Rajiv Gandhi University of Health Sciences Karnataka



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

| | | |

|1 |NAME OF THE CANDIDATE AND ADDRESS |Mr. HIMANSHU RAYAL |

| | |1ST YEAR M.SC.NURSING |

| | |ETCM COLLEGE OF NURSING, KOLAR-563101, KARNATAKA. |

| | | |

|2 |NAME OF THE INSTITUTION |ETCM COLLEGE OF NURSING, KOLAR-563101 |

|3 |COURSE OF STUDY AND SUBJECT |MASTER OF SCIENCE IN NURSING |

| | |MEDICAL SURGICAL NURSING |

|4 |DATE OF ADMISSION TO COURSE | |

| | |15/10/2011 |

|5 |TITLE OF THE TOPIC |“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING THE RISK |

| | |FACTORS AND PREVENT IVE MEASURES OF VARICOSE VEINS AMONG FINAL YEAR NURSING STUDENTS|

| | |IN SELECTED INSTITUTIONS AT KOLAR.” |

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY:

“I have two doctors, my left leg and my right”.

~G.M. Trevelyan

Standing is a daily activity for us but standing for hours on a daily basis can cause several body complaints. Security guards, sales persons, teachers, traffic enforcers, nurses are people who have jobs that require prolonged standing in the performance of their duties. Prolonged standing causes muscles strain at the same time blood remains in the legs and feet and cannot properly circulate. This results in inflammation of the veins and over time, this can progress to varicose veins. The veins become dilated and this will prevent further circulation of the blood going to the heart.1

The term varicose derives from the Latin ‘varix’, which means twisted. A varicose vein is usually tortuous and dilated. Under normal circumstances, blood collected from superficial venous capillaries is directed upward and inward via one-way valves into superficial veins. These in turn drain via perforator veins, which pass through muscle fascia into deeper veins buried under the fascia. Leakage in a valve caused retrograde flow back into the vein. Unlike deep veins which are thick-walled and confined by fascia, superficial veins cannot withstand high pressure and eventually become dilated and tortuous. The failure of one valve puts pressure on its neighbours and may result in retrograde flow, and hence varicosity, of the entire local superficial venous network. The superficial veins in the legs are normally involved, as these are most likely to come under hydrostatic pressure due to gravity.2

According to one estimate prevalence of varicose vein vary based on population, selection criteria, disease definition, and imaging techniques. Generally, prevalence rates are higher in industrialized countries and in more developed regions. Prevalence of visible varicose veins in the Western population older than 15 years of age is 10% to 15% for men and 20% to 25% in women. Prevalence rates in the US are 15% (range from 7% to 40%) in men and 27.7% (25% to 32%) in women. Visible varicose veins are more prevalent in Hispanic people (26.3%) and less prevalent in Asian people (18.7%). The prevalence of varicose veins increases with age. In 1 study, 40-year-olds had a prevalence of 22%, 50-year-olds a prevalence of 35%, and 60-year-olds a prevalence of 41%. A genetic link exists, and the risk of varicose veins developing if both parents are affected is 90%; 62% risk if 1 parent is affected and female offspring; 25% risk if 1 parent is affected and male offspring; and if no parent is affected, the risk is 20%.3

According to one estimate, 15 to 20 per cent of the population in India is suffering from varicose vein disease these days. Women suffer from this disease four times more than men. Today a lot of occupations and professions have sprung up where a person is required to either constantly stand up for a long time or made to sit with legs hanging down for a considerable time. Computer professionals, Nurses, Receptionists, Security guards, Traffic policemen, Salesmen, Teachers and persons doing Desk jobs are the worst sufferers of Varicose veins.4

The prevalence and risk factors of varicose veins in Japan were investigated in 541 Japanese women. Varicose veins were defined as any dilated, tortuous, and elongated veins of the lower extremity and classified into four types. The total prevalence rate was 45%. Saphenous type was observed in 22%, segment type in 35%, reticular type in 28%, and web type in 16%. Varicose veins in Japan seem to be less common than in the United States and Europe but more prevalent than in Africa. Concerning risk factors for varices, age, sex, heredity, and childbirth were related to the incidence of varicosities, as reported by others. However, these risk factors were shown to differ according to type of varicose veins.5

According to experts in vascular diseases, three to five per cent of the population suffers from severe venous problems. In India varicose veins affect 1 out of 2 people over age 50, whose occupation requires prolonged standing. In Bangalore 3-5% of population suffers from venous problems, 10% of population is having varicose vein.6

