RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,



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PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Ms LIYA BABU

FIRST YEAR M.SC (NURSING)

PAEDIATRIC NURSING

YEAR 2010-2012

THE KARNATAKA COLLEGE OF NURSING BANGALORE

#12 TH CROSS KOGILU MAIN ROAD

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

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|1. |Name of the candidate and address. |Ms. LIYA BABU, |

| | |KOGILU MAIN ROAD, |

| | |YELAHANKA, BANGALORE. |

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|2. |Name of the institution. |THE KARNATAKA COLLEGE OF NURSING |

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| | |1st YR M.Sc.NURSING |

|3. |Course of study and subject. |PAEDIATRIC NURSING |

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|4. |Date of admission to course. |15- 06-2010 |

| | |“A STUDY TO ASSESS THE EFFECTIVESNESS OF SELF INSTRUCTIONAL |

| | |MODULE REGARDING THE CARE OF NEONATES ON MECHANICAL |

|5. |Title of the topic. |VENTILATOR AMONG THE STAFF NURSES WHO ARE WORKING IN THE |

| | |NEONATAL INTENSIVE CARE UNIT IN SELECTED HOSPITALS AT |

| | |BANGALORE”. |

6. BRIEF RESUME OF THE INTENDED WORK.

INTRODUCTION

Loving a baby is a circular business, a kind of feedback loop.

The more you give, the more you get and

the more you get the more you feel like giving.

-- Penelope Leach

The Miracle of life begins at conception and continuous throughout the life span. The Manifestation of Miracle was encountered during newborn period and infancy. During the 20th century, amazing progress has been made in the scientific and technological field. The genetic code has been discovered that people are living longer than even before and very low birth weight neonates have survived.1

According to WHO, 140 million children are born in every year, of which 5 million children dies in the first month of life in the developing countries. The care of children has in recent decades, changed dramatically for nurses due to the advances in medical knowledge.

An important index used to estimate Nation’s health is the health status of children in that country. When children are sick and hospitalized, they are treated by using various types of equipments including mechanical ventilators especially when they are admitted in the intensive care unit. The mechanical ventilator plays a vital role to save the life of the children.

Children are not able to adequately ventilate their lungs because of various disorders resulting in respiratory insufficiency or failure. These clients require immediate intervention, including the establishment of an artificial airway and mechanical lung ventilation with a positive pressure ventilator. Mechanical ventilation allows the child to inhale high percentages of oxygen. When children are initially placed on mechanical ventilator, they must be closely observed so that the effectiveness of the therapy can be evaluated and complications can be prevented from occurring. Serious complications that may arise during initial mechanical ventilation include rapid electrolyte changes, severe alkalosis and hypotension due to decrease in cardiac output. 2

The physician decides when to begin weaning a child from mechanical ventilator. The decision is often based on assessments made by nurses and respiratory therapists. The length of time required for successful weaning generally relates to the underlying disease process and to the child’s state of health before a ventilator is used. Careful assessment of ventilator status before and during weaning is necessary, including spontaneous tidal volume; vital capacity; maximal voluntary ventilation; inspiratory effort; breath sounds; cardiovascular and cerebral status; and arterial blood gas. 3

The nurse promotes the effectiveness of ventilation by suctioning, positioning, ensuring that adequate humidification is provided, and providing support and reassurance to the child and the family. All infants and children who are intubated and on mechanical ventilation are placed on a cardio respiratory monitor.

The nurse is the singular person in the neonatal intensive care unit who creates an environment in which critically, unstable, highly vulnerable neonates and children benefit from attentive care. The neonatal intensive care unit nurse co-ordinates the actions of a highly skilled team of patient focused health care professionals.

6.1 NEED FOR THE STUDY.

Over the last years, the nursing profession has witnessed major changes because of the new regulations that apply to this health care field. In order to outline the role of nurses in managing the sophisticated equipment for critically ill patients, these new regulations should be taken into consideration. At present, the deontological code defines the reference criteria for defining nurse’s competence, responsibilities and actions, and for which education and updating are necessary.

