6BRIEF RESUME OF THE INTENDED WORK



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SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Miss. SOUMYA MAX

I YEAR M. Sc NURSING

MEDICAL SURGICAL NURSING

2009-2011

THE KARNATAKA COLLEGE OF NURSING

#12, KOGILU MAIN ROAD, YELAHANKA,

BANGALORE – 560064

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

| | | |

| | |Miss. SOUMYA MAX |

|1. |NAME OF THE CANDIDATE AND ADDRESS |I YEAR M.Sc NURSING |

| | |THE KARNATAKA COLLEGE OF NURSING |

| | |#12, KOGILU MAIN ROAD, YELAHANKA, BANGALORE-560064. |

| | | |

| | |THE KARNATAKA COLLEGE OF NURSING |

|2. |NAME OF THE INSTITUTION |#12, KOGILU MAIN ROAD, YELAHANKA, BANGALORE-560064. |

| | | |

|3. |COURSE OF THE STUDY AND SUBJECT |I YEAR M. Sc NURSING |

| | |MEDICAL SURGICAL NURSING |

| | | |

|4. |DATE OF ADMISSION TO THE COURSE |15/06/2009 |

| | | |

| | |.A STUDY TO ASSESS THE EFFECTIVENESS OF SELF |

| | |INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING |

| | |PREVENTION OF LYMPHEDEMA AMONG PATIENTS WHO ARE POSTED |

|5. |TITLE OF THE STUDY |FOR MASTECTOMY AT SELECTED HOSPITALS, BANGALORE. |

6 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Work joyfully and peacefully, knowing that right thoughts and rights efforts will inevitably bring about right results.”

James Allen

Breast disorders are a significant health concern for women. Though most breast pain is of a benign nature, in a woman’s life there is one in several chances that she will be diagnosed with breast cancer.21 Whether benign or malignant, intense feelings of shock, fear and denial often accompany the initial discovery of a lump or change in the breast. These feelings can be associated both with the fear of death and with the possible loss of a breast.11 Several factors must be taken into consideration when determining the prognosis of a patient with breast cancer. The two most important factors are tumor size and whether the tumor has spread to the lymph nodes under the arm (axilla). 14

Presently a wide range of treatment options are available to both the patients and the health care providers attempting to make critical decisions about what treatment to select. Mastectomy (surgical removal of a breast) is one of the standards of care.11 Throughout history, the female breast has been regarded as a symbol of beauty, feminity, sexuality and motherhood. The potential loss of a breast or a part of a breast may be devastating for many women because of significant psychologic, social, sexual and body image implications associated with it. The surgeries for breast cancer are frequently encountered with many complications. The most common complications after mastectomy is lymphedema.49

Lymphedema is the chronic swelling or feeling of tightness in the arm or hand due to an accumulation of lymphatic fluid in the soft tissue of the arm. It occurs as a result of the excision or radiation of lymphnodes.17 When the axillary nodes cannot return lymph fluid to the central circulation, the fluid accumulates in the arm, causing obstructive pressure on the veins and venous return. The patient may experience heaviness, pain, impaired motor function in the arm, numbness and paresthesia of the fingers as a result from lymphedema. Although lymphedema is not always preventable, it can be controlled somewhat after surgery or radiation. 49

Once lymphedema develops, it tends to be chronic, so preventive strategies are vital. After mastectomy, the patient is taught hand and arm care to prevent injury or trauma to the affected extremity, thus decreasing the likelihood for lymphedema development. The patient is instructed to follow these guidelines for the rest of her life. She is also instructed to contact the physician or a nurse immediately if she suspects that she has lymphedema, because early intervention provides the best chance for control. If allowed to progress without treatment, the swelling can become more difficult to manage.14

Nurses are spending more time with the patients than any other member of the health care team. A nurse has a better opportunity to know about the patient, her physical and psychological illness. A nurse also plays a vital role in teaching clients regarding prevention of lymphedema.

