Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |: |Miss. ROOPA G |

| | | |I YEAR M. Sc NURSING, |

| | | |GOVERNMENT COLLEGE OF NURSING, FORT, BENGALURU-02. |

|2. |NAME OF THE INSTITUTION |: |GOVERNMENT COLLEGE OF NURSING, FORT, BENGALURU-02. |

|3. |COURSE OF STUDY AND SUBJECT |: |M. Sc NURSING |

| | | |MEDICAL SURGICAL NURSING |

|4. |DATE OF ADMISSION |: |27-07-2012 |

|5. |TITLE OF THE TOPIC |: |“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME (STP) |

| | | |REGARDING PREVENTION OF SELECTED MICROVASCULAR |

| | | |COMPLICATIONS ON KNOWLEDGE OF TYPE II DIABETES MELLITUS (DM)|

| | | |CLIENTS IN SELECTED HOSPITALS AT BENGALURU”. |

6. BRIEF RESUME OF THE INTENDED WORK

“Nobody Is Worth More Than Your Body”

Melody Carstairs

INTRODUCTION

Biologically health is a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body1. The endocrine system and nervous system are two of the primary communicating and coordinating systems in the body. The nervous system communicating through the impulses and the endocrine system is communicating through the mechanical substance known as hormones. The endocrine system is composed of glands that produce, store and secrete hormones and it plays a role in reproduction, growth and development and regulation of energy2.

Glucose is the main source of energy for the body and all the food that we consume is digested and converted into glucose to use as energy in the cells or stored in the liver as glycogen for future use. Food raises the blood glucose, insulin and exercise lowers the blood glucose and keeps balance3. Insulin is the hormone secreted by the islets of Langerhans of the pancreas and regulates the blood glucose level within normal limit2.

Diabetes mellitus is a metabolic disorder of multiple etiological factors characterized by chronic hyperglycaemia with disturbance of carbohydrates, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both4. Diabetes mellitus is classified into three types, type I, type II and Gestational DM2. Type 2 diabetes mellitus is the commonest form of diabetes constituting 90% of the diabetes population5.

High blood sugar level over a period of time can cause many of chronic complications of diabetes mellitus and damage to the heart, blood vessels, eyes, kidney, and nerves6. The chronic complications of diabetes are divided into two categories.

• Macro vascular complications consist of coronary artery disease, cerebro vascular disease and peripheral vascular disease.

• Micro vascular complications consist of diabetic retinopathy, diabetic nephropathy, diabetic neuropathy and diabetic vasculopathy2.

Consequences of chronic complication of diabetes mellitus causes

• Increases risk of heart disease and stroke.

• Diabetic retinopathy important cause of blindness.

• Diabetic nephropathy the leading cause of kidney failure.

• Diabetic neuropathy in foot increases the chance of foot ulcer.

Macro vascular atherosclerosis changes are seen in both diabetic and non diabetic patients, but micro vascular changes are unique to diabetes. Diabetic micro vascular disease is characterized by capillary basement membrane thickness. Researchers believe that increased blood glucose level react through a series of biochemical responses to thicken the basement membrane to several times its normal thickness.

Simple measures are shown to be effective in the prevention of diabetes and its complications, people should follow;

• Achieve and maintain healthy body weight.

• Be physically active.

• Eat a healthy diet.

• Avoid tobacco and alcohol use6.

6.1 NEED FOR THE STUDY

WHO’s world health statistics 2012 report estimates 347 million people worldwide have diabetes and 1 in 10 suffers from diabetes globally. India, the world’s second most populous, now has the more people with type 2 diabetes than any other country7.The International Diabetes Federation estimates the total number of people in India with diabetes to be around 50.8 million in 2010, raising to 87.0 million by 20308.

According to WHO diabetes fact sheet N0312 September 2012, 50% of people with diabetes die of cardio vascular disease. 10% severe visual impairment, 10-20% of people with diabetes die of kidney failure, 50% of people with diabetes affects with diabetic neuropathy7. Type II DM could result in both microvascular and macrovascular complications but the presentation of these complications could vary globally and be influenced by diabetic control9.