According to this criterion, nurses are responsible for and should act autonomously in managing problems of health care assistance and in putting into practice diagnostic-therapeutic prescriptions. The high level of clinical nursing competence necessary to use these complex devices approximately can only be achieved by dedicated training programmes and professional experience, including educational programmes for new and experienced staff. 4

Technologic advances influences staff nurses role in increasing technical skills related to child care are inevitable future trends. Nurses are required to continually update their knowledge and prove this unique contribution. The need for mechanical ventilation is a common one in the neonatal and pediatric intensive care unit. The goals are to facilitate adequate gas exchange, minimize the risk of lung injury, and decrease the child’s work of breathing and to optimize the child’s comfort. Nurses are responsible for ongoing assessment and care of neonates undergoing mechanical ventilation.5

Mechanical ventilation is an essential life saving technology. There are however numerous associated complications that influence the morbidity and mortality of patients, receiving intensive care. Therefore it is essential to educate nurses to use ventilators safely and most effectively. Ventilator associated pneumonia is the second most common hospital acquired infection in children with mechanical ventilation. Although mechanical ventilation is frequently life saving it can cause complications if improperly used.6

Informal educators might reinforce negative believes and practices through their teachings and behavior. There is a need for the nurse to continually upgrade this knowledge and attend in-service and continuing education programmes to face the newer neonatal challenges and problems poured day after day in clinical practice.

World wide, the neonatal deaths accounts to about 3.9 million per year. The current neonatal mortality is 44 deaths per 1000 lives births in the world. In Karnataka, the infant mortality rate is 53/1000 lives births per year. Indeed it is essential for the nurses to take part in reducing the mortality rate.7

When surrounded by machines nurses may sometimes overlook the child and focus on the machines exclusively. Neonates on ventilators are highly dependent and need comprehensive, holistic care with meticulous attention in detail. They need health care providers who are not only skillful in managing the machines but also understanding and supportive during stressful experiences.8

Mechanical ventilation is a process by which gases are moved into and out of the lungs by means of a ventilator, a machine that delivers a controlled flow of gas to a patient’s airway. The reasons for mechanical ventilation include respiratory arrest, acute lung injury, critical illness and respiratory support following surgery. Ventilatory management has changed over the past few decades with the advent of high frequency ventilator for which a multidisciplinary approach is essential.9

Mechanical ventilation is an essential life-saving technology. There are however, numerous associated complications that influence the morbidity and mortality of the patients receiving intensive care. Therefore, it is essential to use the safest and the most effective form of ventilation for the shortest possible duration. Further research is required that better qualifies critical care nurses role in weaning practices and the contextual issues that influence the nurses role.

Rose L and Nelson S. (2006) states that a responsibility of critical care nurses for management of mechanical ventilation differs. Organizational interventions, including weaning protocols, have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. Critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning.10

Hansen BS and Severinsson E. (2005) conducted a study to identify pediatric intensive care nurses perceptions regarding protocol- directed weaning, by means of focus group interviews and qualitative content analysis. The results showed that the nurses perceived the protocol as useful. When prescribed, it represented inter professional agreement that allowed them to act in the absence of a physician. It focused on weaning, saved time, was easy to use and led to a feeling of safety and continuity in the weaning process. Nurses in the study expressed the need for a knowledge base in order to improve skill.11

Fenstermacher D and Hong D. (2004) reports that mechanical ventilation is the second most frequently performed therapeutic intervention in intensive care units today. In this survey, over half of senior internal medicine residents reported on their training on mechanical ventilation as inadequate, whereas the majority of critical care nurses reported having received no formal education on its use. 12

From the available literature reviewed it was found that the complications of mechanical ventilation in neonates include marked hypoxia, hypercapnia, peripheral airway obstruction, chest wall deformities and central nervous system abnormalities. Nurses caring for these neonates must posses’ adequate knowledge of the underlying disease process as well as normal respiratory physiology and technical features of ventilators to reduce the ventilator related mortality rate. So the researcher found it relevant to evaluate the effectiveness of a self instructional module on nursing care of neonates on mechanical ventilator among the staff nurses who are working in the neonatal intensive care unit.

6.2 REVIEW OF LITERATURE.

The primary purpose of reviewing relevant literature is to gain a broad background or understanding of the information that is available related to a problem. In conducting research, the literature review facilitates selecting a problem and purpose, developing a framework and formulating a research plan. Literature review is a key step in research process. Review of relevant literature is an analysis and synthesis of research sources to generate a picture of what is known about a particular situation and the knowledge gaps that exist in the situation. 13

In order to accomplish this goal in the present study, an attempt has been made to review and discuss the related literature.

