RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON INCENTIVE SPIROMETRY IN

PREVENTING PULMONARY COMPLICATIONS OF PATIENTS UNDERGOING CARDIAC SURGERY AMONG NURSING STUDENTS IN SELECTED COLLEGES

IN BANGALORE

PROFORMA FOR REGISTRATION ON SUBJECT FOR DISSERTATION

Mr. APPU V

HILLSIDE COLLEGE OF NURSING

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1

NAME OF THE CANDIDATE AND ADDRESS

Mr. APPU.V

HILLSIDE COLLEGE OF NUSING

No.9, GUBBALALA, RAGHUVANAHALLI, KANAKAPURA MAIN ROAD, BANGALORE- 62.

2

NAME OF THE INSTITUTION

HILLSIDE COLLEGE OF NUSING

No.9, GUBBALALA, RAGHUVANAHALLI, KANAKAPURA MAIN ROAD, BANGALORE- 62.

3

COURSE OF STUDY AND SUBJECT

DEGREE OF MASTER OF SCIENCE IN

MEDICAL SURGICAL NURSING.

4

DATE OD ADMISSION TO COURSE

05/07/2011

5

TITLE OF THE TOPIC

THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON INCENTIVE SPIROMETRY IN PREVENTING PULMONARY COMPLICATIONS OF PATIENTS UNDERGOING CARDIAC SURGERY AMONG NURSING STUDENTS IN SELECTED COLLEGES IN BANGALORE.

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

“Life and respiration are complementary. There is nothing living which does not breathe nor anything which breathing which does not live”

William Harvey

Health is a state of being hale, sound, or whole, in body, mind, or soul; especially, the state of being free from physical disease or pain. In humans, it is the general condition of a person in the mind, body and spirit, usually meaning to be free from illness, injury or pain. Systematic activities to prevent or cure health problems and promote good health in humans are delivered by health care providers.  In addition to health care interventions and a person's surroundings, a number of other factors are known to influence the health status of individuals, including their background, lifestyle, and economic and social conditions and these are referred to as "determinants of health".1

Cardiopulmonary function is the interrelationship between the workings of the heart and lungs. The most important function of the cardiopulmonary system is with respect to the flow and regulation of blood between the heart and the lungs, a process that centers upon the connection between the heart and the lungs made through the pulmonary artery. The function of the cardiopulmonary system is best understood when contrasted with the two interrelated, cardio-centered systems. The cardiovascular system is the mechanism by which the heart and the entire network of blood vessels function together to direct the flow of blood throughout the body. The cardio respiratory system is a specialized component of the larger cardiovascular works. The cardio respiratory system describes the function of the heart in relation to the body's entire breathing mechanism, from the nose and throat to the lungs and these three systems functions interdependently.2

Following coronary artery bypass graft (CABG), the main causes of postoperative morbidity and mortality are postoperative pulmonary complications, respiratory dysfunction and arterial hypoxemia. CABG interferes with the lungs, causing sections of it to collapse which may lead to pneumonia. Re-inflating areas of collapsed lung may be done by a device - an incentive spirometer - that reinforces a pattern of breathing which prevents and reverses the process. This device is used alone or in combination with other physiotherapy techniques. Use of an incentive spirometer device is important because most heart surgeries require the use of a heart-lung machine. As a result, the heart is stopped and cooled. During this procedure, the lungs are deflated which can create mucous within the lungs.3

An incentive spirometer is a medical device that helps patients to improve the function of their lungs. After surgery that affects the respiratory function, especially surgery to the lungs, the device assists in respiration. It is also commonly prescribed for post-operative cardiac patients, or other surgery involving extra time under anesthesia and subsequent recovery. The incentive spirometer also minimizes the chance of fluid build-up in patients recovering from rib damage.1

Knowledge about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. This includes the opportunity for the patient to practice coughing and deep breathing exercises, use an incentive spirometer, and practice splinting the incision. Additionally, the patient should be informed about early ambulation (getting out of bed). The patient should also be taught that the respiratory interventions decrease the occurrence of pneumonia, and that early leg exercises and ambulation decrease the risk of blood clots.4