A survey was done on the prevalence of micro vascular complications among 787 patients of south-Asian origin in diabetic clinics in the UK (n=351), Mauritius (n=173) and India (n=263). The result found the prevalence of microvascular complications such as retinopathy (India 16.3%; Mauritius 2.3%; UK 2.6%), nephropathy (India 20.5%; Mauritius 10.5%; UK 2.3%) and neuropathy (India 8.4%; Mauritius 1.2%; UK 5.1%) complications to be significantly higher in India. The study findings suggested that microvascular complications are higher in India due to poorer diabetic control9.

A study was conducted to determine the prevalence of vascular complications among 726 south India non insulin dependent diabetes mellitus patients with over 25 years duration of diabetes in M V diabetic specialist centre Madras. Out of 726 patients retinopathy was detected in 52.0% of patients; nephropathy was present in 12.7% of patients and neuropathy in 69.8% of patients. While 32.8% of patients had ischemic heart disease, the prevalence of peripheral vascular disease was only 15.4%10.

A clinical study was conducted regarding microvascular complications in a newly diagnosed diabetes mellitus among 50 newly diagnosed diabetic patients either admitted or seen as outpatients over a period of 2 years in KIMS Hospital, Bengaluru. The study findings revealed 36% of patients had peripheral neuropathy, 28% of patients had diabetic nephropathy and 24% had diabetic retinopathy11.

A study was conducted to assess the relationship between and risk factors for micro vascular complications of diabetes among 1736 subjects with type 2diabetes in urban south Indian. Results suggested diabetic retinopathy was present in 282(17.5%), diabetic neuropathy was present in 414(25.7%), diabetic nephropathy was present in 82(5.1%). The common risk factors identified for all micro vascular complications of diabetes were age, HbA1c, duration of diabetes and serum triglycerides12.

A randomized study was conducted to assess the self care knowledge on diabetes among 456 diabetic patients in Warangal region. The study findings revealed 3.50% diabetic population were with >80% knowledge and 29.38% population were with 60-90% knowledge. The study suggested, there is definite need to empower patients with knowledge required to help them obtain maximum benefit from their treatment for diabetes13.

A hospital based, cross sectional, observational study was conducted to assess the knowledge, attitude and self reported practices regarding diabetes using a pretested questionnaire among 64 patients attending a diabetic clinic in tertiary care hospital in Kolkata. The findings of the study revealed that knowledge regarding symptoms and complications of the disease was poor except for frequent urination( 42.2%) and eye complication(62.5); however, only 25% patients had gone for eye examination during the last one year of their treatment. Awareness on detecting early complication of diabetes like periodic eye examination, BP monitoring and awareness on hypoglycaemia, foot care were found to be poor14.

The above statistics and studies signify that microvascular complications are more prevalent among Indian DM clients because of the poor glycemic control and it is evident that they also have poor knowledge regarding microvascular complications and their prevention. During clinical exposure also the investigator has come across diabetic clients with one or more microvascular complications such as diabetic retinopathy, diabetic nephropathy and diabetic neuropathy. Since there is immediate need to caution and educate them about prevention of microvascular complications. The investigator selected the following study.

6.2 REVIEW OF LITERATURE

Review of literature is an account of what is already known about a particular phenomenon. It conveys the readers about the work already done and the knowledge and ideas that have been already established on a particular topic of research. Literature review is defined as a broad, comprehensive, in depth, systematic and critical review of scholarly publications, unpublished printed or audiovisual materials and personal communications15.

A cross sectional study was conducted to determine the prevalence of micro vascular complications on 4067 type 2 diabetic patients in a diabetic clinic attached to medical college, North west India. The findings of the study revealed that retinopathy was seen in 1176 patients (28.9%), nephropathy in 1323 patients (32.5%), neuropathy in 1225 patients (30.1%), cardiovascular diseases 780 patients (19.2%) and peripheral vascular diseases in 735 patients (18%). This study highlights the high prevalence of various micro and macrovascular complications especially neuropathy and nephropathy in Indian population16.