6.1 NEED FOR THE STUDY

Behind every problem, there is a need for the study to find out a solution in order to solve that problem.

Breast cancer cases at present are estimated to reach 1.2 million worldwide. The incidence of breast cancer in India is on the rise and is rapidly becoming the number one cancer in females, moving the cervical cancer to the second spot. The rise is being documented mainly in the metros but it can be safely said that many cases in rural areas go unnoticed. It is reported that 1 in 22 women in India is likely to suffer from breast cancer during her lifetime, while the figure is definitely more in America with 1 in 8 being a victim of this deadly cancer. 37

A 2005 study conducted by the International Association of Cancer Research based in Lyon and France, projected that there would be 250,000 cases of breast cancer in India by 2015, a 3% increase per year. Currently India reports roughly 100,000 new cases annually. There are also significant regional variations in incidence rates. The overall rate is now estimated at 80 new cases per 100,000 population per year, but in Delhi that rate is pegged at 146 per 100,000.By contrast the national rate was 23.5 in 1990.50 There are several types of lymphedema, the acute, temporary and mild types of lymphedema, occurs within a few days after surgery and lasts a short period of time. 4

The acute and more painful type of lymphedema can occur at about 4-6 weeks following surgery. However, the most common type of lymphedema is slow and painless and may occur 18-24 months after surgery.4 When the lymphatic vessels are removed, the lymph cannot be drained properly. It accumulates and causes swelling. About 40% of women can experience mild to moderate lymphedema after mastectomy. Most of the time, this goes away with proper exercises. In about 5% of the cases it becomes a chronic problem and you will need further consultation and treatment to deal with the problem7.

A study reported in the journal of clinical oncology says that, breast cancer survivors who develop lymphedema report a lower quality of life and higher levels of anxiety and depression. Previous research has shown that up to 50% of breast cancer survivors develop lymphedema with 32% having persistent swelling three years after surgery9. A pubmed search was conducted through January 2008 to locate articles on lymphedema treatment factors after breast cancer diagnosis that, it concluded that, mastectomy, extent of axillary node dissection, radiation therapy and presence of positive nodes increased risk of developing arm lymphedema after mastectomy.38

The incidence of upper extremity lymphedema varies from 2%-40% in women with breast cancer who have been treated with surgery, radiation or both.5 Lymphedema occurs in about 10%-30% of patients who undergo axillary lymphnode dissection and in about 0%-7% of patients who have sentinel lymphnode biopsy. The risk factors of lymphedema includes increasing age, obesity, presence of extensive axillary disease, radiation, treatment an injury or infection to the extremity34.

With the transformation of breast cancer into a chronic disease, there is a greater emphasis on quality of life and long term post treatment sequelae. Lymphedema can cause severe physical and psychological morbidity in breast cancer survivors and measurable reduction in quality of life in respect to functional, emotional, physical and social wellbeing.22Sammarco A (2004) in his study on psychological stages and quality of life of breast cancer survivors stated that, although lymphedema is not always preventable, it can be controlled somewhat after surgery or radiation.49

Petrek J., Pressman P etal (2000) suggested the measures which is used to prevent lymphedema after axillary lymph node dissection must be practiced by the nurse and taught to the woman. The patient must be aware that, she is at risk for developing lymphedema for the rest of her life. Ahmed etal (2006) examined the effects of supervised upper an lower body weight training on the incidence and symptoms of lymphedema in 45 breast cancer survivors and recommends that exercises helps in preventing lymphedema. 32

Schmitz etal (2009) assessed the safety of a graduated exercise programme on 295 survivors with breast cancer and recommends that individuals who are at risk for lymphedema or who have lymphedema can participate in exercise, provided it is progressed slowly and their limbs are assessed for any signs of increased or developing swelling throughout the programme and the programme is modified accordingly. The key is proper evaluation and assessment for signs of swelling, tightness or skin and tissue changes before during and after exercises.35 A woman undergoing mastectomy needs good nursing care, emotional support and extensive education on post operative care.37

Education of patients regarding the importance of prevention of lymphedema is the need of the hour; primary prevention of lymphedema is relatively simple and should be practical as established part of good medical care. Efforts to ensure primary prevention of lymphedema should focus on the education of the patients on importance of measures to avoid occurrence of lymphedema.

