, baked, green) Fenu greek leaves. b. CEREALS: Bengal gram, green gram, black gram, horse gram, lentils whole, red gram. c. NUTS: Gingelly seed, ground nut, peas, dry gram. d. OTHERS: Sweet bread is one of the riches sources of uric acid. e. ALL MEAT AND FISH. 3. PATIENTS WHO HAVE PHOSPHORUS STONE Patients who diagnose to have phosphate stone should restrict the intake of excess amount of phosphorus. The following are some foods rich in phosphorus, you have to drink extra amount of water if you consumed the following foods.

a. VEGETABLES: Green leafy vegetables, (carrot leaves, agathy, amaranth), carrot, potato, cauliflower, beans.

b. FRUITS: Banana. c. WHOLE CEREALS: Bajra, maize, oat meal, little millet,

wheat flour.

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d. PULSES: Beans, lentils, peas, soyabeans. e. NUTS AND OIL SEEDS f. MEAT & FISH g. EGG – Hen h. MILK AND MILK PRODUCTS i. FOODS CONTAINING FLOUR.

4 FOR PATIENTS WHO HAVE OXALATE STONES

Patients who diagnosed to have oxalate stone should restrict the intake of excess amount of oxalate. The following are some foods rich in oxalate. You have to drink extra amount of water if you consume the following foods.

a) VEGETABLES: Spinach, tomato b) FRUITS: Chickoo, strawberries c) BEVERAGES: Cocoa, tea, chocolates d) NUTS: Cashew nuts, groundnuts e) MEAT: Beef

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157

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r) PÁ¬ÄUÀ¼ÀÄ : UÉÃgÀÄ ©Ãd, £É®UÀqÀ¯É E) ªÀiÁA¸À: zÀ£ÀzÀ ªÀiÁA¸À.

158

159

158

13

Lists of experts of content validity 1. Prof. B.V Kathyayani

Principal and HOD of Medical Surgical Department Dr. M.V Shetty Institute of Health Sciences, Mangalore 2. Sr. Anndrose HOD of Medical Surgical Department Fr. Muller’s College of Nursing, Mangalore 3. Mini Sacharias

Assistant Professor College of Nursing, Kottayam

4. Theresa Leonelda Mindonea

Assistant Professor Laxmi Memorial College of Nursing, Mangalore 5. Elsa Sanatombi Devi

Lecturer Manipal College of Nursing, MAHE Manipal 6. Dr. Jitendra Singh

Consultant Urologist Shija Hospital and Research Institute

Imphal, Manipur

7. Dr. S. P Shenoy Senior Consultant Urologist

A.J Hospital and Research Centre, Mangalore 8. Dr. Sinam Rajendra Singh

Associate Professor Department of Urology Regional Institute of Medical Sciences, Imphal, Manipur

9. Dr. Harish Nayak

Surgeon, Alva’s Health Centre Moodbidri, Mangalore

159

10. Dr. Y. Achouba Singh Surgeon, Raj Polyclinics, Royal Hospital Imphal, Manipur 11. Dr. Sadananda Naik

Medicine, Alva’s Health Centre Moodbidri, Mangalore

12. Dr. Sheetal Kumar General Medicine Community Health Centre Belthangady

13. Mrs. Archana Prabhat Lecturer, Department of Food, Nutrition and Dietatics Alva’s College of BFND Moodbidri, Mangalore

160

14a

CODE FOR MASTER DATA SHEET

CODE

AREAS

AGE 1a 1b 1c 1d SEX 2a 2b EBGD 3a 3b 3c 3d 3e MS 4a 4b 4c OS 5a 5b 5c 5d 5e 5f PCIF 6a 6b 6c 6d

Age 21 – 35 years 36 – 50 years 51 – 65 years > 66 years Sex Male Female Educational Background Primary School Education High School Education Pre degree Graduate Post Graduate Marital Status Married Unmarried Divorced Occupational Status Coolie Agriculture Beedi Worker House Wife Business Any other (Student/Teacher/Driver/Bank Employee /Government Employee)

Per Capita Income in Rupees 1 – 1500 1501 – 3000 3001 – 4500 >4501

161

RGN 7a 7b 7c DP 8a 8b PHA 9a 9b NPHA 10a 10b 10c FHRC 11a 11b SHI 12a 12b 12c 12d HBT 13a 13b 13c 13d K1 – K3 KI K2 K3 TKNOW