6.1 NEED FOR THE STUDY

Cardiovascular disease is the world's leading killer, accounting for 8.3 million or 34 per cent of total global deaths in 2007. In India in the past five decades, rates of coronary disease among urban populations have risen from 4 per cent to 11 per cent. Almost 2.6 million Indians are predicted to die due to coronary heart disease (CHD), which constitutes 54.1% of all CVD deaths in India by 2020. The World Health Organization (WHO) estimates that 60 per cent of the world's cardiac patients will be Indian by 2012.5

Postoperative respiratory failure among cardiac patients (often defined as the need for ventilation for more than 48 hours after surgery) is an extremely morbid event. General anesthesia and surgery are the main causes of postoperative respiratory complications. Atelectasis, a common respiratory complication, may contribute to pneumonia and acute respiratory failure. Recently, it has been shown that activation of abdominal muscles during the induction of anesthesia contributes to a reduction of lung capacity, leading to a higher degree of atelectasis. Additionally, long-term mortality at 5 and 10 years has recently been shown to remain significantly increased in patients with respiratory complications. Prevention or early therapy of respiratory complications may, therefore, be beneficial in improving outcome in postoperative patients. Postoperative respiratory complications may have significant deleterious consequences. Increasing the understanding of the underlying causes of respiratory complications and developing early treatment strategies will likely provide improved benefits. To date, early treatment with prophylactic or therapeutic continuous positive airway pressure has proved beneficial in an abdominal surgical patient population; however, the efficacy in a general population remains unclear.9

A study was conducted to compare the outcomes of patients with and without respiratory failure as a complication of surgery. Among patients with respiratory failure, 26% died within 30 days, 6% had a myocardial infarction, 35% developed pneumonia, 10% developed acute renal failure, and 3% developed a deep vein thrombosis or pulmonary embolism; in contrast, rates of each of these events were lower than 2% among patients without respiratory failure.6

The National Surgical Quality Improvement Program (NSQIP) compared hospitalization costs and length of stay among patients with various postoperative complications.  Among infectious, cardiovascular, venous thromboembolic, and pulmonary complications, pulmonary complications were by far the most costly and, along with venous thromboembolic complications, required the longest mean hospital stay. For these reasons, identifying patients at risk for pulmonary complications and developing a strategy to reduce the risk is clearly worthwhile.7

Postoperative pulmonary complications contribute significantly to overall perioperative morbidity and mortality rates. Such complications account for about 25% of deaths occurring within 6 days of surgery. The frequency rate of these complications varies from 5-70%.One of the more comprehensive lists of postoperative pulmonary complications includes fever (due to microatelectasis), cough, dyspnea, bronchospasm, hypoxemia, atelectasis, hypercapnia, adverse reaction to a pulmonary medication, pleural effusion, pneumonia, pneumothorax, and ventilatory failure.8

The incidence of pneumonia after coronary artery bypass surgery ranges from 3% to 16% and from 5% to 7% after valvular surgery.10,11 However, lesser complications, such as atelectasis and pleural effusions, occur more frequently. In a large series, 63% of patients had atelectasis and/or pleural effusion detected on postoperative chest radiographs.12 The incidence of severe hypoxemia (PaO2 ≤150 mm Hg) was found to be 12% in a group of patients without preexisting pulmonary hypertension or obstructive or restrictive lung disease undergoing coronary bypass and valve replacement14. Such patients have a higher mortality rate and longer hospital stay. Another study observed that, before surgery, patients with valvular heart disease had increased lung and respiratory elastances and lung resistance than patients with ischemic disease, probably because of the higher incidence of left ventricular failure in the former group. These differences decreased postoperatively. Long-term respiratory outcome after valve surgery is favorable, as pulmonary function actually improves after surgery13.

Incentive spirometry remains a widely used technique for the prophylaxis and treatment of respiratory complications in postsurgical patients. A study15 surveyed its use in the United States and reported that 95% of hospitals in which cardiothoracic and abdominal surgery was performed used incentive spirometer in postoperative care. Another study16 reported a usage rate of 44% in hospitals in which coronary artery bypass graft (CABG) surgery was carried out in the United Kingdom. More recently, a study17 repeated this survey and found that the usage rate had increased to 71%, despite recent publications that have cast doubt on both the need for insentive spirometer in patients undergoing CABG surgery and the effectiveness of incentive spirometer in this population.18,19,20

6.2 REVIEW OF LITERATURE

“Always aim at complete harmony of thought and word and deed.

