RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES.BANGALORE - KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THECANDIDATE

ANDADDRESS

MRS. B.RAJESWARI I YEAR M.Sc NURSING ADARSHA COLLEGE OF NURSING BANGALORE- 560043

2. NAME OF THEINSTITUTION ADARSHA COLLEGE OF NURSING

3. COURSE OF STUDY

AND SUBJECT

M.Sc NURSING, MEDICAL & SURGICAL NURSING.

4. DATE OF ADMISSION TOTHE COURSE

30.06.2008

5. TITLE OF THE TOPIC

“A STUDY TO ASSESS THE

EFFECTIVENESS OF SELF

INSTRUCTIONAL MODULE (SIM)

REGARDING HOME CARE MANAGEMENT

OF MYOCARDIAL INFARCTION ON

KNOWLEDGE AMONG PATIENTS WITH

MYOCARDIAL INFARCTION ATTENDING

CARDIOLOGY OPD IN SELECTED

CARDIOLOGY HOSPITAL, BANGALORE

6. BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION:

Heart is described by the size of clenched fist. It lies immediately behind the

sternum closer to anterior than posterior chestwall. Superior boarder is at the level of

sternal angle ie., second costal cartilage. The right boarder follows parallel course to

the right of body of sternum to the level of fifth intercostal space. The inferior boarder

passes to the left above xiphoid process to the 10 cms of midline. The inferior boarder

ends to the left at fifth intercostal space known as apex of the heart. The left boarder

then runs upwards towards sternal angle.1

The Heart is the muscular organ of the circulatory system that constantly pumps

the blood through out the body. The heart is composed of cardiac muscle tissue that is

very strong and able to contract and relax rhythmatically through out a person’s

lifetime. A human heart is actually two pumps in one. The right side receives the

oxygen poor blood from the various regions of the body and delivers it to the lungs. In

the lungs oxygen is absorbed in the blood. The left side of the heart receives the

oxygen rich blood from the lungs and delivers it to the rest of the body.2

The heart requires a balance between oxygen supply and oxygen demand in

order to function properly. The integrity of coronary arteries is an important

determinant of oxygen supply to the heart muscle. Any disorder that reduces the lumen

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of the coronary artery may cause a decrease in blood flow and oxygen delivers to the

area of myocardium supplied by that vessel and lead to acute myocardial infarction

and sudden cardiac death.3

Acute coronary syndromes are responsible for more than 5,29,000 deaths

annually and 1.1 millions of Americans have myocardial infarction every year. These

are result from a progressive atherosclerotic process that culminates in the rupture of

atherosclerotic plaques and thrombus formation. So medications are typically

administered with in 4 to 6 hrs of heart attack to dissolve the blood clots and reduce

the mortality rates. In some cases interventional heart catheterization is required to

restore the blood flow.4

Survival rate of heart attacks are directly related to the amount of heart tissue

affected by the obstruction, the time elapsed before treatment and physical condition

of the victim and heart at the time of heart attack.5

6.1. NEED FOR THE STUDY:

A heart attack or myocardial infarction begins when a portion of heart muscle

suddenly looses its blood supply due to an obstruction of the coronary arteries. The

obstruction is typically due to coronary arteriosclerosis. If the obstruction persists for

more than a few minutes the affected cardiac muscle tissue will begin to die.6

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Statistics by British heart foundation (2008) estimate the incidence of 67,000

heart attacks per year in all men and 46,000 in women giving a total of 1,13,000 heart

attacks in UK. The incidence rate of heart attack is higher in men than in women and

increased with age. It is highly likely that incidence rates like mortality rates are higher

in Scotland, Northern Ireland and North England than in South England.7

The WHO MONICA (monitoring trends and determinants in cardiovascular

diseases) project collected the data on the incidence of heart attack in 35 population in

21 countries during the mid 1980’s until the mid 1990’s. Results showed that

incidence rate in the population of UK were highest among the world particularly in

the women.8

Akahmed & Bhopal.R (2005) conducted a study on the incidence and

prevalence of myocardial infarction in India. The aim of the study was to investigate

whether coronary artery disease is raising in India, 31 studies were reviewed. The

sample size of studies varied approximately 500 to 14,000 and many studies were in

and around the Delhi. The 3 incidence studies used different diagnostic criteria

however the incidence of MI in the urban areas in the last 14 years to 1991 similar at

about 6/10000 in males and 2/1000 in females. Prevalence was higher in urban than in

rural areas in men (35 to 90/1000 V 17 to 45/1000) and women (28 to 93/1000 V 31 to

43/1000). It was found that CHD is common in urban areas than in rural areas of

India.9

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Rowley J.M, Hampton J.R. and Mitchell J.R (2006) conducted a study on home

care for patient with myocardial infarction: Use made by general practitioners of a

hospital team for initial management. Two hundred and sixty three general

practitioners were offered the use of a hospital based service consisting of a medical

senior house officer, a nurse attached to a coronary care unit, and a specially equipped

ambulance estate car to help with the initial management of patients with suspected

myocardial infarction who might be suitable for home care. 529 patients with

suspected infarction were admitted without the intervention of a general practitioner.

