RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



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Ms. KUMARI SHEELA

1STYEAR MSc NURSING

MEDICAL AND

SURGICAL NURSING

2012-2014

SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD,

TUMKUR-572102

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

| | | |

|1 |NAME OF THE CANDIDATE AND ADDRESS |Ms. KUMARI SHEELA |

| | |I YEAR M.SC.NURSING |

| | |SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, |

| | |TUMKUR-572 102 |

| | | |

|2 |NAME OF THE INSTITUTION |SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B.H.ROAD, |

| | |TUMKUR.-572 102. |

| | | |

|3 |COURSE OF STUDY AND SUBJECT | |

| | |MASTER OF SCIENCE IN NURSING |

| | |MEDICAL AND SURGICAL NURSING |

| | | |

| | | |

|4 |DATE OF ADMISSION | |

| | |10-07-2012 |

| | | |

|5 |STATEMENT OF THE PROBLEM |‘A STUDY TO ASSESS THE KNOWLEDGE REGARDING GLAUCOMA AND ITS MANAGEMENT AMONG |

| | |PATIENTS WITH GLAUCOMA IN SELECTED HOSPITALS AT TUMKUR WITH A VIEW TO DEVELOP|

| | |AN INFORMATION BOOKLET’ |

| | | |

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“Its coincidence that four of the six letters in health are “heal”.

-Ed north strum

Person’s orientation to the world is primarily visual. People will learn much about their environment and themselves through their eyes practically every behavior is affected by the visual sense.1

Because so much sensory information research the brain through the eyes. Eye problems and resultant visual interfere with patient’s ability to function independently, to perceive meaning in the world, to enjoy aesthetic pleasure, and to communicate. Although fewer people today lose their sight from infections, the incidence of blindness is rising.

The ability to see the world clearly can easily be taken for granted .The eye is a sensitive, highly specialized sense organ subject to various disorders, many of which lead to impaired vision. Impaired vision affects an individual’s independence in self-care, work and lifestyle choices, sense, self-esteem, safety, ability to interact with society and the environment, and overall quality of life. Many of the leading causes of visual impairment are associated with aging glaucoma and two thirds of the visually impaired population is older than 65 years of age.2

Glaucoma is a disease of the major nerve of vision, called the optic nerve. The optic nerve receives light-generated nerve impulses from the retina and transmits these to the brain, where we recognize those electrical signals as vision. If glaucoma is not diagnosed and treated, it can progress to loss of central vision and blindness. Glaucoma is usually, but not always, associated with elevated pressure in the eye. Generally, it is this elevated eye pressure that leads to damage of the eye (optic) nerve. In some cases, glaucoma may occur in the presence of normal eye pressure. This form of glaucoma is believed to be caused by poor regulation of blood flow to the optic nerve.3

Early glaucoma in adults is often vague and variable, making it hard to detect.  As glaucoma disease advances, symptoms such as blurred vision or a gradual loss of peripheral vision can occur. A major risk factor for glaucoma is a family history of the disease. If a parent with glaucoma, risk of glaucoma is three to five times the average risk. If have a sibling with glaucoma, risk is seven to nine times the average risk. The incidence of glaucoma also increases with age.  Other risk factors for glaucoma include previous eye injuries, exposure to steroid medications, short-sightedness, diabetes, history of migraines, and high blood pressure.4

As of 2010, there were 44.7 million people in the world with open angle glaucoma. The same year, there were 2.8 million people in the United States with open angle glaucoma. By 2020, the prevalence is projected to increase to 58.6 million worldwide and 3.4 million the United States. WHO has estimated that 4.5 million people are blind due to glaucoma.5

The modern goals of glaucoma management are to avoid glaucomatous damage and nerve damage, and preserve visual field and total quality of life for patients, with minimal side effects. This requires appropriate diagnostic techniques and follow-up examinations, and judicious selection of treatments for the individual patient. Although intraocular pressure is only one of the major risk factors for glaucoma, lowering it via various pharmaceuticals and/or surgical techniques is currently the main stay of glaucoma treatment.6

All management options have potential complications, especially surgery, which yields the best success rate. In United States, medical management is the common approach, and surgical management is the last resort.