Always aim at purifying your thoughts and everything will be well”

-Mohandas Gandhi

The review of literature is described as a broad, comprehensive in depth, systematic and critical review of scholarly publication, unpublished scholarly print materials, audiovisual materials and personal communications.

Review of literature for the present study is divided into three categories

6.2.1 Reviews related to pulmonary complications after cardiac surgery

6.2.2 Reviews related to preoperative and postoperative effectiveness of incentive spirometry in cardiothoracic surgeries

6.2.3 Reviews related to the cost-effectiveness of incentive spirometry

6.2.1 REVIEWS RELATED TO PULMONARY COMPLICATIONS AFTER CARDIAC SURGERY

Investigators from the Veterans Affairs Medical Centers developed a respiratory failure index using a design similar to those of well-established indices for cardiac risk.21 The same group also developed a separate risk index for pneumonia.22 This respiratory failure index was recently updated to reflect experience from private and academic hospitals, making the results more generally applicable. The researchers evaluated data from 180,000 patients undergoing major general or vascular surgery (defined according to the NSQIP) over a 3-year period. Respiratory failure was defined as requiring at least 48 hours of ventilation or unplanned reintubation. Of the 45 potential risk factors evaluated, 28 were identified as independent risk factors for respiratory failure on the basis of a multivariate analysis. Each factor was weighted according to risk and combined into a point-based index, which performed very well in predicting postoperative respiratory failure: the highest of the three broad point-based risk groups had a 6.8% risk of respiratory failure, while the lowest-risk group had a 0.1% risk.

 A study was conducted to compare the outcomes of patients with and without respiratory failure as a complication of surgery. Among patients with respiratory failure, 26% died within 30 days, 6% had a myocardial infarction, 35% developed pneumonia, 10% developed acute renal failure, and 3% developed a deep vein thrombosis or pulmonary embolism; in contrast, rates of each of these events were lower than 2% among patients without respiratory failure.6

In 2006, in Catalonia, a prospective study on postoperative outcome in a representative general surgical population (ARISCAT study). They studied on two randomized subsamples of patients The C statistic was 0.905 (95% CI, 0.864 to 0.946) in the development subsample. A simplified risk score was derived from the coefficient for each variable. The most relevant risk score cut point was 43 (sensitivity 69.7%, specificity 92.4%), which indicated moderate risk; a score over 60 points indicated high risk. The study concluded and found a 5% incidence of PPC. The 30-day mortality of patients with PPC was 20%. The ARISCAT also identified 9 independent risk factors for PPC (age, male sex, low preoperative SpO2, acute respiratory infection during the previous month, preoperative anemia, positive cough test, upper abdominal or intrathoracic surgery, surgical duration >2 hours and emergency surgery) in two randomized subsamples of patients.33

6.2.2 REVIEWS RELATED TO PREOPERATIVE AND POSTOPERATIVE EFFECTIVENESS OF INCENTIVE SPIROMETRY IN CARDIOTHORACIC SURGERIES

A study was conducted to evaluate a training program for preoperative inspiratory muscle held at home and to improve respiratory function, reduced the morbidity and / or mortality in adult patients undergoing coronary artery bypass grafting and/or plasty. Thirty volunteers of both sexes and aged at least 50 years, while waiting for coronary artery bypass grafting and / or heart valve surgery were randomly divided into two groups. Fifteen patients were enrolled in a home program of at least two weeks of training preoperative inspiratory muscle, using a device with a load of 40% of maximal inspiratory pressure. The other 15 received general guidance and not trained the inspiratory muscles. Spirometry before and after the training program, as well as the evolution of arterial blood gases and inspiratory and expiratory pressure maximum before and after the operation were evaluated in both groups. They observed that inspiratory muscle training increased FVC, maximum voluntary ventilation and EEV1no relationship between the first and second days after surgery. The study concluded that the home program of inspiratory muscle training was safe and improved forced vital capacity and maximal voluntary ventilation.23