Religion Hindu Muslim Christian Dietary Pattern Vegetarian Non-vegetarian Previous hospital Admission Yes No Number of Previous Hospital Admission One time Two times Three times Any Family History of Renal Calculi Yes No Sources of health information on the disease condition Doctor Relatives Friends Any other Habit(s) Smoking Betal leaves chewing Alcohol None of the above Content areas of Knowledge Questionnaire 0 – 11 12 – 23 24 – 34 Total Knowledge Questionnaire

162

14b Master data sheet (pretest)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Total

Score1 01 0 0 01 0 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 0 0 01 01 01 01 01 0 0 01 01 25 2 01 01 0 01 01 0 0 0 01 0 0 0 0 01 01 01 01 01 01 0 0 0 0 01 0 0 0 01 0 01 01 0 01 0 17 3 01 01 0 0 0 01 0 0 01 0 0 01 01 01 0 01 01 0 01 01 0 0 0 0 0 0 0 0 0 01 0 0 01 01 17 4 01 01 0 0 0 01 0 01 01 0 0 01 0 0 01 01 0 0 01 0 0 0 0 0 0 0 0 01 0 01 01 0 01 01 14 5 01 01 0 01 01 0 01 0 01 0 0 0 0 0 01 01 01 01 01 0 0 01 01 0 01 0 0 01 01 0 01 0 0 01 18 6 01 01 0 01 01 01 0 0 0 01 0 0 0 0 0 01 01 0 01 0 0 0 01 0 0 01 0 0 0 01 0 0 0 01 13 7 01 01 0 0 0 0 0 0 01 01 0 01 01 0 01 01 01 0 01 01 0 01 0 0 01 01 0 01 01 0 0 0 0 0 16 8 01 01 0 01 01 01 0 0 01 0 01 01 01 01 01 01 01 0 01 01 0 0 0 0 0 0 0 0 0 01 0 0 01 01 18 9 01 01 0 01 0 0 01 0 01 0 0 01 0 0 01 01 01 01 0 01 0 0 0 0 01 01 0 0 01 0 01 0 01 01 17 10 01 01 0 0 0 01 01 01 0 0 0 0 01 01 01 01 01 01 01 01 0 01 01 0 01 01 01 0 0 01 0 0 0 01 20 11 01 01 0 01 0 01 0 0 01 0 0 01 0 0 01 01 01 01 0 01 0 01 01 0 0 01 01 0 01 0 01 0 0 01 18 12 01 01 01 01 01 0 01 0 01 01 0 01 0 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 0 01 01 0 01 27 13 01 01 01 01 0 0 01 01 0 01 0 0 0 0 0 01 01 01 0 0 0 0 0 01 01 01 0 0 0 01 0 01 0 01 16 14 01 01 0 01 0 0 01 0 0 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 01 0 01 0 01 0 0 0 01 17 15 01 01 0 01 0 0 01 0 0 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 01 0 01 0 01 0 0 0 01 22 16 01 01 01 01 0 0 01 0 0 01 0 01 01 01 01 01 01 01 0 0 0 0 01 01 0 0 0 01 0 0 01 01 01 01 20 17 01 0 0 01 0 01 0 01 0 01 0 0 0 0 01 01 01 01 0 0 0 01 01 01 0 0 01 01 01 0 01 01 0 01 18 18 01 0 0 01 01 0 0 0 0 0 0 0 0 0 01 01 01 01 01 0 01 0 01 01 0 0 01 0 0 0 01 01 01 01 16 19 01 0 0 01 01 0 01 01 0 01 01 01 01 01 01 01 01 01 01 0 0 01 01 0 01 01 01 01 01 0 0 01 0 01 24 20 01 01 0 01 01 01 01 0 01 0 0 01 01 0 01 01 01 01 01 0 0 0 01 0 01 01 01 01 0 01 0 0 0 01 21 21 01 0 0 01 0 0 0 0 01 01 0 01 01 0 01 01 01 0 01 0 0 0 01 0 0 0 0 01 01 01 0 01 01 01 17 22 01 01 01 01 01 0 01 0 0 01 0 01 01 0 01 01 01 01 01 0 0 01 0 0 0 0 0 01 0 0 0 0 0 01 17 23 01 01 0 01 0 0 0 01 01 0 0 01 01 01 0 01 01 01 01 0 0 01 01 0 01 01 01 01 0 01 0 01 0 01 21 24 01 01 0 01 0 0 01 01 01 0 0 01 01 0 01 01 01 01 01 0 0 0 01 0 01 0 01 0 0 0 0 0 0 01 17 25 01 01 0 0 0 0 01 0 0 01 01 01 01 01 01 01 01 01 01 01 0 0 01 01 01 01 0 0 0 01 01 01 0 01 22 26 01 0 01 0 01 0 0 0 0 0 0 0 0 01 01 01 01 01 01 01 01 0 01 0 01 0 0 0 0 0 0 01 0 01 15 27 01 01 0 01 0 01 0 01 01 0 0 0 01 01 01 01 01 01 01 0 0 0 0 0 0 0 0 01 01 0 0 01 01 01 18