Surgical techniques may be used to increase drainage. These techniques include using lasers (laser trabeculectomy) to treat the trabecular meshwork implanting artificial drainage valves, and surgically cutting additional passageways to drain the fluid. Risks associated with these surgical procedures include infection, cataracts, bleeding, and hypotony. Even if the surgery is initially successful, scarring may close the drainage channels at the surface layers in the course of months to years.7

The surgery will normally recommend to relieve the internal pressure. But this does not remove the cause of the excess fluid. Hence the operation does not guarantee that the trouble does not recure or will not affect the other eye. The natural treatment of the glaucoma, which is the same as that for any other condition arising from toxicity and is targeted toward preserving the remaining sight. Glaucoma cannot cure in the advanced stages but proper nutrition and other natural methods can control the problem and taking care of the remaining sight.8

The patients suffering from glaucoma want to avoid certain foodstuffs. Coffee is the main food to avoid due to its high caffeine content. Drink moderate amount of tea. Do not take excess fluids like juice, milk or water. Instead have small amounts many times with a gap of one hour. Diet should be mainly of seeds, nuts and grains, vegetables and fruits. Plenty of vitamin C-rich foods, fresh fruits and vegetables. Breakfast should consist of oranges or grapes or any other juicy fruits of the season and a small amount of nuts or seeds. Raw vegetable salad with olive oil and lemon juice dressing, two or three whole wheat chapattis and a glass of buttermilk for lunch. Steamed vegetables, butter and cottage cheese should form your dinner.9

The success of treatment for glaucoma depends on patients learning about the disease using their medicines as prescribed, and getting routine check-ups to monitor the condition and prevent complications. By doing so, patients can decrease their chance of losing their eyesight.10

An exploratory study was conducted to assess Knowledge on Glaucoma Prevention and treatment among Patients in a Public Hospital in São Paulo, Brazil. A structured questionnaire was prepared. The sample was formed by 405 patient, 72.6% female; age range 20 and 92 years, average 66.2 years old. The result shows that Out of the patients who declared they have received explanations about glaucoma’s control, 95.8% stated they know the disease well. The majority stated that glaucoma leads to blindness (89.4%), that it is “high pressure in the eye” (83.2%) and that provokes eye blurring (71.1%). Patients referred to the eye doctor specialist a source of explanations on glaucoma (49.9%). The study concluded that Patients demonstrated lack and inadequacy of knowledge in relation to glaucoma, its prevention and control. This fact suggests the need for educational actions aiming at spreading information on glaucoma among patients and the population as an attempt to prevent visual loss.11

In researcher opinion, the patients should know about what glaucoma is, how it comes about, depending upon the type of glaucoma that particular patient may have. The vast majority of cases can be controlled but not cured, and that best shot at keeping vision is to prevent further damage because it can’t reverse damage once it has occurred. At last it will cause blindness.12

. 6.2 NEED FOR THE STUDY

Glaucoma is a group of ocular conditions characterized by optic nerve damage. There is a range of pressures that have been considered “normal” but that may be associated with vision loss in some patients. Glaucoma is one of the leading causes of irreversible blindness in the world and is the leading cause of blindness among adults in the United States. It is estimated that at least 2 million Americans have glaucoma and that 5to 10 million more are at risk. Glaucoma is more prevalent among people older than 40 years of age, and the incidence increases with age. It is also more prevalent among men than women and in the African American and Asian populations.13

The Eye Foundation’s Australian and New Zealand Registry of Advanced Glaucoma (ANRAG) is a research project looking at ways to identify people at high risk of developing glaucoma so that they can be diagnosed early and treated before they start losing vision. To help find out what puts people in a high-risk category for glaucoma, the project is establishing the world’s largest registry of advanced glaucoma cases. The project team is researching DNA to identify new genes linked to glaucoma and gain a better understanding of glaucoma and its management.14

A study was conducted o estimate the prevalence of glaucoma among people worldwide. Glaucoma prevalence reviewed to determine the relation of open angle and angle closure glaucoma with age in people of European, African, and Asian origin. A comparison was made with estimated world population data for the year 2000. The number of people with primary glaucoma in the world by the year 2000 is estimated at nearly 66.8 million, with 6.7 million suffering from bilateral blindness. In developed countries, fewer than 50% of those with glaucoma are aware of their disease. In the developing world, the rate of known disease is even lower. Glaucoma is the second leading cause of vision loss in the world. Improved methods of screening and therapy for glaucoma are urgently needed.15

According to World Health, Dr. Robert beagle hole, Director of Chronic Diseases and Health Promotion in Geneva. Gathered a new statistics in 2002, show that glaucoma is now the second leading cause of blindness globally, after cataracts. WHO officials are looking into ways to address the problems caused by glaucoma which was until now estimated to be the third leading cause of blindness. 16