A randomized study done on 279 patients undergoing coronary artery bypass graft surgery who were at high risk for developing pulmonary complications to either usual care or inspiratory muscle training. The latter intervention involved 20 minutes per day of incentive spirometry, active breathing, and forced expiration techniques for at least 2 weeks prior to surgery. Rates of high-grade postoperative pulmonary complications were cut in half (OR = 0.52; 95% CI, 0.30–0.92) and rates of pneumonia were reduced by 60% (OR = 0.40; 95% CI, 0.19–0.84) in patients who received inspiratory muscle training relative to the usual-care group.24

A study by evaluated the ventilator profile, radiological and clinical data of patients undergoing elective coronary artery bypass graft (CABG) in a cardiology referral hospital in southern Brazil, with a sample of 108 individuals, using spirometry and ventilatory muscle strength (VMS) of manuvacuometry to evaluate lung volumes and capacities, as well as the presence of respiratory disorders. The assessments were conducted preoperatively and at six days after surgery, where there was significant reduction in end-expiratory volume (EEV1), forced vital capacity (FVC) and VMS expressed in maximal inspiratory pressure and pressure maximal expiratory comparing the preoperative period to the sixth postoperative day. The incidence of pulmonary complications was higher in the sixth postoperative day (78%) when compared to the first postoperative day (40%). Patients undergoing CABG surgery have a significant reduction in lung volumes and capacities, as well as the VMS in the postoperative period. This proof demonstrates the necessity of preoperative physiotherapeutic procedures on patients who require CABG surgery.25

A study was conducted in Brazil to evaluate evaluate breathing pattern, thoracoabdominal motion and muscular activity during three breathing exercises: diaphragmatic breathing (DB), flow-oriented (Triflo II) incentive spirometry and volume-oriented (Voldyne) incentive spirometry. Seventeen healthy subjects (12 females, 5 males) aged 23 ± 5 years (mean ± SD) were studied. Calibrated respiratory inductive plethysmography was used to measure the following variables during rest (baseline) and breathing exercises: tidal volume (Vt), respiratory frequency (f), rib cage contribution to Vt (RC/Vt), inspiratory duty cycle (Ti/Ttot), and phase angle (PhAng). Exercises changed the breathing pattern and increased PhAng, a variable of thoracoabdominal asynchrony, compared to baseline. The only difference between DB and Voldyne was a significant increase of Ti/Ttot compared to baseline. Triflo II was associated with higher f values and electromyographic activity of the sternocleidomastoid. In conclusion, DB and Voldyne showed similar results while Triflo II showed disadvantages compared to the other breathing exercises.26

In a literature review on the different techniques used in chest physiotherapy after cardiac surgery, selected eleven randomized controlled trials. Among the studies included, incentive spirometry was used in three, deep breathing exercises in six, deep breathing exercises associated with positive expiratory pressure in four and positive expiratory pressure increased inspiratory resistance in two. Three studies used intermittent positive pressure breathing. Continuous positive airway pressure and bi-level positive were used in three and two studies, respectively. The protocols used were varied and the co-interventions were present in most of them. Despite the known importance of postoperative physical therapy, there is, so far, consensus regarding the superiority of one technique over the other.27

A study was conducted to assess the effect of intermittent positive pressure and incentive spirometry in the post operative of myocardial revascularization. A sample of 40 patients after CABG was selected for study, divided into two groups: one was submitted to the application of intermittent positive pressure breathing (IPPB) and the other to incentive spirometry (IS). Patients were assessed preoperatively and 24, 48 and 72 hours postoperatively, with resources being applied postoperatively. The following parameters were analyzed: oxygen saturation, respiratory rate, minute volume, tidal volume, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). The groups were homogeneous in relation to demographic and clinical variables. In the group submitted to IPPB, there was an increase in oxygen saturation 48 (P = 0.007) and 72 hours (P = 0.0001) after surgery, when compared to IR. The respiratory rate, minute volume and tidal volume, there was no statistically significant differences between groups. The group submitted to IS showed a significant increase in MEP 24 (P= 0.02) and 48 hours (P = 0.01) after surgery. With the goal of reversing hypoxemia earlier, IPPB was more efficient compared to the IS, however, the incentive spirometry was more effective in improving respiratory muscle strength.28

