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RAJIV GANDHI UNVERSITY OF HELATH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |: |ASHA ABRAHAM |

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

| | | |INDIAN COLLEGE OF NURSING, TILAK NAGAR, BYPASS ROAD, |

| | | |CANTONMENT, |

| | | |BELLARY – 583104 |

|2. |NAME OF THE INSTITUTION |: |INDIAN COLLEGE OF NURSING, TILAKNAGAR, BYPASS ROAD, |

| | | |CANTONMENT, |

| | | |BELLARY – 583104 |

|3. |COURSE OF STUDY AND SUBJECT |: |DEGREE OF MASTER OF NURSING , |

| | | |MEDICAL SURGICAL NURSING |

|4. |DATE OF ADMISSION TO COURSE |: |15-06-2012 |

|5. |TITLE OF THE TOPIC |: |“A STUDY TO EVALUATE THE EFFECTIVENESSOF STRUCTURED TEACHING|

| | | |PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF DEEP VEIN |

| | | |THROMBOSIS AMONG ORTHOPAEDIC PATIENTS IN SELECTED HOSPITALS |

| | | |AT BELLARY KARNATAKA.” |

6. BRIEF RESUME THE INTENDED WORK

INTRODUCTION:

The goal of medicines is to promote, preserve and restore health. These goals are embodied in the word prevention. Successful prevention depends upon knowledge of causation, identification of risk factors, groups, availability of prophylaxis, early detection and treatment measures. Early detection and treatment are the main intervention of disease control 1.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a single disease entity, namely, venous thromboembolism (VTE). The earliest known reference to peripheral venous disease is found on the Eber papyrus, which dates from 1550 BC and documents the potentially fatal hemorrhage that may ensue from surgery on varicose veins. In 1644, Schenk first observed venous thrombosis when he described an occlusion in the inferior vena cava. In 1846, Virchow recognized the association between venous thrombosis in the legs and PE. DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening PE 2.

VTE is the most frequent serious complication following hip and knee replacement surgery. It is the most common cause for re-hospitalization in this patient group. The most common type of VTE is deep vein thrombosis (DVT), occurring in veins deep within the muscles of the leg and in the pelvis. Some of the recognized factors that increase the risk of DVT include major surgery (such as hip or knee replacement), cancer, inherited abnormalities in the blood-borne proteins involved in coagulation, and hospitalization for a major medical illness 3. Deep vein thrombosis (DVT) is a silent killer. It is a serious threat to recovery from surgery and is the third most common vascular disease, after ischemic heart disease and stroke. DVT is mostly preventable and national and international consensus groups on venous thrombo prophylaxis have all recommended that hospital patients should be assessed for clinical risk factors and an overall risk of thromboembolism. Patients should then receive prophylaxis according to their risk categories4. The complication of deep vein thrombosis includes: thromboembolism, embolism, pulmonary embolism, post-phlebitic syndrome and pulmonary thromboembolism. Thromboembolism remains a major preventable cause of postoperative mortality and morbidity in the Western world; very little attention has been given to this condition in the Indian patients 5.

Orthopedic patients will have impairment in mobility results from prescribed restriction of movement in the form of bed rest, physical restriction of movement or impairment of motor skeletal function. In orthopedic patients the treatment of choice following surgery or injury are varying in rest and motion. The effect of immobilization leads to many complications related to different systems in our body. The patients with acute medical condition in hospital may be for few days but patients with orthopedic condition may be for many days. When patients are immobilized following trauma there is high risk for deep vein thrombosis and post operative stiffness due to limited range of motion 6. The risk of deep vein thrombosis is increased in a number of circumstances. The surgery heightens the body's tendency for coagulation or clotting. In addition, when the leg is manipulated during surgery there may be irritation to the walls of the major blood vessels in the leg. Finally, during and after surgery the lower extremity is not used as much and, therefore, the normal blood flow rate is decreased. The leg muscles usually help venous blood return to the heart when they are used.