2. REVIEW OF LITERATURE

The review of literature is an integral component of any research. It enhances the depth of knowledge and provides a clear understanding regarding a topic. It refers to an extensive, exhaustive and systematic examination of publications relevant to the research project2. This chapter presents a review of selected literature relevant to the study which is discussed under the following headings.

1. Literature related to incidence of lymphedema after mastectomy.

2. Literature related to prevention of lymphedema after mastectomy.

3. Literature related to assessment of knowledge on prevention of lymphedema among patients undergoing mastectomy.

4. Literature related to effectiveness of self instructional module on prevention

of lymphedema among patients undergoing mastectomy.

1. Literature related to incidence of lymphedema after mastectomy.

Park J. etal (2008) conducted a study on incidence and risk factors of breast cancer lymphedema among women with breast cancer. A descriptive design with structured questionnaire as a tool was used. It included a sample size of 450 patients who underwent mastectomy. The findings of the study revealed that 24.9% had developed lymphedema and the risk factors were higher staging, modified radical mastectomy, and had axillarynode dissection, received axillary radiotherapy and body mass index greater than 25 kg /m2.30

Panobianco M.S.etal (2008) studied the incidence of lymphedema in the first three months after mastectomy. It included 17 samples who underwent mastectomy. The data was collected by means of postoperative follow-up .Edema was detected in 11 women, 9 of which were in mild level and 2 in moderate level. The findings revealed the importance of patient guidance aiming at edema prevention.44

Sandra C. Hayes etal (2007) studied lymphedema after breast cancer: incidence, risk factors and effect on upper body function. It included a sample of 287 patients who underwent mastectomy who were evaluated on 5 occasions using bioimpedence spectroscopy, upper body functions was assessed using the validated disability of the arm, shoulder and hand questionnaire. In the findings, 335 of the sample were classified as having lymphedema; of these 40% had long term lymphedema.33

Clark B. etal (2005) conducted a study on incidence and risk of arm edema following treatment for breast cancer: a three year follow up study. Prospective observation study was carried out on 251 samples who had surgical treatment for breast cancer. Measurements of limbs were carried out preoperatively and at regular intervals postoperatively. According to the researcher 39 patients(20.7%) had developed lymphedema.18

Geller B.M. etal (2003) conducted a study on incidence of lymphedema and associated risk factors in women with invasive breast cancer following surgery. The data was baseline and follow up interview, sample was 145. The findings of the study stated 38% incidence of lymphedema, the risk factors being age above 50, axillary node dissection, received chemotherapy, worked outside the home and had a high household income.20

Mary Ann Kosir etal (2000) studied the surgical outcomes after breast cancer surgery: measuring acute lymphedema. The purpose was to measure the onset and incidence of lymphedema among breast cancer survivors using strict criteria for limb evaluation. Thirty women undergoing breast cancer surgery were included. The findings of study revealed that overall 35% of the sample experienced lymphedema by 3 months.24

2. Literature related to prevention of lymphedema after mastectomy.

Boccardo F.M. etal (2009) conducted a study on prospective evaluation of a preventive protocol for lymphedema following surgery for breast cancer. 55 women who had modified radical mastectomy were included. The preventive protocol included exercises using principles for lymphedema risk minimization. The findings of the study suggested that prophylactic strategies appear to reduce the development of secondary lymphedma and alter its progression.16

Sager A., etal (2009) studied on physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow up. A sample of 204 was included. The patients underwent rehabilitation programme for six months which included moderate resistance exercise. The findings suggested that patients should be encouraged to maintain physical activity without restrictions.47