Of the patients seen by the team, 54 required immediate admission to hospital; 17 of

the remaining patients who initially appeared suitable for home care later required

admission to hospital.

The care is minimal by the patient after discharge from the hospital and more

prone to get the complications. From the available literature viewed, it is relevant that

patients should be educated about the home care management of myocardial

infarction, so the researcher found it is necessary to asses the effectiveness of self

instructional module on home care management of myocardial infarction among

patients with myocardial infarction in selected cardiology hospital Bangalore.10

6.2. REVIEW OF LITERATURE:

According to Nancy burns, the review of literature is a research report and it is

a summary of current knowledge about a particular practice problem and includes,

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what is known and not known about the problem. The literature is reviewed to

summarize knowledge for use in practice or to provide basis for conducting a study.11

James PA, LiP, Ward MM (2007) conducted a study on aerobic exercise on

post myocardial infarction patient. The randomised test of cardiac rehabilitation after

myocardial infarction demonstrates that regular exercises reduces the risk of over all

mortality and cardiovascular mortality. In patients with established coronary artery

disease exercises with improved activity tolerance, modification of risk factors and

improvement in quality of life. Randomised control test demonstrate that older patients

after coronary artery events substantially less fit than younger patients. They obtained

similar relative improvement of aerobic capacity with graded conditioning programme.

Despite the similar clinical profiles to men and women are less likely to participate in

exercise programme.12

The American heart association (2003) conducted a study on cholesterol

restricted diet. Part of circulating cholesterol orginates from diet and restricting

cholesterol intake may reduce the blood cholesterol level. The association complies the

list of acceptable / unacceptable foods for those who are diagnosed with coronary

artery disease and hyperlipidemia. Focus the diet on plant foods like rice reducing the

bad fats, adding high fiber diet is the key to reduce the cholesterol. Certain foods like

olive oil whole grains, high fiber foods, vegetables, beans and cultured food helps in

cholesterol reduction. Eat smaller meals especially late at night. Supplements like

niacin, vitamin c, minerals, calcium, copper, zinc and chromium are also helpful.

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Apples, banana, carrots and grape fruits are just additional recommendations. Drink

fresh juices daily especially carrot and lemon juice. Walnuts should only be eaten

when they raw. Avoid gas forming foods like cabbage, cauliflower and sweet pickles.13

Tulpule.T.H (2004) conducted a study on yoga method of relaxation for

rehabilitation after myocardial infarction. Patients who had unequivocal evidence of

acute myocardial infarction were selected for this study. All the patients were male,

had a typical history of sudden retrostrenal pain accompanied by sweating. All the

patients received medical treatment wherever necessary and indicated. They were

advised to walk slowly in the hospital and then at home after discharge from hospital.

The emphasis is on the time and not on the distance walked. The patients were divided

into two groups. The trial group was taught about yogic practices by teacher and only

after the teacher was allowed to practice at home at without supervision. The time

required to achieve the correct performance of the techniques shown a significant

variation and dependent on ability and adaptability of the patient. The results of yogic

postures did not change the basal status of the patient and did not produce any cardiac

decompensation or angina or other complications. So the rehabilitation by some sort of

physical activity after myocardial infarction has been accepted all over the world. 14

Birchwood.B (2008) conducted a study on serum lipids and lipo proteins

following acute MI in women. Serum lipids and lipo protein electrophoresis were

studied in 12 female patients following acute myocardial infarction, during the

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recovery and following discharge from the hospital. All were on normal hospital diet

‘calculated to maintain the weight’. No significant changes occurred in serum lipids at

any time but lipo protein pattern changed in 4 patients following recovery from the

acute episode.15

Harvard school of public health (2004) conducted a study on cholesterol. It is a

wax like substance. The liver makes it link to carrier proteins called lipo proteins that

let dissolve in blood & be transported to all parts of the body. Too much cholesterol in

the blood through can lead to problems. In the 1960 and 70’s scientists established a

link between high blood cholesterol & heart diseases. Deposists of the cholesterol can

buildup inside the artieries called plaques can narrow the artery enough to slow or

block the blood flow. Formed plaques rupture causing blood clots that may lead to

heart attack or sudden death.16

Jolly K, Tayor RS, Lip GY, et al., (2007) conducted a randomised controlled

trial study on home based exercised rehabilitation among myocardial infarction

patients. 642 patients were contacted: 289 (45%) declined to participate, 183 (39%)