A study was conducted to assess the prevalence of micro vascular complications among 200 hundred indoor diabetic patients at department of diabetology and endocrinology, Hayatabad medical college, Peshawar. Relevant information of all patients was recorded with the help of a prescribed proforma. They were investigated for retinopathy, nephropathy and neuropathy detected in 55% cases, nephropathy in 67% cases while 68.5% patients had the problem of neuropathy17.

A community based study was carried out to determine the prevalence of DM and its association diabetic complications among 1266 participants in a rural setting Goa, India. The participants were interviewed using a semi structured questionnaire and were subjected to anthropometric, clinical evaluation and biochemical investigations. The results revealed among 1266 study participants 130(10.3%) were diabetics. The prevalence of the associated diabetic complications were as follows viz. diabetic neuropathy 60%, Coronary artery disease 32.3%, and cataract 20% diabetic retinopathy 15.4%, peripheral vascular disease 11.5%, and cerebrovascular accidents 6.9%18.

A descriptive study was conducted among 500 type 2 diabetes patients to determine the prevalence of chronic complications and associated factors in Karachi, Pakistan. Clients were examined through laboratory investigations of HbA1c, lipid profile and serum creatinine and urine examination for albumin and micro albumin. Out of 500 patients retinopathy was seen in 43%, neuropathy in 39.6% and foot ulcers in 4% and nephropathy was found in 20.2% cases. The prevalence of micro vascular complications was higher in the group of patients with HbA1c >8% and was significantly related to duration of diabetes, hypertension and obesity19.

A study was conducted to determine factors associated with poor glycaemia control among systematic random sample of 917 Jordanian patients with type 2 diabetes by using pre structured questionnaire and patient records. Results showed 65.1% had HbA1c ≥ 7%. Negative attitude towards diabetes and increased barrier to adherence scale scores were significantly associated with increased odds of poor glycaemic control. The study suggested the need of an educational program that emphasizes lifestyle modification with importance of adherence to treatment regime would be of great benefit in glycaemic control20.

A structured questionnaire was administered on knowledge, beliefs, and practices regarding diabetes among 199 persons with diabetes (92.5% type2) attending the Aga Khan University Hospital, Karachi. Scores were classed as good (>60%) in only 13.6% of participants for knowledge, 17.6% for beliefs and 11.2% for practices. About 38% of the participants had education on diabetic care21.

A study was conducted to examine whether intensive glycaemic control could decrease the frequency or severity of diabetic microvascular complications, an 8years prospective study of 110 Japanese patients with type 2 diabetes. Total of 110 patients were randomly assigned to multiple insulin injection therapy groups and administered three or more daily insulin injections or assigned to conventional insulin injection therapy groups and administered one or two insulin injections. The results showed cumulative worsening in retinopathy and nephropathy were significantly lower in the MIT groups than in the CIT groups.22

STATEMENT OF THE PROBLEM

“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME (STP) REGARDING PREVENTION OF SELECTED MICROVASCULAR COMPLICATIONS ON KNOWLEDGE OF TYPE II DIABETES MELLITUS (DM) CLIENTS IN SELECTED HOSPITALS AT BENGALURU”.

6.3 OBJECTIVES OF THE STUDY

• To assess the knowledge of type II DM clients before and after administering of STP regarding prevention of selected microvascular complications.

• To find the association between pre-test knowledge level of type II DM clients regarding prevention of selected microvascular complications and their selected demographic variables.

1. RESEARCH ASSUMPTIONS

➢ The type II DM clients may have some knowledge about microvascular complications of diabetes mellitus and their prevention.

➢ STP can enhance the knowledge of type II DM clients regarding prevention of selected microvascular complications.