Prevention of deep vein thrombosis is very important among orthopedic clients. Many healthcare providers are under the false impression that this life-threatening illness is not a problem in their hospital or among their patients. All patients who are admitted should be screened for their risk for deep vein thrombosis. Some common risk factors for deep vein thrombosis are orthopedic surgery, pelvic surgery, prolonged surgery, immobilization, coagulation disorders, cancer, sepsis etc 7. Based on the presence or absence of these risk factors, which carry varying weight age, patients can be stratified into high, moderate and low risk for deep vein thrombosis. Those at high or very high risk should receive prophylaxis—both mechanical and pharmacological Mechanical measures such as elastic graduated compression stockings, intermittent pneumatic compression and venous foot pumps should be used in bed-ridden patients and those undergoing surgery .Pharmacological prophylaxis involves the use of heparin in low doses which are associated with no or little increase in the risk of clinically important bleeding and do not warrant monitoring the coagulation profile. It should be continued for at least seven days or until the patient is ambulant. Patients at high risk of bleeding and those with contraindications to heparin should receive mechanical prophylaxis only.

Deep vein thrombosis prophylaxis is effective—it reduces the risk of deep vein thrombosis by two-thirds. Deep vein thrombosis prophylaxis has been identified as the number one measure to improve the safety of hospitalized patient. Most mechanical methods of thrombo prophylaxis aim to reduce venous stasis and thus the propensity for clot formation. They found that mechanical methods can be used in patients at low risk of venous thromboembolism and in those with contraindication to pharmacologic therapy 8.

6.1 NEED FOR STUDY:

Deep vein thrombosis or DVT is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and lumps together. Most deep vein blood clots occur in the lower leg or thigh. They can also occur in other parts of body. Blood clots in the thighs are more likely to break off and cause PE than blood clots in the lower legs or other parts of the body. Major orthopaedic trauma (which includes spine, hip and pelvic-acetabular fractures; multiple long bone fractures of the lower extremity) is a compelling risk factor for developing of VTE and its potential sequellae pulmonary embolism. The incidence of VTE and its complications is more in patients undergoing major orthopaedic surgery than in those undergoing other surgical procedures. Around 90 per cent of DVT incidence was in the proximal veins of the legs 9.

In United States more people die each year from Deep Vein Thrombosis than motor vehicle accidents, breast cancer, and AIDS etc. The APHA and the Centers for Disease Control and Prevention (CDC) convened 60 of the nation’s leading medical experts and patient advocates in Washington, D.C. in early 2003 10. DVT is one of the most prevalent medical problems today, with an annual incidence of 80 cases per 100,000. Each year in the United States, more than 200,000 people develop venous thrombosis; of those, 50,000 cases are complicated by PE. Lower-extremity DVT is the most common venous thrombosis, with a prevalence of 1 case per 1000 population. In addition, it is the underlying source of 90% of acute PEs, which cause 25,000 deaths per year in the United States (National Center for Health Statistics [NCHS], 2006).

This event, the Public Health Leadership Conference on Deep-Vein Thrombosis, brought into the spotlight the urgency for increased diligence related to prevention on the part of the healthcare community – as well as the need to raise awareness of DVT and its complications among the public 11.

In Canada it is reported that pulmonary embolism from DVT causes death of more than 1, 00,000 patients each year and it remains a leading cause of death 12. The Chinese literature found an increasing incidence of VTE among the Chinese population, and they placed the orthopaedic surgery of the lower limbs in the high risk group 13. Similarly among the Japanese population, the rate of incidence of VTE after arthroplasty surgeries was found to be increasing over the last four decades, though not equivalent to that in North America and Europe 14.

According to International Consensus Statements (1997; 2002). Incidence of DVT by patient groups comprises under specialities like general surgery is 25%, orthopedic surgery is 45-51%, urology is 9-32%, gynecological surgery is 14-22%, neurosurgery including strokes is 22-56%, multiple trauma is 50%, general medicine is 17% 15. A world wide survey conducted by WHO, 1999 showed that Deep Vein Thrombosis is a common disease with an average incidence rate of more than one per thousand. It is also lethal disease owing to pulmonary embolism and almost 25% of cases may have sudden death. Almost 30% of patient develop serious venous stasis syndrome within 10 years 16.