A study of was conducted to test the use of incentive spirometry (IS) associated with positive expiratory pressure in the airway (PEPA) after CABG in improvement of dyspnea, feeling of perceived exertion and quality of life after CABG. Sixteen patients undergoing CABG were randomized to the control group (n = 8) or the IS + PEPA group (n = 8). The protocol IS + PEPA was conducted in the immediate postoperative period and for another 4 weeks at home and were evaluated respiratory muscle strength, functional capacity, lung function, quality of life and level of physical activity. After the walk test (TC6), the score for dyspnea (1.6 ± 0.6 vs. 0.6 ± 0.3, P <0.05) and the sense of effort (13.4 ± 1 2 vs. 9.1 ± 0.7, P <0.05) were higher in the control group compared with the IS + PEPA group. In evaluating the quality of life, the rule related to limitations on the physical aspects was better in the IS + PEPA group (93.7 ± 4.1 vs 50 ± 17, P <0.02). Patients who underwent IS + PEPA have less dyspnea, less sense of effort after the TC6 and also better quality of life after CABG.29

A study was conducted in University of Marburg, Germany to evaluate intensive short-term respiratory physical therapy treatment (incentive spirometry) in the postanesthesia care unit (PACU) and its impact on pulmonary function in the obese.They studied 60 obese patients (BMI 30–40) undergoing surgery, half of which were randomly assigned to receive respiratory physiotherapy during their PACU stay, while the others received routine treatment. Premedication, general anesthesia, and respiratory settings were standardized. They measured arterial oxygen saturation by pulse oximetry on air breathing. Inspiratory and expiratory lung functions were measured preoperatively (baseline) and at 10 min, 1, 2, 6, and 24 h after extubation, with the patient supine, in a 30° head-up position. The two groups were compared and concluded that Short-term respiratory physiotherapy during the PACU stay promotes more rapid recovery of postoperative lung function in the obese during the first 24h.30

A study was conducted in the ICU of university hospital to evaluate the impact of the additional imposed work of breathing (WBimp) generated by two different spirometers on postoperative incentive spirometry performance in patients at high risk and moderate risk for postoperative pulmonary complications (PPCs). The study design was Prospective, randomized, single-blind clinical trial. Thirty male patients were assigned to a group at high risk for PPCs (group A; inspiratory capacity [IC], < 1.6 L) or to a group at moderate risk for PPCs (group B; IC, 1.6 to 2.5 L) after upper-abdominal, thoracic, or two-cavity surgery. On the first or second postoperative day WBimp, IC, and PImax were recorded without spirometers (baseline) and during incentive spirometry with the Mediflo spirometer (Medimex; Hamburg, Germany) (high WBimp) and the Coach spirometer (Kendall; Neustadt, Germany) (low WBimp) using a pneumotachograph. They concluded their study that Incentive spirometers differ considerably in their additional Wbimp with a potential impact on the efficacy of postoperative incentive spirometry performance. PImax might be an easy clinical estimate for the WBimp during incentive spirometry. Incentive spirometers with low WBimp permit increased maximal sustained inspiration and, thus, enhanced incentive spirometry performance, and, therefore, it might be more suitable for use in postoperative respiratory care.31

6.2.3 REVIEWS RELATED TO THE COST-EFFECTIVENESS OF INCENTIVE SPIROMETRY

A study was conducted in Madison, WI USA on analysis of respiratory therapy services at two general hospitals showed a notable change from 1971 to 1979. There was a large decrease in intermittent positive-pressure breathing (IPPB) treatments at both hospitals. These were partially replaced with general chest physiotherapy maneuvers at one hospital and with incentive spirometry at another. Both hospitals demonstrated a substantial increase in time spent in management of mechanical ventilators. Staffs had increased along with time spent per patient. The reduction in IPPB was not associated with lower costs of respiratory therapy services at either hospital but, rather, a shift in the types of service performed. These changes must be considered in determining cost-effectiveness of respiratory therapy services.32

The National Surgical Quality Improvement Program (NSQIP) compared hospitalization costs and length of stay among patients with various postoperative complications. Among infectious, cardiovascular, venous thromboembolic, and pulmonary complications; pulmonary complications were by far the most costly and, along with venous thromboembolic complications, required the longest mean hospital stay.7The study compared 275 postoperative patients at 30 hospital. The study also suggests the hospital stay due to postoperative pulmonary complication can be reduced with the effective use of low cost respiratory exercises.