2. RESEARCH HYPOTHESES

➢ H1: There will be significant difference between mean pre-test and post test knowledge scores of type II DM clients regarding prevention of selected microvascular complications.

➢ H2: There will be a significant association between pre test knowledge level of type II DM clients regarding prevention of selected microvascular complications and their selected demographic variables.

3. DELIMITATION

➢ The study is delimited to 40 type II DM clients in selected hospitals at Bengaluru.

6.3.4 RESEARCH VARIABLES

➢ Independent variable: Structured teaching programme regarding prevention of selected microvascular complications.

➢ Dependent variable: knowledge of type II DM clients regarding prevention of selected microvascular complications

➢ Demographic variables: it includes all demographic variables such as age, gender, educational status, occupation, duration of illness and previous exposure to the information.

6.3.5 OPERATIONAL DEFINITION

i) Effectiveness: It refers to significant gain in post test knowledge of type II DM clients regarding prevention of selected microvascular complications.

ii) Structured Teaching Programme: It refers to a systematically developed instructional method & visual aids designed to impart knowledge regarding prevention of selected microvascular complications.

iii) Prevention: In this study, prevention refers to precautionary measures taken to reduce the risk of developing micro vascular complications among type II DM clients.

iv) Selected Micro vascular complications: In this study, selected Micro vascular complications refer to diabetic retinopathy, diabetic nephropathy and diabetic neuropathy.

v) Knowledge: It refers to the correct responses given by type II DM clients to the items included in the structured interview schedule expressed in terms of scores and will be further classified into adequate, average and inadequate.

vi) Type 2 Diabetic clients: In this study, type II DM clients refer to the individuals those who are diagnosed as diabetes mellitus after 30 years of age.

7. MATERIALS AND METHODS

|7.1 |Source of Data |: |Data will be collected from the |

| | | |type II DM clients in selected hospitals, at Bengaluru. |

|7.2 |Method of collection of Data | | |

|7.2.1 | Definition of the Study Subject |: | Type II DM clients in selected hospitals, at Bengaluru. |

|7.2.2 |Inclusion and exclusion criteria | | |

| | Inclusion Criteria |: |Type 2 diabetes mellitus clients who |

| | | |Are willing to participate in the study. |

| | | |Present at the time of data collection. |

| | | |Can comprehend Kannada and English. |

| |Exclusion criteria |: |Type II DM clients who are critically ill. |

| | | |Type I DM clients. |

|7.2.3 |Research Approach |: |Experimental research. |

|7.2.4 |Research Design |: |Pre experimental -one group pre test and post test design. |

|7.2.5 |Setting |: |Research will be conducted in selected hospitals at Bengaluru.|

|7.2.6 |Sampling Technique |: | Convenient sampling technique will be adopted to draw the |

| | | |sample. |

|7.2.7 |(a)Sample size |: |40 type II DM clients. |

| |(b)Duration of Study |: |3 – 4 Weeks. |

|7.2.8 |Tools of Research |: |Data collection tool is structured interview schedule which |

| | | |consists of following parts: |

| | | |Part-I: Deals with demographic variables which include age, |

| | | |gender, education status, occupation, duration of illness and |

| | | |previous exposure to the information. |

| | | |Part-II: Consists of multiple choice questions regarding |

| | | |prevention of selected microvascular complications. |

|7.2.9 |Collection of Data |: |After getting permission from the concerned authority and |

| | | |consent from the sample, the investigator will collect the |

| | | |data from 40 type II DM clients by using structured interview |

| | | |schedule to assess the knowledge regarding prevention of |

| | | |selected microvascular complications and conducts structured |

| | | |teaching programme on the same day. After seven days post test|

| | | |will be conducted by using the same structured interview |

| | | |schedule. |

|7.2.10 |Method of Data analysis and Presentation |: |The collected data will be analysed by using Descriptive and |