Cinar N. etal (2008) studied the effectiveness of early rehabilitation in patients with modified radical mastectomy. Fifty-seven patients were included who underwent 15 sessions of individual rehabilitation programme. The findings stated that

early onset rehabilitation programme after modified radical mastectomy provides improvement in shoulder mobility and functional capacity without causing adverse effect in postoperative period.39

Box R. C. etal (2008) conducted a study on physiotherapy after breast cancer surgery: a randomized controlled study to minimize lymphedema. It included 65 women, who were randomly assigned under treatment group and control group. The treatment group underwent physiotherapy intervention programme. The incidence of lymphedema was 11% in treatment group compared to 30% in control group, which stated that these strategies appear to reduce the development of lymphedema and alter its progression.36

Lanck etal (2005) studied the effect of a whole body exercise programme on arm volume and arm circumference in women treated for breast cancer. It included a 20 week exercise programme on 16 samples and included exercises such as – seated row, bench press, latissimus dorsi muscle pull-down, rowing, triceps muscle extension, and biceps muscle curl. The findings of the study revealed that women treated for breast cancer should engage in exercises without fear of developing lymphedema.26

Kolden etal (2002) examined the feasibility, safety and benefits of a structured group exercise programme. The sample consisted of 40 women who had been surgically treated for breast cancer. They underwent a 16 week group exercise programme. The findings suggested that exercises reduce the development of lymphedema. 23

3. Literature related to assessment of knowledge on prevention of lymphedema among patients undergoing mastectomy.

Lee Y. M. etal (2008) conducted a study on lymphedema care of breast cancer patients in a breast cancer clinic: a survey on knowledge and health practice. 171 patients were included. The tool used was self administered questionnaire. The findings revealed that 82.5% of patients knew that they were at risk of developing lymphedema. However, the level of knowledge about preventive care in lymphedema was inadequate, with a mean score of 4.07 out of a full mark of 10.43

Rankinen, Sirkku, etal (2007) conducted a study to compare the surgical patients knowledge expectations at admission with knowledge they received during their hospital stay. A descriptive and comparative design was with a structured questionnaire was used on 237 samples. The findings stated that mastectomy patients received less knowledge than they felt they expected.45

Rolnick, Sharon, etal (2007) conducted a study on, what women wish they knew before prophylactic mastectomy? A study to assess the knowledge and health practice. They included 967 women and used a structured questionnaire. The findings suggested that more concerns (69%) were related to reconstruction, on the longevity, pain and numbness, prevention of lymphedema, scarring and reconstruction options.47

Lee Nelson etal (2002) studied the knowledge about preventing and managing lymphedema. A survey of 148 recently treated breast cancer patients was done. Awareness, current practice and intervention to practice was assessed. The findings suggested that the lymphedema prevention information is not getting to breast cancer survivors in a timely fashion and underscore the urgent need to develop and implement appropriate educational strategies.42

Pasket E.D. etal (2000) conducted a study on lymphedema: knowledge, treatment and impact among breast cancer survivors. Forty women with breast cancer and 10 physicians who treated them were included. Overall, women knew little to nothing about lymphedema before they developed it. Most physicians reported that they did not routinely counsel then or provide written information on lymphedema prevention to their patients. This finding has implications for interventions aimed at educating women and provides knowledge about lymphedema.31

Coward D. D. etal (1999) conducted a study on lymphedema prevention and management knowledge in women treated for breast cancer. A descriptive correlation survey was used. 72 women with breast cancer were included. A survey instrument, the lymphedema knowledge scale was used to collect data. The findings revealed that, although many respondents were aware of their risk of lymphedema, their knowledge and use of prevention strategies was poor.38

4. Literature related to effectiveness of self instructional module on prevention of lymphedema among patients undergoing mastectomy.