163

28 01 01 0 0 0 01 0 01 0 0 01 01 01 0 01 01 01 01 01 0 0 01 01 0 01 01 01 01 0 0 0 0 01 01 20 29 01 01 0 01 0 0 01 0 0 0 0 01 0 0 01 01 01 0 01 0 0 0 0 0 01 01 0 01 0 01 01 01 0 01 16 30 01 01 0 01 01 01 01 0 0 01 01 0 0 0 01 01 01 01 01 0 0 01 0 0 0 0 0 01 0 01 0 01 0 01 18 31 01 01 01 01 0 01 0 0 0 01 0 0 0 01 0 01 01 0 0 01 01 0 0 0 01 0 01 0 0 01 0 01 01 01 17 32 01 01 01 01 01 0 0 0 01 01 01 0 0 0 0 01 01 01 0 0 0 0 01 0 01 0 0 01 0 01 0 01 0 01 17 33 01 0 01 0 01 01 0 0 0 01 01 0 01 0 01 01 01 01 0 01 01 0 0 01 0 0 01 0 0 0 01 01 0 01 18 34 01 01 0 01 0 0 0 0 0 01 0 01 0 01 01 01 01 01 0 0 01 01 01 01 0 01 0 01 01 01 0 0 0 01 19 35 01 01 0 01 0 01 01 01 0 01 0 01 01 01 01 01 01 0 01 0 0 01 01 0 0 0 01 01 0 0 0 01 01 01 21 36 01 01 0 01 0 0 0 0 01 0 0 0 01 01 01 01 01 01 01 01 0 0 01 0 0 01 0 0 0 0 01 01 0 01 17 37 01 01 0 01 01 01 01 01 0 0 0 0 01 01 01 01 01 01 01 01 0 01 01 01 01 0 0 01 01 01 0 01 0 01 24 38 01 0 01 01 0 0 01 0 0 01 01 0 01 0 01 01 01 01 01 01 0 01 0 0 0 01 01 01 01 01 0 0 0 01 20 39 01 01 0 0 0 0 0 01 01 01 0 0 01 01 0 01 01 0 01 01 0 0 0 0 01 01 01 01 0 01 0 01 0 01 18 40 01 01 0 01 0 0 0 01 0 0 0 01 01 0 01 01 01 01 01 01 0 01 0 0 01 0 0 01 0 0 01 0 0 01 17 41 01 0 0 01 01 01 0 0 01 0 01 0 0 01 01 01 01 0 01 0 01 0 0 0 0 0 0 01 0 01 01 0 01 01 17 42 01 01 0 0 01 0 01 0 0 01 01 01 0 0 01 01 01 0 01 0 01 0 0 01 0 0 01 0 01 01 01 01 0 01 19 43 01 01 0 01 0 0 0 0 0 01 01 01 01 01 01 01 01 01 01 0 0 0 0 0 01 01 01 01 0 01 01 01 01 01 22 44 01 01 0 01 01 01 01 0 01 0 0 01 01 0 01 01 01 01 01 0 0 01 01 0 01 01 01 0 01 01 01 01 0 01 24 45 01 01 0 01 01 01 01 0 0 0 0 0 01 01 01 01 01 01 01 01 0 0 01 01 0 01 0 01 0 01 01 01 0 01 20 46 01 01 01 01 0 0 0 01 01 0 0 01 01 0 01 01 01 01 01 0 0 0 01 0 0 0 0 01 0 0 0 0 0 01 16 47 01 0 0 0 01 01 0 0 0 0 01 0 01 01 01 01 01 01 0 0 01 01 0 0 01 0 0 01 01 01 0 01 01 01 19 48 01 01 0 01 0 0 01 01 01 0 01 01 01 0 01 01 01 01 01 0 0 0 01 01 01 0 01 01 0 01 01 0 0 01 22