Chinna Devi M. (2006) did a study to evaluate the effectiveness of a planned teaching programme, on care of babies on mechanical ventilator, in terms of knowledge of staff nurses working in neonatal intensive care unit. The sample consisted of 30 staff nurses working in the neonatal intensive care unit. The study findings revealed that, staff nurses had inadequate knowledge regarding care of babies on mechanical ventilaton before the introduction of the planned teaching programme. The mean knowledge scores of the staff nurses were increased to 78.22% from 40.66%, after the administration of a planned teaching programme. The study concludes that the planned teaching programme was effective in enhancing the knowledge of staff nurses regarding care of babies on mechanical ventilator.14

Noyes J. (2006) in a qualitative study reports on the experiences of ventilator dependent children and their parents. The study had two phases of data collection and was conducted on 35 ventilator dependent children and their parents. The study reveled that nurses were focusing more on machines rather than the child. The study findings suggest that the nursing care boundaries need to be redefined around the children’s needs. Study concludes that nurses need to be educated on care of physical as well as emotional needs of children on mechanical ventilator. 15

Wills BC, Graham AS, Yoon E, Wetzel RC and Newth CJ. (2005)

The study was conducted to compare the pressure rate products and phase angles of children during minimal support ventilation and after extubation. A pediatric intensive care unit was opted in a tertiary children’s hospital. There were 17 endotrchealy intubated and mechanically ventilated children placed on T-piece ventilation. The continuous positive airway pressure, esophageal pressure swings, respiratory mechanics and physiological parameters were measured. Pressure rate product post extubation was significantly higher than on support modes. Eventually it was assessed that post extubation pressure rate product and hence “effort of breathing” in children is best approximated by T- piece ventilation. 16

Rose L, Nelson S, Johnston L and Presneill JJ. (2004) investigated on the role of critical care nurses in the management of mechanical ventilation. A 3 month, prospective cohort study was performed on 474 patients who received mechanical ventilation. The study findings revealed that decisions for weaning made purely by the nurses gave a positive outcome (64%). Majority of extubations where decisions made by the doctors had some complications and needed reintubation. The study concludes that nurses if properly trained can manage patients effectively on mechanical ventilator. 17

Hewitt-Taylor J. (2004) reports about the perceived education and training needs of staff who care for children with complex needs, including assisted ventilation. Children who live with conditions that were previously considered incompatible with long-term survival are now highly dependent on medical technology, interventions and equipment. This includes an increasing number of children who require long-term assisted ventilation. This identified that one of the many factors that impede the discharge of children requiring mechanical ventilation is a lack of staff who are able to provide care and support for them and their families. The study concludes that increasing the number of staff who is able to provide such support will therefore assist in improving the provision of appropriate care for this group.18

Keogh S, Courtney M and Coyer F. (2003) have done an intervention study on weaning from ventilation in pediatric intensive care unit. The study sample consists of a total of 220 children. A time score design was used. The study focused on standardization of pediatric intensive care unit teams approach to wean pediatric patients from mechanical ventilator. They found that weaning from mechanical ventilator can be performed safely and effectively with the aid of collaborative guidelines.19

Crocker C. (2002) has done a study on nursed led weaning from ventilatory and respiratory support. A retrospective audit revealed that patients were ventilated for more than 16 days in one intensive care unit. Initially there were no weaning protocols. Later when weaning protocols were used, nurse led weaning was initiated. Following this monthly statistics were collected and it revealed that the weaning time had reduced to 10 days. The study concluded that lack of knowledge and lack of weaning guidelines prolong duration of ventilator requirement. So if nurses are educated they can provide quality patient care.20

Beveridge M. (2001) states that weaning a patient from mechanical ventilator and then to extubation is a challenge for critical care nurses. Critical care nurses play a vital role in assessing a patient’s readiness for weaning and managing the weaning trials. Traditionally, a critical care nurse performs this process only under the direction and supervision of the doctor. This team work is important but it lead to delays. The author cites that with a protocol, which provides a valid frame work, the critical care nurse can perform weaning and unnecessary delays can be avoided. 21

Schultz TR, Lin RJ, Watzman HM, Durning SM, Hales R, Woodson A et.al, (2001) compared the outcomes between physician directed and protocol directed weaning from mechanical ventilation in pediatric patients. A prospective-randomized design was used. The study reveled that in samples were nurse directed weaning was used the outcome was better with a reduced ventilation time. The study concluded that nurses if trained properly can render safe and effective patient care. 22

Kollef M H. (2000) has done a randomized controlled trial of protocol directed versus physician directed weaning from mechanical ventilator. The objective of the study was to compare the practice of protocol directed weaning from mechanical ventilation implemented by nurses with the traditional physician directed weaning. The study was done on 357 patients requiring mechanical ventilation (n= 179 received protocol directed weaning and n=178 received physician directed weaning). The study findings demonstrated that patients who received protocol directed weaning performed by the nurses had significantly shorter duration of mechanical ventilation and higher success rate of weaning when compared to patients who received physician directed weaning.23

6.3 STATEMENT OF THE PROBLEM.

“A STUDY TO ASSESS THE EFFECTIVESNESS OF SELF INSTRUCTIONAL MODULE REGARDING THE CARE OF NEONATES ON MECHANICAL VENTILATOR AMONG THE STAFF NURSES WHO ARE WORKING IN THE NEONATAL INTENSIVE CARE UNIT IN SELECTED HOSPITALS AT BANGALORE”

6.4 OBJECTIVES OF THE STUDY.

The objectives of the study are to:

• To assess the existing level of knowledge regarding the care of neonates on mechanical ventilator among the staff nurses.