A prospective study was conducted to document the incidence of proximal deep vein thrombosis and pulmonary embolism in 58 consecutive Japanese patients undergoing total hip arthroplasty or total knee arthroplasty. Patients were routinely examined for proximal deep vein thrombosis by B-mode ultrasonography before and after surgery. Those patients who had ultrasonographic findings of deep vein thrombosis were also investigated for pulmonary embolism by ventilation-perfusion lung scan. The incidence of deep vein thrombosis after total hip arthroplasty and total knee arthroplasty were 9.1% and 4.0% respectively and the incidence of pulmonary embolism were 3.0% and 0%, respectively. There were no cases of fatal pulmonary embolism. The study concluded that the incidence of deep vein thrombosis and pulmonary embolism in Japanese patients may have increased over the last few decades 17.

Thromboprophylaxis after trauma is still not widely practiced in India, the cause of which can be attributed to lack of awareness, underestimation of the problem, fear about thromboprophylaxis complications and most importantly the popular belief among surgeons that Indian have low incidence of DVT contrary to previous belief, most of the recent studies show increasing incidence of VTE among Indian and Asian population and it is almost equivalent to that reported in Caucasians 18.

The survey conducted by INDORSE (Indian observational survey on prevalence of venous thromboembolism ‘VTE’ risk and prophylaxis in the acute care hospital unit) in 2009 and analyzed later on in the year 2010 showed that of the 7481 hospitalized patients from 46 hospitals across 11 states in India, 67 percent were at the risk of Deep-Vein Thrombosis (DVT) and only 19 percent of these patients were given any kind of prophylaxis (prevention) 19.Data summarized from the National Institute of Health panel shows the overall incidence of Deep Vein Thrombosis after elective hip surgery is 45 to 70 percent; clinical pulmonary embolism is about 20 percent and of fatal pulmonary embolism is 1 to 4 percent 20. The incidence of deep vein thrombosis in India as reported is one percent of the adult population after the age of 40 and is 15 to 20% in hospitalized patient and the risk of deep vein thrombosis is 50% in patients undergoing orthopaedic surgery particularly involving the hip and knee. It is 40% in those patients undergoing abdominal or thoracic surgery, 1/100 that develop deep vein thrombosis dies, usually from the blood clot traveled to the lungs which is called as pulmonary embolism.

A study conducted to determine the incidence of DVT in Indian patients undergoing major limb surgery. Incidence was 60% among patients undergoing total knee arthoplasty 21.

Incidence of Deep Vein Thrombosis in India and globally following surgical interventions varies and ranges from 59 per cent of post-hip surgeries and 29 per cent of post-knee surgeries, as per Dr.Ashish Anand, consultant orthopedic surgeon, Wockhardt Hospital 22. An autopsy study on 1000 medical patients at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh revealed that pulmonary embolism was present in 159 (16%) of 1000 patients who died in the hospital—it was a fatal embolus in 36 and was a major contributor to death in 90 patients; in 30 patients, the embolus was an incidental finding at autopsy as death occurred due to some other cause 23.

The Autar DVT scale (1994, 1996b) was developed to identify patients at risk, so that the recommended prophylaxis could be promptly initiated. The Autar DVT scale (1994) comprised seven subscales: increasing age, build and body mass index (BMI), immobility, special DVT risk, trauma, surgery and high risk disease 24.

Deep vein thrombosis (DVT) poses a threat to hospitalized client's recovery. It is a preventable disease; the cost of its treatment is considerably more than that of its preventive measures. Accurate DVT risk assessment facilitates the application of the most appropriate venous thrombo prophylaxis. The rapid increase in magnitude of complications needs the attention of health professionals. In order to reduce the immediate and long term dangers of DVT the investigator feels that early detection and prevention is very necessary. Hence the investigator planned to impart the knowledge by conducting structured teaching programme to orthopaedic patients.