164

14c Master data sheet (posttest)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Total

score 1 01 01 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 30 2 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 31 3 01 01 01 01 01 01 0 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 01 01 01 0 01 01 0 01 01 0 01 01 28 4 01 01 01 01 01 01 0 01 01 0 0 01 0 01 01 01 01 01 01 01 0 01 01 01 0 01 01 01 0 01 01 0 01 01 26 5 01 01 0 01 01 01 01 0 01 0 01 01 01 01 01 01 01 0 01 01 0 01 0 01 01 01 01 01 01 0 01 01 01 01 27 6 01 01 0 01 0 01 01 0 01 0 01 0 0 01 0 01 01 0 01 01 0 01 01 01 01 0 01 01 0 01 0 01 0 01 21 7 01 01 01 01 0 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 0 01 01 01 01 01 01 01 0 01 01 29 8 01 01 01 01 0 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 0 01 01 28 9 01 01 0 01 0 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 0 01 0 01 0 01 01 27 10 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 0 01 01 01 01 01 01 0 01 01 01 30 11 01 01 01 01 01 01 0 0 01 01 01 01 01 0 01 01 01 01 0 01 0 01 01 01 0 01 01 0 01 01 01 01 0 01 26 12 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 34 13 01 01 01 01 0 0 01 01 01 01 01 0 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 01 01 01 01 0 01 28 14 01 01 0 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 0 01 01 01 30 15 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 0 01 0 01 30 16 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 01 01 01 01 01 01 31 17 01 01 01 01 0 01 0 01 0 01 01 01 01 0 01 01 01 01 01 01 0 01 01 01 01 0 01 01 01 01 01 01 0 01 27 18 01 01 0 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 0 01 01 01 01 01 01 01 01 30 19 01 01 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 30 20 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 30 21 01 01 01 01 01 0 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 01 01 29 22 01 01 01 01 01 01 01 01 01 01 0 01 01 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 30 23 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 32 24 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 0 01 01 01 01 01 01 0 01 30 25 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 32 26 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 0 01 31 27 01 01 0 01 01 01 01 0 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 0 01 01 01 0 0 01 01 01 27

165

28 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 31 29 01 01 01 01 01 01 01 01 0 0 01 01 01 01 01 01 01 01 01 01 0 0 01 01 01 01 0 01 01 01 01 01 0 01 28 30 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 31 31 01 01 01 01 01 0 0 01 01 01 01 01 0 01 01 01 01 01 01 01 0 0 01 01 01 01 01 01 01 01 0 01 01 01 28 32 01 01 0 01 01 0 0 01 01 0 01 01 01 0 01 01 01 01 0 01 01 01 01 0 01 01 01 01 01 01 0 01 01 01 26 33 01 01 0 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 30 34 01 01 01 01 01 0 01 0 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 0 0 01 27 35 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 0 01 0 01 01 01 01 01 01 30 36 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 0 0 01 01 01 01 01 01 01 0 01 29 37 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 32 38 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 0 01 0 01 01 01 01 01 01 01 01 01 01 01 31 39 01 01 0 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 0 01 01 0 01 29 40 01 01 0 01 0 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 0 01 01 01 01 0 01 01 29 41 01 01 0 01 0 01 01 01 01 0 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 0 01 01 01 01 01 0 01 28 42 01 01 0 01 01 0 01 0 0 01 01 0 0 0 01 01 01 01 01 01 01 01 01 01 01 01 0 0 01 01 01 01 0 01 24 43 01 01 0 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 0 0 01 01 01 01 01 01 01 01 01 01 01 01 30 44 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 01 01 0 01 01 0 01 01 01 01 0 01 01 01 01 01 30 45 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 0 01 33 46 01 01 01 01 01 01 01 01 01 0 01 01 01 0 01 01 01 01 01 01 0 01 01 01 01 0 01 01 01 01 01 0 0 01 28 47 01 01 0 01 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 0 01 01 0 01 0 0 0 0 01 0 0 01 01 24 48 01 01 0 01 01 01 01 0 01 01 01 01 01 0 01 01 01 01 01 01 0 01 01 01 01 01 01 01 01 01 01 0 01 01 29