had an exclusion

criterion and 169 (26%) agreed to randomization and results suggested many patients

had co-morbidities preventing exercise and others had concerns about undertaking an

exercise programme.17

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Bagheri H, Memarian R, Alhani F (2007) done a randomized controlled trial

study to evaluate the effects of group counseling on post myocardial infarction

patients. Sixty-two patients with myocardial infarction were chosen, case group, (31

patients), distributed in five subgroup (each subgroup conclude six or seven patients)

and control group (31 patients). A group-counseling programme was performed two

days per week, each session last one hour. However, no counseling was performed for

the control group. The data were analyzed using SPSS software. Results indicated that

there was no significant difference between the mean quality of life score of case and

control groups before group counseling programme. While there was a significant

difference (P = 0.001) between the mean of quality of life score after the group

counseling in both groups. The mean of quality of life score, before and after group

counseling programme indicated a significant difference (P < 0.001) in the case group,

while there was no significant difference in the control group. As indicated by the

results of this study, group counseling programme can promote patient’s quality of life

in all dimensions.18

Oliveira J, Ribeiro F, Gomes H. (2008) conducted research on effects of home

based cardiac rehabilitation and the physical activity levels of patients with coronary

artery disease. Thirty patients with history of recent myocardial infarction were

recruited and equally divided into intervention (mean age = 67.2 +/- 5.4 years) and

control (mean age = 69.8 +/- 6.14 years) groups. The results indicated that the

intervention group significantly increased daily PA index (from 278.2 +/- 128.0 to

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525.5 +/- 153.4 counts per minute per day, P < .05) and time spent in moderate-

intensity PA (from 16.8 +/-12.6 to 63.7 +/- 23.3 minutes per day, P < .05) during the

intervention period. No changes were observed in the control group. Patients

participating in the home-based intervention increased PA throughout the day.19

Ketil Lunde (2003) done a study regarding improvement in left ventricular

function after intra coronary injection of autologous cells derived from bone marrow in

the acute phase of myocardial infarction. Results of 50 patients assigned to treatment

with mononuclear BMC, 47 underwent intracoronary injection of cells at median of 6

days after myocardial infarction successfully.20

Arnetz JE, Winblad U, Arnetz BB, Hoglund AT (2008) conducted a

questionnaire study to measure the physician’s and nurse’s perceptions of patient

involvement in myocardial infarction care. Questionnaire were distributed among

cardiology staff at twelve Swedish hospitals. The questionnaire included six scales

measuring staff views and behaviour. Physicians, registered nurses, and practical

nurses did not differ significantly in their views of patient involvement, but did differ

significantly in behaviour (p<.001). Physicians and registered nurses viewed time

constraints as a hinder for patient involvement, while practical nurses felt unsure in

communicating with patients. Considering these organizational and professional issues

may improve patient involvement and health outcomes in myocardial infarction care.21

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6.3 STATEMENT OF PROBLEM :

A study to assess the effectiveness of self instructional module regarding home

care management of myocardial infarction on knowledge among patients with

myocardial infarction attending cardiology OPD, in selected cardiology hospital

Bangalore.

6.4 OBJECTIVES OF THE STUDY :

1. To assess the knowledge of patients with myocardial infarction on home care management of myocardial infarction before implementation of self instructional module.

2. To assess the effectiveness of self instructional module regarding home care

management of myocardial infarction.

3. To find out association between knowledge of patients with myocardial infarction

regarding home care management of myocardial infarction with their selected

demographic variables.

6.5 HYPOTHESIS :

H1 - The mean post test knowledge scores of the patients with myocardial

infarction regarding home care management of myocardial infarction will be

significantly higher than the mean pre-test knowledge scores.

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H2 - There will be a significant association between the selected demographic

variables and the mean knowledge scores of patients with myocardial infarction

regarding home care management of myocardial infarction

6.6 OPERATIONAL DEFINITIONS:

Knowledge

Knowledge refers to the responses received from the patients with myocardial

infarction regarding home care management of myocardial infarction elicited through

the closed-ended questionnaire.

Effectiveness

Refers to a significant gain in difference between pre-test and post-test knowledge

scores.

SIM

Self instructional module is an instructional material prepared by the investigator in

english and kannada on the home care management of myocardial infarction to learn

by himself or herself.

Patients with myocardial infarction

In this study patients refers to the persons who are suffering with myocardial infarction

and attending cardiology OPD, at selected hospital, Bangalore.

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Home care management of myocardial infarction

Refers to the activities those are carried out by the patients with myocardial infarction

at home by himself/herself.

6.7 ASSUMPTIONS:

1. Patients with myocardial infarction will have some knowledge regarding home

care management of myocardial infarction..