A cross sectional study was done to know the prevalence of varicose vein in Karnataka. Total numbers of 3402 patients were examined for oral and other varices. Oral varices were much more common than varicosities of other veins. Varices were found to increase with age. Overall prevalence rate was 59.3 per 1000. This rate was highest in the about 60 years age group being 329.94 per 1000. The study shows that old age people are more prone to get varicose vein compare to younger.7

The causes of varicose and spider veins are not entirely understood. In some instances, the absence or weakness of valves in the veins may cause the poor venous circulation (blood flow in the veins) and lead to varicose veins. Valves inside veins normally act to ensure that blood in the veins does not go the wrong direction (or backwards) away from the large (deep) veins and the heart. In other cases, weaknesses in the vein walls may cause the pooling of the blood. The walls of the blood vessels can become weaker and less competent than normal, causing the volume of blood in the veins to increase and leading to varicose veins. Less commonly, varicose veins are caused by such diseases as, phlebitis, blood clots or any obstruction to blood flow in the veins, or congenital abnormalities of the veins. Some of the common symptoms of varicose vein include, aching, cramping, itching, swelling, and fatigue with complain of a dull ache and pressure sensation from varicose veins.8

Medical measures which are used to prevent the further worsening of varicose veins are Self-care - such as exercising, losing weight, not wearing tight clothes, elevating your legs, and avoiding long periods of standing or sitting. Wearing compression stockings is often the first approach to try before moving on to other treatments. Compression stockings are worn all day. They steadily squeeze legs, helping veins and leg muscles move blood more efficiently. Additional treatments for more severe varicose veins are Sclerotherapy, Vein stripping, Ambulatory phlebectomy, Endoscopic vein surgery etc.9

Surgical measures which can be utilized to treat varicose veins are; Sapheno-femoral ligation, Stripping of long saphenous vein, Multiple avulsions, Sapheno-popliteal ligation, Perforator ligation, Redo-groin surgery etc. There may be some possible complications of which patients must be warned. Common complications include minor hemorrhage, hematomas and wound problems (infection, lymph leak. Rare complications include direct injuries to underlying structures (deep veins, arteries and major nerves), permanent lymphoedema and thromboembolism.10

A descriptive study was conducted in USA to find out Mechanisms of varicose vein formation valve dysfunction and wall dilation. Varicose veins are a common venous disease of the lower extremity. In varicose veins, there are reflux and incompetent valves as well as vein wall dilation. Primary structural changes in the valves may make them 'leaky', with progressive reflux causing secondary changes in the vein wall. Alternatively, or concurrently, the valves may become incompetent secondary to structural abnormalities and focal dilation in vein wall segments near the valve junctions, and the reflux ensues as an epiphenomenon. The increase in venous pressure will leads to further venous dilation. Thus, vein wall dilation appears to precede valve dysfunction, and the MMP activation and superimposed inflammation and fibrosis would then lead to chronic and progressive venous insufficiency and varicose vein formation.11

From the above studies and statistics it is clear that varicose veins are increasing worldwide. Since the final year nursing students are the future nurses they will occupy themselves in many fields of occupation and will spend most of the time standing during their working hours. so they are prone to get lower limb symptoms like itchiness, cramps, burning sensation, pain especially when standing. They result in superficial swollen veins, which later develop to varicose veins. So there is a need to educate the final year nursing students regarding this condition in order to prevent it. This urged the investigator to take up the present study with an intention to provide Structured teaching programme on knowledge regarding risk factors and preventive measures of varicose veins.

6.2 REVIEW OF LITERATURE

Review of literature is the task of reviewing literature which involves the identification, selection, critical analysis and reporting of existing information on the topic of interest. It provides the bases to locate the data, new ideas that need to be included in the present study .It helps the researcher to find the accurate data that could be used for supporting the present finding and drawing conclusion.

The review of literature is presented under the following heading:

6.2.1 Review of literature related to risk factors and preventive measures of varicose vein.

6.2.2 Review of literature related to effectiveness of structured teaching programme.

6.2.1 Review of literature related to risk factors and preventive measures of varicose vein:

A prospective randomized study was conducted on Prolonged standing at work and hospitalization due to varicose veins among the Danish population with representative random sample of 9653 working age adults interviewed by telephone (response rate 90%).Reported that respondents (2939 were men’s and 2708 were women’s). Risk ratios for VV were estimated by log-linear Poisson regression models separately for men and women with adjustment for smoking status, body mass index (BMI), heavy lifting, and, for females only, number of children at baseline During 12 years of follow up, 40 hospitalizations due to VV were observed among the men and 71 among the women. For employees with jobs that require prolonged standing or walking compared to all other employees, the relative risk was 1.75 (95% CI 0.92 to 3.34) for men and 1.82 (95% CI 1.12 to 2.95) for women. The pooled estimate of the relative risk was 1.78 (95% CI 1.19 to 2.68). The etiological fraction of prolonged standing or walking at work was estimated as 22.5% for men and 22.6% for women. This prospective study confirms that prolonged standing at work constitutes an excess risk of hospital treatment due to varicose veins and accounts for more than one fifth of all cases of working age.12