166

14d

MASTER DATA SHEET

PRETEST P0STTEST AGE SEX EBGD MS OS PCIF RGN DP PHA NPHA FHRC SHI HBT K1 K2 K3 TKNOW K1 K2 K3 TKNOW

1 1b 2a 3b 4a 5c 6a 7b 8b 9a 10a 11a 12b 13d 7 11 7 25 9 10 10 30 2 1b 2b 3c 4a 5b 6b 7b 8b 9b 10a 11b 12a 13d 5 6 6 17 10 10 10 31 3 1c 2b 3a 4a 5d 6c 7c 8b 9b 10a 11b 12a 13d 5 8 4 17 11 8 8 28 4 1d 2a 3b 4a 5c 6a 7a 8a 9a 10b 11b 12d 13b 5 4 5 14 8 8 10 26 5 1d 2a 3a 4a 5c 6a 7a 8b 9a 10b 11b 12b 13d 6 7 5 18 8 10 7 27 6 1c 2b 3a 4a 5d 6b 7a 8b 9a 10c 11b 12a 13d 6 4 3 13 7 7 9 21 7 1d 2a 3a 4a 5e 6a 7a 8b 9b 10a 11b 12a 13d 4 8 4 16 9 9 7 29 8 1a 2a 3b 4b 5a 6a 7a 8a 9a 10b 11b 12a 13d 7 8 3 18 10 7 8 28 9 1c 2a 3c 4a 5f 6b 7c 8b 9a 10c 11b 12a 13d 5 6 6 17 8 8 9 27 10 1a 2a 3d 4a 5e 6d 7b 8b 9b 10a 11b 12a 13d 5 10 5 20 10 9 8 30 11 1b 2a 3c 4a 5b 6b 7a 8b 9b 10a 11b 12a 13d 5 8 5 18 9 8 11 26 12 1c 2a 3c 4a 5f 6d 7b 8b 9b 10a 11b 12a 13d 8 10 9 27 11 11 9 34 13 1b 2a 3b 4a 5e 6c 7a 8a 9b 10a 11b 12a 13d 7 3 6 16 9 9 9 28 14 1c 2a 3b 4a 5b 6c 7a 8b 9b 10a 11b 12a 13c 6 7 4 17 9 9 8 30 15 1a 2b 3d 4a 5f 6c 7a 8b 9b 10a 11b 12a 13d 6 11 5 22 10 8 10 30 16 1a 2a 3c 4a 5e 6d 7c 8b 9b 10a 11b 12a 13d 6 8 6 20 10 10 9 31 17 1c 2b 3a 4a 5e 6b 7a 8b 9b 10a 11b 12a 13a 5 6 7 18 8 9 10 27 18 1d 2a 3b 4c 5e 6c 7a 8b 9b 10a 11b 12a 13d 3 7 6 16 9 10 10 30 19 1a 2a 3d 4b 5f 6c 7a 8b 9b 10a 11b 12a 13d 7 10 7 24 9 10 10 30 20 1a 2a 3d 4a 5f 6d 7a 8b 9b 10a 11b 12a 13d 7 8 6 21 10 10 9 30 21 1b 2a 3c 4a 5e 6d 7a 8b 9b 10a 11b 12c 13a,b 4 7 6 17 9 9 10 29 22 1b 2a 3c 4a 5d 6b 7c 8b 9b 10a 11b 12a 13d 7 8 2 17 10 10 10 30 23 1a 2b 3c 4b 5f 6d 7c 8b 9b 10a 11b 12a 13d 5 9 7 21 10 10 9 32 24 1b 2a 3d 4a 5f 6b 7c 8b 9b 10a 11b 12a 13d 6 8 3 17 10 9 10 30