• To find out the effectiveness of self instructional module regarding the care of neonates on mechanical ventilator among the staff nurses.

• To associate the pretest knowledge regarding the care of neonates on mechanical ventilator among the staff nurses with selected demographic variables.

6.5 HYPOTHESIS.

H1 There will be a significant difference between the pretest and post test knowledge regarding the care of neonates on mechanical ventilator among the staff nurses.

H2 There will be a significant association between the post test knowledge regarding the care of neonates on mechanical ventilator among the staff nurses with selected demographic variables.

6. VARIABLES

1. Dependent variable: It refers to the knowledge regarding the care of neonates on mechanical ventilator among the staff nurses.

2. Independent variable: It refers to the self instructional module which brings change in the knowledge of staff nurses.

3. Extraneous variable: These are all variables present in the research environment, which affect the depend variables and may interfere with research findings.

6.7 OPERATIONAL DEFINITION OF TERMS.

a) Assess:

In this study, the term assess refers to checking the knowledge regarding the care of neonates on mechanical ventilator among the staff nurses.

b) Effectiveness:

It refers to the extent to which the self instructional module has achieved the desired results as evidenced in terms of gain in knowledge scoring, regarding the care of neonates on mechanical ventilator.

c) Self Instructional Module:

It is a planned teaching and learning process between the investigator and study subjects that helps the study subject to change his/her knowledge regarding the care of neonates on mechanical ventilator.

d)  Neonates:

Infants less than 28 day of life who are admitted in the Neonatal Intensive Care Unit in selected hospitals at Bangalore.

e) Mechanical Ventilator:

A mechanical ventilator is a machine that generates a controlled flow of gas into a patient’s airways.

f) Staff Nurses:

It refers to the registered nurses with the qualification of GNM who are freshers currently working in neonatal intensive care unit in selected hospitals at Bangalore.

g) Neonatal Intensive Care Unit:

It is a highly technical specialized unit designed for the care of high risk and critically ill neonates in the Neonatal Intensive Care Unit in selected hospitals at Bangalore.

6.8 ASSUMPTIONS.

• Staff nurses may have inadequate knowledge regarding the care of neonates on mechanical ventilator.

• Self instructional module may improve the knowledge regarding the care of neonates on mechanical ventilator among the staff nurses.

• Staff nurses will be expressing willingness to learn and understand about the care of neonates on mechanical ventilator.

6.9 DELIMITATIONS.

The study is delimited to:

• Study samples limited to 60 only.

• Study is limited to selected hospitals at Bangalore.

• Study is limited to registered nurses.

7. MATERIALS AND METHODS.

7.1 Source of data.

Staff nurses who are working in NICU in selected hospitals at Bangalore

7.2 Method of collection of data.

- Research method : Quasi experimental method.

- Research design : One group pre test-post test design.

- Sampling technique : Convenience sampling.

- Sample size : 60

- Setting of the study : Selected hospitals in Bangalore.

7.2.1 CRITERIA FOR SELECTION OF SAMPLE.

INCLUSION CRITERIA

This study includes ‘Staff Nurses’

1. Who are available at the time of the study.

2. Who are willing to participate.

3. Both male and females will be included.

4. Working in Neonatal Intensive Care Unit will be included.

EXCLUSION CRITERIA

1. Staff nurses who have attended workshops or seminars on mechanical ventilators.

2. Staff nurses who are not present at the time of the study.

7.2.2: DATA COLLECTION TOOL.

A structured knowledge questionnaire will be prepared to assess the knowledge of staff nurses regarding care of neonates on mechanical ventilator. A Self Instructional Module also will be prepared regarding care of a neonate on mechanical ventilator. Content validity of the tool will be ascertained in consultation with guide and experts from various fields like medicine and nursing.

Reliability of the tool will be established by split half method. Prior to the study written permission will be obtained from the concerned authority. Further consent will be taken from the staff nurses regarding their willingness to participate in the study.