Ana Maria de Almeida etal (2009) conducted a study on pretreatment lymphedema education and identified educational resources in breast cancer patients. The subjects were 33 women with mastectomies and 16 members of health care team. Discussion circles and structured questionnaire were used for data collection. According to the researcher, self instructional module must cover the characterization of the lymphatic system and lymphedema detection, control actions, risk factors and the importance of self care.15

Fu Mei R etal (2008) conducted a study on breast cancer related lymphedema: information, symptoms and risk reduction behaviors using self instructional module. The purpose was to explore the effects of providing lymphedema information on breast cancer survivors. Self instructional module was administered to 136 patients. A cross sectional design was used; data was collected through interviews, questionnaire and checklist. The findings of the study stated there was 75% increase in knowledge prevention of lymphedema by using self instructional module.19

Mathews Maria etal (2007) conducted a study on increasing public and provides knowledge of lymphedema: evaluation of the effectiveness of lymphedema road shows. Participants included 400 public and health care providers. The intervention included workshops and distribution of self instructional module. The participants completed pre-workshop and post-workshop surveys to determine if interventions changed their attitudes and knowledge of post cancer lymphedema prevention. The findings suggested that self instructional module increased the participant’s knowledge and practice regarding prevention of lymphedema, the percentage of increase being 59% .28

Kilgour R. D. etal (2006) studied the effectiveness of self administered home based rehabilitation programme with the help of self instructional module for prevention of lymphedema among women following modified radical mastectomy. 57 samples were included, women were instructed the guidelines of rehabilitation programme by using self instructional module. The result suggested that there was an overall increase in the knowledge after the administration of self instructional module on prevention of lymphedema.41

Rider S. H. etal (1998) conducted a study to compare patient’s recall of lymphedma pre-treatment education between women with and without breast cancer related lymphedema. 149 breast cancer survivors were included; data collection was done through questionnaire. The result suggested that individuals with lymphedema consistently recalled receiving less education and a decline in recalled risk reduction behavior. 69% of patients suggested the educational material needed as self instructional module. 46

Feather B. L., Wainstock J. M (1998), studied about post mastectomy educational needs and social support .The purpose of the study was to include the educational needs of the patient in the self instructional module. The study included 933 samples, questionnaire on educational needs and social support was administered. Respondents ranked their educational needs in 6 categories from greatest to least important. 1. Information about breast cancer recurrence, 2. Prevention of lymphedema, 3. Personal hygiene and exercise, 4.nutrition and weight control, 5. Social support, 6. Sexual issues.40

6.3 A) STATEMENT OF THE PROBLEM

A study to assess the effectiveness of self instructional module on knowledge regarding prevention of lymphedema among patients who are posted for mastectomy at selected hospitals, Bangalore.

6.3 B) OBJECTIVES

1. To assess the pre-interventional knowledge regarding prevention of lymphedema.

2. To determine the effectiveness of self instructional module on prevention of lymphedema.

3. To assess the post-interventional knowledge of patients regarding prevention of lymphedema.

4. To find out the association between selected demographic variables with knowledge regarding prevention of lymphedema.

3. C) OPERATIONAL DEFINITION

1. Assess

It refers to the act of estimation of the effectiveness of self instructional module on knowledge regarding prevention of lymphedema among patients posted for mastectomy.

2. Effectiveness

It refers to the successfulness in producing desired or intended result that is brought by administration of self instructional module.

3. Self instructional module

It refers to the learning material prepared in Kannada and English language, by the researcher to provide information regarding prevention of lymphedema.

4. Knowledge

It refers to the level of understanding and awareness of patients on prevention of lymphedema assessed by self administered questionnaire.

5. Prevention

It refers to the intervention prior to the onset of a disease.

6. Lymphedema

It refers to the arm or leg swelling which is caused by building up of extra lymph fluid in tissues. It occurs when the lymph vessels are blocked, damaged or removed by surgery.

6. Mastectomy

It refers to the surgery which is performed to remove the breast, pectoral muscles, axillary lymph nodes, and all fat and adjuvant tissue.