WHO has estimated that 4.5 million people are blind due to glaucoma. Published projections indicate that 4.5 million people will be blind due to open-angle glaucoma and 3.9 million due to primary angle closure glaucoma in 2010. Furthermore, about 60.5 million people will have glaucoma by the year 2010 (44.7 million with open-angle glaucoma and 15.7 million with angle-closure glaucoma). Given the ageing of the world’s population, this number may increase to almost 80 million by 2020. The published projections also indicate that nearly half of the bilateral blindness attributable to glaucoma by 2020 will be caused by angle-closure glaucoma (11.2 million people).17

The prevalence of glaucoma has been reported by the Vellore Eye Survey, Andhra Pradesh Eye Disease Study, Aravind Comprehensive Eye Survey, Chennai Glaucoma Study, and West Bengal Glaucoma Study. There are approximately 11.2 million persons aged 40 years and older with glaucoma in India. Primary open angle glaucoma is estimated to affect 6.48 million persons. The estimated number with primary angle-closure glaucoma is 2.54 million. Those with any form of primary angle-closure disease could comprise 27.6 million persons. Most of those with disease are undetected and there exist major challenges in detecting and treating those with disease. In the light of the existing manpower and resource constraints. The evaluated options are used for improving case detection rates in the country.18

A cohort study was conducted to assess the 12-year incidence of glaucoma- related visual field loss in Italy. Primary open-angle, primary angle –closure and secondary glaucoma were diagnosed according to the 3-tier system of evidence developed by the international society, geographical and epidemiological ophthalmology. The 12-year incidence of definite PAOG was 3.8%, annual rate of 0.32%, PACG and PEX glaucoma were 0.5% 0.8%. The annual average incidence of definite PAOG in ponzas lower then that reported in persons of African ancestry and higher than that observed in certain other white populations.19

The medical and surgical management of glaucoma slows the progression of glaucoma but does not cure it. The lifelong therapeutic regimen mandates patient education for patients with severe glaucoma and impaired function, referral to services that assist the patient in performing customary activities may be needed. Reassurance and emotional support are important aspects of care. A lifelong disease involving a possible loss of sight has psychological, physical, social, and vocational ramifications.20

Generally, Glaucoma is an insidious condition. it is often without symptom and very difficult to diagnose. Because of its insidious nature, the disease does not inspire patients to urgent action to control it. Therefore, inadequate knowledge, incorrect beliefs, negative feelings and attitudes as well as poor social relationships and contacts, could inhibit treatment compliance and lead to incurable blindness.

An information booklet is one of the effective teaching strategies which consist of figures which will help to draw the attention of the clients. The contents of this information booklet depend on the results of the study. Information Booklet is not only effective for patients; it can be used by any person in the community.

In the light of above, I found it desirable to evaluate the knowledge of patients about Glaucoma and its management. The decision for selecting the topic on glaucoma for the study grew out of my clinical experience during my study period with patients who had limited awareness regarding the origin, treatment, and prevention and control measures of glaucoma. Therefore it is very clear that the patients must need to update their knowledge regarding Glaucoma and its management.

6.3 REVIEW OF LITERATURE

A descriptive study was conducted to assess the awareness and knowledge level about glaucoma and its determinants in an urban population of Chennai in south India. A total of 3850 subjects aged 40 years or above were participated in the urban. A systematic random sample of 1926 (50.0%) subjects completed a questionnaire that assessed their awareness and knowledge level of glaucoma. The result shows that 13.5% were aware of glaucoma; the age-gender adjusted rate for awareness was 13.3%. Overall 8.7% had some knowledge about glaucoma. Among those who had knowledge 0.5% had good knowledge about glaucoma, 4% had fair knowledge and 4.2% had poor knowledge. Awareness and knowledge about glaucoma was very low among the urban population of Chennai. The study concluded that younger subjects and men were less aware of glaucoma. The study findings stress the need for health education for effective prevention of blindness due to glaucoma.21

A retrospective study was conducted to assess adherence patterns to the UK National Institute of Health and Clinical Excellence (NICE) guidelines on glaucoma management (2009) in a tertiary referral centre shared care setting and in a district general hospital (DGH) setting. The two centers involved were a consultant-guided teaching hospital optometry-led shared care setting (setting 1) and a consultant-led DGH clinic setting (setting 2). The result shows that main outcome measures were compliance with eight of the main NICE guidelines on glaucoma diagnosis and management (2009). Both centers showed good adherence to the guidelines regarding the choice of initial treatment and arranging appropriate monitoring intervals. The study concluded that it provides evidence to suggest that a hospital-based shared care service with trained optometrists using assessment sheets compares favorably to non-specialist glaucoma care delivered by ophthalmologists. 22