| | | |inferential statistics. Which includes - |

| | | |Descriptive statistics: |

| | | |1) Frequency and percentage distribution will be used to |

| | | |analyse the demographic variables. |

| | | |2) Mean, mean percentage and standard deviation will be used |

| | | |to assess the level of knowledge of type II DM clients |

| | | |regarding prevention of selected microvascular complications. |

| | | |Inferential statistics: |

| | | |1) Paired t-test will be used to determine the effectiveness |

| | | |of structured teaching programme. |

| | | |2) Chi-square test will be used to find the association |

| | | |between pre-test knowledge with demographic variables. |

| | | |3) The analysed data will be presented in the form of tables, |

| | | |diagrams and graphs. |

7.3 Does the study require any investigation to be conducted on patients or other human or animals? If so please describe briefly?

The type II DM clients will be subjected to structured teaching programme.

7.4 Has ethical clearance has been obtained from your institution in case of 7.3?

Yes

8. LIST OF REFERENCES

1. Park k. Preventive and social medicine. 20th ed. M/s Banarsidas Bhanot Publishers: Jabalpur; 2009.P.15.

2. Patricia Graber o Brien, Sharon L Lewis and Margaret A Medvedev. Medical-Surgical Nursing: Assessment and Management of Clinical Problem. 7th ed. Elsevier Mosby: London; 2007.p.1253.

3.

4. A Sundarnath et al. A Study To Assess The Knowledge And Practice Of Insulin Self Administration Among Patients With Diabetes Mellitus. Asian journal of pharmaceutical and clinical research. Vol 5, Issue 1, 2012.

Issn – 0974-2441.

5. V Mohan, S. Sandeep, R. Deepa, B. Shah and C. Varghese. Epidemiology of type 2 diabetes: Indian Scenario. Indian J Med Res 125, March 2007, pp 217-230.

6.

7. states 17 may 2012

8. A Ramachandran et al. Current Status of Diabetes In India And Need For Novel Therapeutic Agents. SUPPLMENT TOJAPI.JUNE 2010.VOL.58.

9. Potluri R, Purmah Y, Dowlut M, Sewpaul N and Lavu D. Microvascular Diabetic Complications Are More Prevalent In India Compared To Mauritius And Uk Due To Poorer Diabetic Control.

Available from

10. V Mohan, R. Vijayaprabha and M Rema. Vascular Complications In Long Term South Indian NIDDM Of Over 25 Years Duration. Diabetes Research and Clinical Practice 31(1996) 133-140.

11. Dr. Nandish. A Clinical Study of Micro vascular Complications In A Newly Diagnosed DM. 2007.

12. Pradeep R et.al. Risk Factors For Micro vascular Complications Of Diabetes Among South Indian Subjects With Type 2 Diabetes. 2010 Oct; 12(10):755-61 Available from

13. Swetha Thungathruthi, Smitha Thungathruthi and Vijay Kumar G. Self Care Knowledge On Diabetes Among Diabetic Patients In Warangal Region. International Journal Of Life Science And Pharma Research. Vol 2/Issue 2/Apr-Jun 2012. ISSN 2250-0480.

14. Prianka Mukhopadhyay, Bhaskar Paul, Debasis Das, Nilanjan Sengupta and Rachamajumder. Perception and Practices Of Type 2 Diabetics. Downloaded free from on Monday, October 11, 2010, IP: 59.183.191.199.

15. Dr Suresh K Sharma. Nursing research and Statistics. First edition. Elsevier: India; 2011. P. 70-71

16. Agrawal RP et.al. Prevalence of Micro and Macro Vascular Complications In Type 2 Diabetes And Their Risk Factors. INT.J.DIAB.DEV.COUNTRIES (2004), VOL.24.

17. Shafiqur-Rahman and Irfan zia. Prevalence of Microvascular Complications Among Diabetec Patients. Pakistan J.Med.Res. Vol.43 No.4, 2004.

18. Nasif C Vaz, AM Ferreira, MS Kulkarni, Frederick S Vaz, and NR Pinto. Prevalence of Diabetic Complications In Rural Goa, India. Indian J Community Med. 2011 Oct-Dec; 36(4):283-286.