6.2 REVIEW OF LITERATURE:

Review of literature is a key step in research process. Review of literature refers to an extensive, exhaustive and systemic examination of publications relevant to research project 25.

Section 1: Studies related to knowledge on deep vein thrombosis.

Section 2: Studies related to prevention of deep vein thrombosis.

Section 1: Studies related to knowledge on deep vein thrombosis.

A systematic review was conducted to assess the symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models. The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies. The study concluded that using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge 26.

A Systematic review and meta-analysis on the rate of postoperative venous thromboembolism was conducted in orthopaedic surgery in Asian patients without thromboprophylaxis. The pooled proportion was back-calculated by Freeman-Tukey variant transformation, using a random-effects model. Twenty-two studies (total population 2454) published from 1979 to 2009 were included. Using venography, the pooled rates of all-site, proximal, distal and isolated distal DVT were 31·7, 8·9, 22·5 and 18·8 per cent respectively. With duplex ultrasonography, the respective rates were 9·4, 5·9, 5·9 and 5·8 per cent. After THA or HFS, using venography, the pooled rates of all-site and proximal DVT were 25·8 and 9·6 per cent; with ultrasonography, the respective rates were 10·8 and 7·2 per cent. In TKA groups, using venography, the pooled rates of all-site and proximal DVT were 42·5 and 8·7 per cent; with ultrasonography, the respective rates were 9·5 and 5·2 per cent. The overall pooled rates of symptomatic DVT and symptomatic pulmonary embolism (PE) were 4·5 and 0·6 per cent. No patient died from PE (pooled rate 0·2 per cent).The study concluded that none of these Asian patients undergoing orthopaedic surgery died from VTE. Pooled rates of proximal and symptomatic DVT were lower than in Western reports 27.

A prospective study of risk factor profile and incidence of deep venous thrombosis among medically-ill hospitalized patients at a tertiary care hospital in AIIMS New Delhi, India. All adults admitted to the medical wards and intensive care unit with level 1 or 2 mobility over a period of two years (July 2006 to July 2008) at the AIIMS, New Delhi, were prospectively studied. Patients having DVT at admission or an anticipated hospital stay less than 48 h were excluded. The presence of clinical risk factors for DVT was recorded and laboratory evaluation was done for hypercoagulable state. A routine surveillance venous compression Doppler ultrasonography was performed 12 ± 8 days after hospital admission. Of the 163 patients, 77 (47%) had more than one risk factor for DVT. Five (3%) patients developed DVT; none of them had symptomatic DVT. None of these patients received anticoagulation prior to the development of DVT. The mean age of those who developed DVT was 40 ± 13 (25-50) yr; two of five were male. The incidence rate of DVT was 2.7 per 1000 person-days of hospital stay [95% confidence interval (CI): 0.87 to 6.27]. None of the factors was found to be significantly associated with the risk of DVT. In the setting, although many hospitalized medically-ill patients had risk factors for DVT; the absolute risk of DVT was low compared to the western population but clearly elevated compared to non hospitalized patients. Large studies from India are required to confirm the findings 28.

A study was conducted on trends in prevalence of deep venous thrombosis among hospitalized patients in an Asian institution. Venous thromboembolism (VTE) has long been considered a disease of secondary importance among Asians because of its perceived low prevalence. They studied the prevalence and patterns of deep venous thrombosis (DVT) among hospitalized patients in our tertiary referral centre. Primary and secondary DVT prevalence among hospitalized patients was 0.453%, a significant rise from reported rates of 0.079% and 0.158% in 1989-1990 and 1996-1997, respectively. Malignancies and orthopaedic surgery were the most common risk factors for DVT. Further comparisons with the two earlier Singaporean studies showed no changes in the gender and ethnic background of patients but a higher proportion of elderly patients (>80 years) was recorded in the current study (11.7% vs. 7.0%, p = 0.04). Statistically significant increases were found in all medical and surgical disciplines except among obstetrics and gynecology patients. Orthopaedic patients had the highest increase in DVT rates between the 1989-1990 and 2002-2003 periods (0.082% vs. 0.96%, p ................
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