A non-randomised study was conducted to evaluate the cost-effectiveness of incentive spirometry following thoracic surgery. They used a cross-sectional design with historical controls. One hundred and nineteen patients received intensive chest physiotherapy, specifically receiving instruction in deep breathing exercises and cough, they were also exercised using a static bicycle and  treadmill. They were compared with a group of 520 similar patients previously treated at the same hospital who had received routine nursing care and incentive spirometry. Selected outcomes included 30 days mortality, respiratory complications (atelectasis and pneumonia), and LOS. The prevalence of atelectasis and LOS were decreased in the compared group 2% vs. 7.7% and 5.7 vs. 8.33 days, respectively. The analysis showed that overall cost for hospital treatment in group using incentive spirometry was lower.34

6.3 STATEMENT OF THE PROBLEM

THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON INCENTIVE SPIROMETRY IN PREVENTING PULMONARY COMPLICATIONS OF PATIENTS UNDERGOING CARDIAC SURGERY AMONG NURSING STUDENTS IN SELECTED COLLEGES IN BANGALORE.

6.4 OBJECTIVES OF THE STUDY

1. To assess the knowledge and attitude of students regarding incentive spirometry in preventing pulmonary complication of patient undergoing cardiac surgery.

2. To determine the association between knowledge and attitude of incentive spirometry in preventing pulmonary complication of patient undergoing cardiac surgery and selected demographic variables.

3. To assess the effectiveness of STP in improving the knowledge of incentive spirometry in preventing pulmonary complication of patient undergoing cardiac surgery.

6.5 RESEARCH HYPOTHESIS.

H1 – There will be a significant difference between pre tests and post test scores.

H2 – There will be significant association between pretests scores with selected

demographic variables.

6.6 RESEARCH VARIABLES.

INDEPENDENT VARIABLE

Structured Teaching Programme on incentive spirometry in preventing pulmonary complication after cardiac surgery

DEPENDENT VARIABLE

Knowledge of BSc nursing students regarding incentive spirometry in preventing pulmonary complication after cardiac surgery.

6.7 OPERATIONAL DEFINITIONS

Effectiveness: refers to gain in knowledge regarding incentive spirometry in preventing pulmonary complication after cardiac surgery determined by significant difference between pre and post test knowledge scores.

Structured Teaching Programme: refers to the systematically developed instructional method and teaching aid designed for BSc nursing students to provide information regarding incentive spirometry in preventing pulmonary complication after cardiac surgery.

Incentive spirometry: refers to a medical device used to help patients improve the functioning of their lungs.

Pulmonary complication: refers to complication related to respiratory system such as pneumonia, cough, atelectasis etc.

Cardiac surgery: refers to the surgery related to heart

Nursing students: refers to the 4th year BSc nursing students in selected colleges in Bangalore.

6.8 ASSUMPTIONS

1. The BSc nursing students may have some knowledge regarding incentive spirometry in preventing pulmonary complications after cardiac surgery.

2. The BSc nursing students may have interest to know about the incentive spirometry in preventing pulmonary complications after cardiac surgery.

6.9 DELIMITATIONS

1. The study is limited to the 4th year BSc nursing students of selected colleges in Bangalore .

2. The duration of the study is limited to four weeks only.

3. sample size is limited to 60 only

7 MATERIALS AND METHODS

7.1 SOURCE OF DATA.

Data will be collected from 4th year BSc nursing students of selected colleges in Bangalore .

7.2 Method OF DATA collection

Structured questionnaire

7.2.1 Research approach

Pre experimental approach will be adapted.

7.2.2 Research Design

One group pre and post test design.

7.2.3 Research Setting

Study will be conducted in selected nursing colleges in Bangalore .

7.2.4 Population

The population of the study comprises of BSC nursing students of selected nursing college in Bangalore.

7.2.5 Sample Size

Total sample of the study will consists of 60 BSc nursing 4th year students of selected nursing colleges in Bangalore.