167

25 1a 2a 3d 4b 5f 6d 7c 8b 9b 10a 11b 12a 13d 5 10 7 22 10 10 10 32 26 1b 2b 3a 4a 5a 6a 7b 8b 9b 10a 11b 12a 13a,c 3 9 3 15 10 10 8 31 27 1b 2b 3a 4a 5d 6b 7b 8b 9b 10a 11b 12a 13d 6 7 5 18 8 8 10 27 28 1b 2a 3d 4a 5f 6d 7a 8b 9b 10a 11b 12a 13d 5 9 6 20 9 10 9 31 29 1c 2a 3a 4a 5b 6b 7a 8a 9b 10a 11b 12a 13a,c 4 5 7 16 9 9 10 28 30 1b 2a 3b 4a 5d 6c 7a 8b 9a 10a 11b 12a 13d 8 6 4 18 10 10 10 31 31 1c 2a 3a 4a 5b 6b 7a 8b 9a 10a 11b 12a 13c 6 5 6 17 9 10 9 28 32 1c 2a 3a 4a 5b 6b 7b 8b 9b 10a 11b 12a 13a 7 5 5 17 7 9 10 26 33 1c 2a 3a 4a 5b 6b 7a 8a 9b 10a 11b 12a 13c 6 6 5 18 10 10 7 30 34 1a 2a 3b 4a 5b 6b 7b 8b 9b 10a 11b 12a 13d 4 9 6 19 8 7 9 27 35 1a 2a 3d 4a 5f 6c 7a 8b 9b 10a 11b 12a 13d 7 9 5 21 10 11 8 30 36 1c 2a 3b 4a 5b 6b 7a 8b 9b 10a 11b 12a 13c 4 9 4 17 10 11 11 29 37 1b 2a 3c 4a 5f 6c 7a 8b 9b 10a 11b 12a 13d 7 10 7 24 10 11 11 32 38 1b 2a 3b 4a 5d 6c 7a 8a 9b 10a 11b 12a 13d 6 8 6 20 10 10 9 31 39 1a 2a 3d 4a 5f 6d 7c 8b 9b 10a 11b 12a 13c 5 6 7 18 10 10 8 29 40 1a 2b 3c 4b 5f 6b 7b 8b 9b 10a 11b 12a 13c 4 9 4 17 9 12 9 29 41 1b 2b 3a 4a 5d 6a 7a 8b 9b 10a 11b 12a 13c 6 6 5 17 7 12 8 28 42 1c 2a 3b 4a 5f 6b 7a 8b 9b 10a 11b 12a 13a 6 6 7 19 7 11 11 24 43 1c 2a 3c 4a 5d 6c 7a 8b 9b 10a 11b 12a 13a,b 5 8 9 22 9 10 9 30 44 1a 2a 3c 4a 5f 6d 7a 8b 9b 10a 11b 12a 13d 7 9 8 24 10 11 10 30 45 1a 2b 3c 4a 5d 6c 7a 8b 9b 10a 11b 12a 13d 6 7 7 20 11 12 10 33 46 1b 2a 3b 4a 5e 6b 7a 8b 9b 10a 11b 12b 13a 6 8 2 16 10 10 8 28 47 1c 2a 3a 4a 5a 6a 7a 8b 9b 10a 11b 12a 13a,c 4 18 7 19 9 11 4 24 48 1a 2b 3c 4b 5f 6d 7a 8b 9b 10a 11b 12a 13d 7 8 7 22 9 10 10 29

168

15

STATISTICAL FORMULAE USED FOR ANALYSIS AND INTERPRETATION

1. Formula 1: Karl Pearson’s Co-efficient of Correlation Σ XY γ = ___________________________

_________________ √ Σ X² x Σ Y² __ __ where X = x – x and Y = y - y

2. Formula 2: Spearman’s Brown Prophecy Formula 2r = ___________ 1 + r 3. Formula 3: Paired ‘t’ test ___________ √ Σ (d – d )2 SD (d) = ____________________ n - 1 SD(d) SE (d) = _________ ___ √ n _ d tcal = _________ SE (d)

169

4. Formula 4: Chi Square test with Yates Co-relation N ( | ad-bc | – N/2 )2 χ2 = ______________________ (a+b) (c+d) (a+c) (b+d) 5. Formula 5 Mean Percentage of Actual gain Modified gain = ______________________________ Mean Percentage of Possible gain Mean Percentage of Actual gain = Mean Percentage of Posttest Knowledge scores – Mean Percentage of Pretest Knowledge scores Mean Percentage of Possible gain = 100 – Mean % of Posttest Knowledge scores