A study was conducted to measure knowledge about glaucoma in the Hong Kong Chinese population. Patient aged 40 and above in the Shatin district of Hong Kong were randomly selected as part of a larger study of causes of adult visual loss. The patient were asked by trained interviewers in a standardized fashion about their knowledge of, glaucoma. Their answers were rated for accuracy by a senior ophthalmologist. Out of the 2538 eyes examined, 7.0% had visual acuity less than 6/18. Fully 69.6% of the visual disability for those aged 60 or above was caused by glaucoma. The result shows that sample of the Hong Kong Chinese population had limited knowledge of common eye diseases. The study concluded that Educational programmes to enhance public awareness may be needed to improve the effectiveness of health promotion and thus prevent unnecessary blindness.23

A qualitative study was conducted to develop a questionnaire to assess patient’s satisfaction and compliance with eye -drop treatment. The questionnaire was developed using the patient verbatim, and submitted to six patients (French and English) for cognitive debriefing. Following patients' comments, items were modified and restructured, and a pilot questionnaire was designed. The result shows that a questionnaire, which consisted of 46 items grouped into 6 domains: patient characteristics, treatment characteristics, patient-clinician relationship, patient experience with the disease and the treatment, interaction between the patient and the treatment, and patient knowledge of the disease and the treatment. The study concluded that questionnaire could be used to evaluate patient satisfaction and compliance with eye-drop treatment and would facilitate the identification of patients at risk of being non-compliant prior to clinical trials or innovative device tests.

An epidemiological study was conducted to assess the awareness on glaucoma in a rural eye camp in north Karnataka, India. A total of 100 subjects who were >20 years old, who attended an eye camp at Anwal village, in the Bagalkot district, north Karnataka, India, were enrolled into the study. The responses of the subjects who completed a structured questionnaire regarding the awareness and the knowledge on glaucoma. The result shows that the awareness on glaucoma was poor in the rural area of the Anwal eye camp in Bagalkot district in north Karnataka, India. As compared to the previous studies, the awareness was better, due to improvement in the health care services over the years. The study concluded that Community based health education programmes go a long way in increasing the level of the awareness and the knowledge on glaucoma.

A retrospective study was conducted about the resource utilization in France and Sweden. A total of 267 patient records (121 in France, 146 Sweden) with diagnoses of primary open-angle glaucoma ocular hypertension treated medically, were reviewed for a 2 year period for revelent clinical and resource utilization data. The result show that the annual cost of treating glaucoma was estimated at 531 patients in Sweden and 390 patients in France. In both countries, medication costs comprised about half of the total costs. Surgical procedures and hospitalization represented greater proportion of total cost in France than Sweden. The study concluded that a medication cost represents a high proportion of total treatment costs. These findings highlight the relative importance of medical therapy and of assessing the cost- effectiveness of medications in glaucoma.

An Epidemiological study was conducted about the Effect of Written Instructions on Accuracy of Self–reporting Medications in Glaucoma Patients. All patients at an urban resident glaucoma clinic were offered participation. Two trained interviewers administered a questionnaire consisting of questions regarding the regimen of ophthalmic medications and demographics. At the end of their examination, patients were given a written chart describing their ophthalmic medications, frequency, and dosage. At their next scheduled visit, the same questionnaire was repeated, and a verbatim response was recorded. The patients’ responses from both visits were compared with the regimen they were prescribed and to each other. The result shows that at the first visit, 66 patients (40%) showed less than 100% accuracy. 53 of 66 (83%) patients showed improvement in accuracy at their second visit after written instructions. The study concluded that 131 of 164 patients (80%) showed one hundred percent accuracy of reporting medications after our intervention of written instructions. If patients are reporting medications as they administer them, there is significant improvement in administration of medications after written instructions.

A cross-sectional study Adherence of Finnish people with glaucoma to treatment plans and connected factors. The data were collected at one point in time from Finnish adults diagnosed with glaucoma with a questionnaire covering adherence to treatment. The results show that Sixty-seven percent of the patients with glaucoma were very adherent to the prescribed treatment plan in terms of self-care, treatment and follow-up visits. This study concludes that people with glaucoma in Finland adhere well to care and exceptionally well to medical care. Support and patient education from health care personnel is crucial to maintain patient adherence to treatment.

6.4 STATEMENT OF THE PROBLEM

‘A study to assess the knowledge regarding glaucoma and its management among patients with glaucoma in selected hospitals at Tumkur with a view to develop an Information Booklet’.

6.5 OBJECTIVES OF THE STUDY

➢ To assess the knowledge regarding glaucoma and its management among patients in selected Hospitals at Tumkur.

➢ To find the association between the level of knowledge with selected sociodemographic variables.