A cross-sectional study was conducted in Finland to assess whether smoking, alcohol drinking and dietary factors are linked with varicose veins, A middle-aged general population of 4903 was studied, and prevalence rates at entry and five-year incidence of varicose veins were assessed. Lifestyle habits were recorded at entry and at the end of the follow-up. New varicose veins were significantly more common in individuals with regular alcohol intake, incidence odds ratio (OR) 1.5 (95% confidence interval [CI]: 1.05-2.3) in a multivariate analysis (of 2202 individuals). The association was particularly strong in women. Smokers had a higher incidence of varicose veins compared with non-smokers, OR 1.3 (95% CI: 0.9-1.8). Having daily meals of meat implied less new varicose veins than having 0-2 weekly meals of meat, and was concluded Alcohol was likely to increase the risk of varicose veins in women and smoking in both genders.13

A cross-sectional community based study was conducted to the issue of working conditions and their health ramifications in Israel with special emphasis on occupations requiring prolonged standing. This review article discusses the physiological and medical aspects of prolonged standing in the workplace. Searching the literature, 19 studies were found which specifically examined the effect of prolonged standing versus prolonged sitting at work. Most of these studies suggested that prolonged standing may result in the development and aggravation of chronic venous insufficiency. The conclusion states that there is an association between prolonged standing and venous insufficiency. It was found to be more pronounced in women than in men.14

A cross sectional study was conducted on the effect of standing in the workplace and the development of chronic venous insufficiency of the superficial venous system in the legs. Revealed that mechanical hydrostatic pressure generated by long periods of standing at the workplace is a major etiologic factor in the development of chronic venous insufficiency of the superficial venous system in the legs. Both varicose veins and working while standing are very common, so it is not surprising to find a high percentage of varicose veins amongst those who work standing up. Ambulatory venous pressure while sitting is about 60-80 mm of water, as opposed to 20 mm while walking, and the number is only slightly higher (about 100) while standing. Recent work by J. Bergan and his group demonstrated (in laboratory animals) that increased venous pressure will lead to the disappearance of the valve leaflets. This can explain the high frequency of venous reflux amongst young people (13%) and the even higher frequency (35%) found amongst the elderly population. It has been explained that hydrostatic pressure along with muscle pump failure and venous out flow obstruction is an important contributor of the increased venous pressure. thus it concludes that standing as an important and significant factor in the development of this complex disease process.15

An experimental study was conducted on the Effects of Graduated Compression Stockings on Cutaneous Surface Pressure along the Path of Main Superficial Veins of lower limb. The study participants were instructed to wear each stocking type in the following 7 static postures: standing; standing with knee flexion; tip-toe standing; sitting with 90-degree knee flexion, sitting with leg straight; supine resting with slight elevation of the heel; and supine with knee flexion. The result was tested locations, body postures, and types of GCS significantly influenced the cutaneous pressure recorded along the main superficial veins The pressure gradients along the SSV were enhanced when participants were in the standing position; however, the pressures along SSV were significantly influenced by the various body postures. The flexion exercise of joints and muscle activity of the lower limbs provided more support and compression on the superficial venous system Proper lower limb exercises when wearing GCSs should still be recommended.16

6.2.2 Review of literature related to effectiveness of structured teaching programme:

An experimental study with pretest - posttest control group design was carried out in four selected schools with similar settings in Dharan town of Nepal. Structured teaching program consisting of information on human reproductive system was used as a tool of investigation for the experimental group, whereas conventional teaching method was used for the control group. A total of 200 Adolescent school students were included in this study. The mean (+/-SD) pretest score of the experimental group on knowledge of reproductive health was 39.83 (+/- 16.89) and of the control group was 39.47(+/- 0.08). The same of experimental group after administration of the structured teaching program (84.60+/-10.60) and of the control group with conventional teaching method (43.93+/-10.08) was statistically significant (p ................
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