Available from

19. A. S. Shera, F. Jawad, A. Maqsood, S. Jamal and M. Azfar. Prevalence of chronic complications and associated factors in type 2 diabetes. Available from

20. Maysaa khattab, Yousef S. Khader, Abdelkarim Al-Khawaldeh and Kamel Ajlouni. Factors associated with poor glycemic control among patients with type 2 diabetes. Journal of Diabetes and Its Complications 24 (2010)84-89.

21. G Rafique, S I Azam and F white. Diabetes Knowledge, Beliefs and Practices Among People With Diabetes Attending A University Hospital In Karachi, Pakistan. La Revue de Sante de ka Mediterranee orientale, Vol. 12, No 5, 2006.

22. Motoaki Shichiri, Hideki Kishikawa, Yasuo Ohkubo and Nakayasu Wake. Long Term Results of the Kumamoto Study On Optimal Diabetes Control In Type 2 Diabetic Patients. Available from

|9. |SIGNATURE OF THE CANDIDATE |: | |

|10. |REMARKS OF THE GUIDE |: |Recommended and forwarded. |

| | | | |

| | | | |

| | | | |

|11. |NAME AND DESIGNATION OF GUIDE |: |Mrs. AGATHA P CHRISTY |

| | | |ASST. PROFESSOR |

| | | |DEPT. OF MEDICAL SURGICAL NURSING |

| | | |GOVERNMENT COLLEGE OF NURSING, FORT, BENGALURU-02. |

|11.1 |SIGNATURE |: | |

|11.2 |HEAD OF THE DEPARTMENT |: |Mr. BASAVARAJ G |

| | | |HEAD OF THE DEPARTMENT |

| | | |MEDICAL SURGICAL NURSING |

| | | |GOVERNMENT COLLEGE OF NURSING, FORT, BENGALURU -02 |

|11.3 |SIGNATURE |: | |

|12 |REMARKS OF THE PRINCIPAL |: |Recommended and forwarded |

|12.1 |SIGNATURE |: | |

ETHICAL COMMITTEE CLEARANCE

The study titled “ Effectiveness Of Structured Teaching Programme Regarding Prevention Of Selected Microvascular Complications On Knowledge Of Type II DM Clients In Selected Hospitals At Bengaluru.” proposed to be conducted by Ms. Roopa G as a part of partial fulfilment of requirement for the degree of Master of Science in Medical Surgical nursing under RGUHS, Bengaluru, Karnataka.

Ethical committee members have gone through the study methodology and have opined that the study has no ethical encumbrance, hence ethical clearance is given to the above proposed study.

MEMBERS OF ETHICAL COMMITTEE

|1. |Dr. BHARTI. M | |Signature |

| |Principal |Chairperson | |

| |Government College of Nursing, | | |

| |Fort, Bangalore -02 | | |

| | | | |

|2. |Dr. SUVARNA. B. TALAWAR | | |

| |Head of the Department |Member | |

| |Obstetrics and Gynecological Nursing, Government College of | | |

| |Nursing, Fort, Bangalore -02 | | |

|3. |Smt. RENUKA.N | | |

| |Head of the Department |Member | |

| |Pediatric Nursing, | | |

| |Government College of Nursing, Fort, Bangalore -02 | | |

|4. |Mr. H .B. PRAKASH | | |

| |Head of the Department |Member | |

| |Community Health Nursing, | | |

| |Government College of Nursing, Fort, | | |

| |Bangalore -02 | | |

|5. |Mr. BASAVARAJU. G | | |

| |Head of the Department |Member | |

| |Medical surgical Nursing, | | |

| |Government College of Nursing, Fort, | | |

| |Bangalore -02 | | |

|6. |Mr. GANGADHAR.K.R | | |

| |Head of the Department |Member | |

| |Psychiatric Nursing, | | |

| |Government College of Nursing, Fort, Bangalore -02 | | |

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