2. Patients have potential to learn about home care management

3. Knowledge on home care management of myocardial infarction is measurable

4. Planned self instructional module is an effective way to improve the knowledge of

patients with myocardial infarction

6.8 DELIMITATIONS :

The study will be limited only to the patients with myocardial infarction attending

cardiology OPD at selected hospital, Bangalore

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA Patients with myocardial infarction attending

cardiology OPD of selected hospital, Bangalore.

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7.2 METHOD OF DATA COLLECTION:

Research method : Quasi experimental method.

Experimental design : One group pre-test, post- test design.

Sampling technique : Non-probability purposive sampling

Sample size : 50 patients with myocardial infarction

Setting of the study : Study will be conducted at Jayadeva

cardiac hospital , Bangalore

7.2.1 CRITERIA FOR SELECTION OF SAMPLE

INCLUSION CRITERIA

Patients who are

of both sexes

affected with myocardial infarction

attending the cardiology OPD at selected hospital Bangalore.

present at the time of data collection

willing to participate in the study.

EXCLUSION CRITERIA

Patients who are

affected with other than myocardial infarction

admitted as an inpatients

receiving treatment for cardiac complications.

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7.2.2 DATA COLLECTION TOOL:

It consists of knowledge questionnaire , to assess the pre- test and post –test

knowledge of the patients regarding home care of management of myocardial

infarction. A self instructional module will be prepared on home care management of

myocardial infarction .Content validity of the tool will be obtained in consultation with

guide and experts in the field of cardiology, cardiology nursing, education and

biostatistics. Reliability of the tool will be established by test- retest method. The

tentative period of collection will be from July – August 2009.

7.2.3 METHOD OF DATA ANALYSIS :

Descriptive and inferential statistics will be used for data analysis i.e mean, standard

deviation, frequency, percentage distribution and paired ‘t’ test to compare the pre and

post test knowledge scores and chi-square ( 2א ) test to find out association with the

level of knowledge and selected demographic variables of Patients .

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS? YES1. Intervention as a self instructional module on home care management of

myocardial infarction will be conducted for the patients with myocardial

infarction.

2. No other invasive procedures are performed as the intervention in this

study.

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7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED?

YES1. Confidentiality and anonymity of the subject will be maintained.

2. Informed consent will be obtained from the subjects.

3. A written permission from institutional authority & hospital management

will be obtained prior to the study.

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8. LIST OF REFERENCES :

1. Gupta & Gupta, 2006, “Anatomy and physiology for nurses”, sixth edition, AITBS

publishers, India, PP 129 - 131

2. James P.A. LiP, Word MM, online 2007, “myocardial infarction mortality in rural

and urban hospitals – measures of quality of care”, March – April 5(2), 105 – 11.

3. Rowley J.M, Hampton J.R and Mitchell J.R, online 2006, “Home care for patient

with myocardial infarction – Use made by general practitioners of a hospital team

for initial management”.

4. Arnetz J.E. Winblad U, online 2008, “A study to measure the physicians and nurses

perceptions of patient involvement in MI”, June,7(2):113 – 20.

5. Jolly K, Tayor R.S, LiP GY, online2007, “Home-based exercise rehabilitation in

addition to specialist heart failure nurse care”, March,7:9.

6. Davidson P, Digiacomo M, et al, online 2008, “A cardiac rehabilitation programme

to improve the psychosocial outcome of women with coronary heart disease”, Jan –

Feb 17(1): 123 – 34.

7. Oliveira J, Ribeiro F, online 2008, “Effects of home-based cardiac rehabilitation

programme on the physical activity of patient with CAD”, Nov – Dec, 28(6):392 –

6.

8. Bagheri H, Memarian R, online 2007, “Evaluation of the effects of group

counseling on post myocardial infarction patients”, Feb 16(2):402 – 6.

9. Akahmad & R.Bhopal, online 2005, “Incidence and prevalence of myocardial

infarction in India”, July 9(6) – 13(2).

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10. Birchwood, online 2008, “Serum lipids and Lipo protein following acute MI”, Nov

14:38(47).

11. “Prevalence and incidence of MI”, UK, online Encyclopedia, 2008.

12. Brunner and suddarthas, 2004, “Text book of medical surgical and

nursing”,10th edition, Lippincott company, PP 582 – 588.

13. BMJ 2006, “Cardiologists provide best care for patients with MI”, June 332.

14. Melek Cosan Yilmaz, 2005, “The need assessment of MI patients in discharge

planning and home-health care” Nov PP 2.

15. Joyce M. Black, 2006, “Text book of medical and surgical nursing”, saunder’s

publications, PP 1071 – 1082

16. www.google.com

17. www.pub.med.com

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