6.3 D) HYPOTHESIS

H1.There is a significant difference between pre-test and post-test level of knowledge of the patients after administration of self instructional module on prevention of lymphedema.

H2. There is a significant association between the post-test level of knowledge of patients with selected demographic variables.

6.3 e) LIMITATIONS OF THE STUDY

1. This study is limited to patients at selected hospitals at Bangalore.

2. Sample size is limited to 60.

7. MATERIALS AND METHODS

7.1 source of data

The data will be collected from patients who are posted for mastectomy in selected hospitals at Bangalore.

2. methods of data collection

i) Research design

Non experimental

ii) Research approach

Descriptive survey approach

iii) Research variables

a) Dependent variable – knowledge of patients who are posted for mastectomy on prevention of lymphedema.

b) Independent variable-self instructional module regarding prevention of lymphedema.

c) Demographic variables –it includes the characteristics of the patients such as age, occupation, educational, educational status, income, source of information, socioeconomic status.

iv) Setting

The study will be conducted in the pre-operative and post operative wards of selected hospitals at Bangalore.

v) Population

The accessible population of the study includes patients who are posted for mastectomy and are admitted in surgical wards of selected hospitals at Bangalore.

vi) Sample

The patients who fulfill the inclusion criteria will be considered as samples. The sample size will be 6 for the pilot study and 60 for the main study.

vii) Criteria for sample selection

Inclusion criteria

1. Patients who are posted for mastectomy.

2. Patients who are willing to participate in the study.

3. Patients who can read and write either Kannada or English.

Exclusion criteria

1. Patients who are not willing to participate in the study.

2. Patients who are critically.

viii) Sampling technique

Non probability convenience sampling technique

ix) Tool for data collection

The structured questionnaire scheduled consists of following sessions which is constructed in Kannada and English language.

Section 1 – Demographic proforma It includes sample number, age, sex, educational status, occupation, income, socioeconomic status and information obtained about prevention of lymphedema.

Section 2- Structured questionnaire on knowledge

This consists of structured questionnaire to assess the knowledge of the patients regarding prevention of lymphedema.

x) Method of data collection

Formal permission will be obtained from the concerned authority of selected hospitals, to conduct the study. Informed consent will be taken from the samples and the samples will be selected on the basis of selection criteria.

Phase 1- Pretest will be conducted to assess the knowledge of the patients on prevention of lymphedema using a self-administered questionnaire.

Phase 2 –Self instructional module on prevention of lymphedema will be distributed to the patients.

Phase 3 – After one week post test will be administered to assess the level of knowledge on prevention of lymphedema to the same subjects with the help of same questionnaire.

Duration of the study- 4 weeks

xi) Plan for data analysis

The data will be analyzed by means of descriptive and inferential statistics.

a) Descriptive statistics -mean, median, mode, standard deviation, percentage distribution will be used to assess the knowledge of patients on prevention of lymphedema.

b) Inferential statistics – chi square test will be used to associate the knowledge of patients with selected demographic variables.

xii) Projected outcome

After the pretest, the investigator administers self instructional module to the patients on the prevention of lymphedema which will help them to initiate a positive step in preventing lymphedema after mastectomy.

3. Does the study require any investigations or interventions to the patients or other human beings / animals?

No

4. Has ethical clearance been obtained from the concerned authority to conduct the study?

Yes.

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31. Paskett etal (2000), “Lymphedema: knowledge, treatment and impact on breast cancer survivors”, journal of clinical oncology. 6(6) 373-378.

32. Petrek J, Pressman P etal (2000) “Lymphedema: current issues in research and management”, CA: A cancer journal for clinicians. 50(5) 292-307.

33. Sandra C. Hayer etal (2007), “Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function”, journal of clinical oncology. 26(21) 3536-3542.

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9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation of

11.1 Guide:

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of the department :

11.6 Signature :

12. Remarks of the Principal :

12.1 Signature :

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