7.2.6 Sampling TECHNIQUE.

Simple Random Sampling.

7.2.7 Sampling Criteria

Inclusion Criteria

1. BSc nursing students of 4th year.

2. 4th year nursing students who are available during the study.

3. 4th year nursing students willing to participate in the study.

Exclusion criteria

1. 4th year nursing students who are not willing to participate in the study.

2. 4th year nursing students who are absent during the study.

7.2.8 Data Collection Method

Structured knowledge questionnaire will be used to collect data. It consists of two parts.

PART 1: deals with demographic variables. It includes age, sex, academic performance etc

Part II: deals with knowledge of nursing students regarding incentive spirometry in preventing pulmonary complication after cardiac surgery will be assessed by structured teaching programme.

7.2.9 Data Analysis Method.

Data analysis method will be through descriptive and inferential statistics.

Descriptive Statistics: Mean, median, mode, standard deviation and percentage distribution will be used to assess the knowledge of students regarding incentive spirometry.

Inferential Statistics : Chi Square will be used to find the association between demographic variables and knowledge scores among the students. Paired ‘t’ test will be used to compare the pre test and post test knowledge

7.3 Does the study require any intervention to be conducted on patients OR OTHER humans or ANIMALS?

Yes, the study will be conducted on the students.

7.4 Has ethical clearance been obtained from the ethical committee of the HILLSIDE College Of NURSING?

- Ethical clearance will be obtained from the Ethical Committee of Hillside College of Nursing.

- Permission will be obtained from the concerned authority of the selected nursing colleges in Bangalore.

- Informed consent will be obtained from the subjects who are participating in the study.

8. LIST OF REFERENCES

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3. Freitas ER, Soares BG, Cardoso JR, Atallah AN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004466. Available from URL- http://www.ncbi.nlm.nih.gov/pubmed/17636760

4. Ponsky, Jeffrey, Rosen M, Brodsky J, Brody F, Ponsky JL.  The Cleveland Clinic Guide to Surgical Patient Management, 1st ed. Philadelphia, PA: Mosby, 2002. Available from URL http://www.surgeryencyclopedia.com/Pa-St/ Preoperative-Care.html#ixzz1eQcJfa9m

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9. Ferreyra G, Long Y, Ranieri VM. Respiratory complications after major surgery. Curr Opin Crit Care. 2009 Aug;15(4):P:342-8 Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/19542885

10. Johnson D, Kelm C, Thompson D. The effect of physical therapy on respiratory complications following cardiac valve surgery. Chest 1996;109:P:638–44.

11. Lainez RM, Losuda M, Nieto E. Pneumonia in patients undergoing heart surgery. Enferm Infuc Microbiol Clin 1994;12:P: 4–8.

12. Jindani A, Aps C, Neville E. Postoperative cardiac surgical care: an alternative approach. Br Heart J 1993;69:P:59–64. 

13. Zin WA, Caldeira MPR, Cardoso WV. Expiratory mechanics before and after uncomplicated heart surgery. Chest 1989; 95:P:21– 8.

14. Rady MY, Ryan T, Starr NJ. Early onset of acute pulmonary dysfunction after cardiovascular surgery: risk factors and clinical outcome. Crit Care Med 1997; 25:P:1831–9.

15. O’Donohue WJ. National survey of the usage of lung expansion modalities for the prevention and treatment of post-operative atelectasis following abdominal and thoracic surgery. Chest 1985;87:P:76-80

16. Jenkins SC, Soutar SA. A survey into the use of incentive spirometry following coronary artery by-pass graft surgery. Physiotherapy1986;72:P:492-493

17. Wattie, J. Incentive spirometry following coronary artery bypass surgery. Physiotherapy  1998;84:P:508-514

18. Jenkins SC, Soutar SA, Loukota JM. Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax 1989;44:P:634-639

19. Stiller K, Montarello J, Wallace M. Efficacy of breathing and coughing exercises in prevention of pulmonary complications after coronary artery bypass graft surgery.  Chest  1994;105:P:741-747

20. Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery.Phys Ther 1997;77:P:260-268

21. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg  2000; 232:P:242–253.

22. Arozullah AM, Khuri SF, Henderson WG.  Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 2001; 135:P:847–857.

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