➢ To develop an Information Booklet regarding glaucoma and its management.

6.6 OPERATIONAL DEFINITIONS

➢ Knowledge-In this study the knowledge refers to the correct responses given by the patients regarding glaucoma and its management as it is elicited through self administered knowledge questionnaire.

➢ Glaucoma – It refers to a disease of the eye marked by increased pressure within the eyeball that can result in damage to the optic disk and gradual loss of vision.

➢ Management- In this study management refers to the measures taken to cure the signs and symptoms of glaucoma such as medical, surgical and life style changes.

➢ Patients- in this study patient refer to persons who are diagnosed with glaucoma and attending outpatient department or admitted in the selected Hospitals at Tumkur.

➢ Information Booklet-It refers to the planned self instructional material contains regarding definition, causes and risk factors, clinical features, and management of glaucoma by using pictures based on the result of the study.

6.7 ASSUMPTIONS

Patients may have limited knowledge about glaucoma and its management.

6.8 HYPOTHESIS

H1: There will be a significant association between the level of knowledge with selected sociodemographic variables.

7.0 MATERIALS AND METHODS

7.1 SOURCE OF DATA

Information provided by patients regarding glaucoma and its management.

7.2 METHOD OF DATA COLLECTION

7.2.1 Research design

“Descriptive Research Design”

7.2.2 Settings of the study

Selected hospitals at Tumkur.

7.2.3 Population

Patients with glaucoma.

7.2.4 Sample

Patients with glaucoma in selected hospitals at Tumkur.

7.2.5 Sampling Technique

Non-probability convenient sampling.

7.2.6 Sample size

100 Glaucoma patients

7.2.7 Sampling criteria

Inclusive criteria

1. Patients who are attending OPD in selected hospitals at Tumkur.

2. Patients who are admitted in selected hospital at Tumkur.

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

Exclusive criteria

1. Patients who cannot read and write kannada.

2. Patients who are not available at the time of data collection.

3. Patients who are having blurred vision.

7.2.8 Tool for data collection

Data will be collected by using self administered questionnaire.

Section A- Socio - demographic variables.

Section B- Knowledge questionnaire regarding glaucoma and its management.

7.2.9 Method of data collection

The data will be collected from patients by using self administered questionnaire regarding glaucoma and its management.

Written permission will be taken from the concerned authorities.

7.3 Data analysis and interpretation

1. Descriptive statistics

Descriptive statistical techniques such as frequency, percentage. mean median, mode and standard deviation.

2. Inferential statistics

Chi-square test.

7.4 ETHICAL CLEARANCE:

Does the study require any investigation on interventions to be conducted on

patients?

No

8. BIBLIOGRAPHIC REFERENCES

1. Thesaurus, idioms.Wikipedia,Definition of health, Available at: URL Free Dictionary .com

2. Brunner and siddarth’s.Medical and surgical nursing.10th ed.Lippincott; 2004.

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7. Jacqueline Freudenthal. Complications and Management of Glaucoma Filtering , Nov 20, 2012;Available at .

8. . Jennifer Byrne. Doctor/patient relationship key to glaucoma therapy compliance; April 2005, .

9. Glaucoma. Lifestyles and remedies. Available at http// Mayo clinic .com

10. Glaucoma Prevention. Available at .

11. M.J. L. Silva, E.R. Temporini. Knowledge on Glaucoma Prevention and Treatment of Patients in a Public Hospital. In brazil. [online]. 2004, vol.67.Available at URL

12. .Information of healthy vision. Available at: URL http//nei.glaucoma.robert.asp.

13. Glaucoma.Available at:URL

14. .Glaucoma. Available at: URL .

15. H A Quigley , A T Broman. Br J Ophthalmology The number of people with glaucoma worldwide in 2010 and 2020. . 2006 March; 90(3): 262–267. 2006 March; 90(3): 262–16.Available at : URL

16. Bulletin of the Glaucoma. 1 November 2004.Available at :URL

17. Glaucoma.Available at :URL

18. Prevalence of Glaucoma in India and The World - VISION 2020 .Available at :URL

19. India. Available at: URL

20. Adherence patterns to the UK National Institute of Health and Clinical Excellence (NICE) guidelines on glaucoma management (2009).Available at : URL

21. A L young, ww Tong.B R Journal.vol.88;2004. The prevalence of pseudo exfoliation syndrome in Chinese people. Available at : URL

22. Nordmann JP, Denis P.2007 Aug 6 ;7:124. Development of the conceptual framework for the Eye-Drop Satisfaction Questionnaire (EDSQ) in glaucoma using a qualitative study. Available at :URL

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