7.2.3: DATA ANALYSIS METHOD.

Data analysis will be done by descriptive and inferential statistics. Mean, median, standard deviation, frequency and percentage distribution will be used for data analysis. ‘t’ test will be done to compare the pre and post test knowledge score. Correlation will be done to find out relationship between the mean pre test knowledge score and selected demographic variables.

7.3: DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS?

YES.

The study requires intervention in the form of a Self Instructional Module, no other interventions which cause any physical harm will not be done for the subject.

7.4: HAS ETHICAL CLEARANCE BEEN OBTAINED?

Yes, Consent will be obtained from concerned subjects and authority of hospitals.

Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study will be maintained with honesty and impartiality

8. LIST OF REFERENCES

1. World Health Day Report. Nursing Journal of India. April (1997); 129:3.

2. Black MJ, Jacobs EM. Medical Surgical Nursing. 4th ed. Philadelphia:

Saunders Comp; 1993.p.977-84.

3. Wong LD, Hockenberry JM. Nursing Care of Infants and Children. 7th ed.

Missouri: Mosby; 1999.p.1324.

4. Chellappa M Jessie. Pediatric nursing 2nd ed. Gajana book pub; 1995.p.5-6.

5. Marlow RD, Redding AB. Text Book of Pediatric Nursing. 6th ed.

Philadelphia: Saunders; 1998.p.248-9, 316-7.

6. G Briassoulis, O Filippou. Acute and chronic pediatric intensive care patients:

Current trends and perspectives on resource utilization. QJ Med 2004; 97.

p.507-508.

7. WHO- neonatal & perinatal mortality rates – 2009

8. Parra MM. Nursing and respite care services for ventilator-assisted children.

Caring.2003. May; 22(5):p.6-9.

9. Kendirli T, Kavaz. Mechanical ventilation in children.Turk.T.

Pediatr.2006.oct-dec; 48(4):p.323-7.

10. Rose L, Nelson S. Issues in weaning from mechanical ventilation: Literature

review. J Adv Nurs.2006 Apr; 54(1):p. 73-85.

11. Hansen BS and Severinsson E. Intensive care nurses perceptions of protocol

directed weaning- a qualitative study. Intensive Crit Care Nurs.2005 Aug;

23(4):p. 196-205.

12. Fenstermacher D and Hong D. Mechanical ventilation: what we have

learned? Crit Care Nurs Q. 2004 Jul-Sep; 27(3):p. 258-94.

13. Polit D, Beck CT. Nursing research principles and methods. 7th

ed.philadelphia.lippincott Williams and Wilkins, 2004, p.88-9.

14. Chinna Devi M. Effectiveness of a planned teaching programme on a care of

babies on mechanical ventilator among staff nurses. Nightingale Nursing

Times.2006 Jul; 2(4):p.41-4.

15.Noyes J. Health and quality of life of ventilator-dependent children. J Adv

Nurs.2006 Nov; 56(4):p.392-403.

16. Wills BC, Graham AS, Yoon E, Wetzel RC, Newth CJ. Pressure rate

Products and phase angles in children on minimal support ventilation and

after intubation. Intensive Care Med. 2005 Dec; 31(12):p.1700-5.

17. Rose L, Nelson S, Johnston L and Presneill JJ. Decisions made by Crit

Care Nurses during mechanical ventilation and weaning in an Australian ICU.

Am J Crit Care. 2004 Sep; 16(5):p.434-43.

18. Hewitt –Taylor J. Children who require long-term ventilation: staff education

and training. Intensive Crit Care Nurs. 2004 Apr; 20(2):p.93-102.

19. Keogh S, Courtney M, and Coyer F. Weaning from ventilation in pediatric

Intensive care: an intervention study. Intensive Crit Care Nurs. 2003 Aug;

19(4):p.186-97.

20. Crocker C. Nurse led weaning from ventilatory and respiratory support.

Intensive Crit Care Nurs. 2002 Oct; 18(5):p.272-9.

21. Beveridg M. Weaning- A nursing challenge. Aust J Holist Nurse. 2001 Apr;

5(1):p.39_43.

22. Schultz TR, Lin RJ, Watzman HM, Durning SM, Hales R, Woodson A,

et.al. Weaning children from mechanical ventilation: a prospective

randomized trial of protocol-directed versus physician-directed weaning.

Respair Care.2001 Aug; 46(8):p.772-82.

23. Kollef MH. A randomized, controlled trial of protocol-directed versus

physician directed. Crit care med.2000 Apr; 25(4):p.567-74.

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