Rajiv Gandhi University of Health Sciences Karnataka



A STUDY TO ASSESS THE KNOWLEDGE REGARDING WEANING THE CRITICALLY ILL PATIENT FROM MECHANICAL VENTILATION AMONG ICU NURSES AT SELECTED HOSPITAL IN BANGALORE

M.Sc.Nursing Dissertation Protocol Submitted to

[pic]

Rajiv Gandhi University of Health Sciences, Karnataka, Banglore

By

Miss. Mamta Thapa

M.Sc.Nursing 1st year

2011-2013

Under the Guidance of

HOD, Department of Medical-surgical Nursing

Nightingale College of Nursing

Guruvanna Devara Mutt, Near Binnystone Garden

Banglore - 560023

RAJIV GHANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA

CURRICULUM DEVELOPMENT CELL

ANNEXURE-2

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERATION

|1. |NAME OF THE CANDIDATE AND | MS MAMTA THAPA |

| |ADDRESS |1 YEAR MSC.NURSING NIGHTINGALE COLLEGE OF NURSING GURUVANNA DEVARA |

| | |MUTT, NEAR BINNYSTON GARDEN MAGADI ROAD |

| | |BANGALORE-23 |

|2. |NAME OF THE INSTITUTION |NIGHTINGALE COLLEGE OF NURSING GURAVANNA DEVARA MUTT, MAGADI ROAD |

| | |BANGALORE. |

|3. |COURSE OF STUDY AND SUBJECT |MSC NURSING IN MEDICAL SURGICAL NURSING |

|4. |DATE OF ADMISSION TO THE COURSE |04/05/2011 |

| | |

|5. |TITLE OF THE TOPIC |

| |A STUDY TO ASSESS THE KNOWLEDGE REGARDING WEANING THE CRITICALLY ILL PATIENT FROM MECHANICAL VENTILATION AMONG ICU NURSES AT |

| |SELECTED HOSPITAL IN BANGLORE |

| | |

|6. |BRIEF RESUME OF THE INTENDED WORK |

| |INTRODUCTION |

| |The trouble with always trying to preserve the health of the body is that it is so difficult to do without destroying the health |

| |of the mind. -G.K. Chesterton |

| | |

| |Advanced technology is a major part of the ICU and mechanical ventilation (MV) is one of the most commonly used treatment |

| |modalities in the care of the critically ill patient.1 Up to 90% of patients globally require mechanical ventilation (MV) during |

| |some or most part of their stay in the ICU.2 Mechanical ventilation (MV) is a key component in the care of critically ill and |

| |injured patients. Delays in weaning the patient from MV increase the number of complications and may lead to increased |

| |expenditure. Consequently, weaning constitutes a major challenge for the intensive care staff. It is important to wean the |

| |patient from MV as expeditiously as possible. Several studies indicate that the implementation of nurse-led, protocol-directed |

| |weaning reduces the amount of time spent on MV, the length of ICU stay, and associated costs.3 |

| | |

| | |

| |Mechanical ventilation is often life-saving procedures, but constitutes an expensive treatment modality which is associated with |

| |iatrogenic complications such as ventilator-associated pneumonia (VAP) and ventilator-induced lung injury, which can lead to the |

| |development of the Acute Respiratory Distress Syndrome (ARDS) and increased mortality and morbidity.4 The reasons for initiating |

| |MV are diverse. The most common reasons for initiation of MV are described as follows: pneumonia/acute lung injury (33.2%), |

| |chronic obstructive pulmonary disease (9.7%), cardiogenic pulmonary oedema (5.2%), neurological emergencies (16.9%), |

| |post-operative complications (24%) and cardiopulmonary arrest (11%).5 |

| | |

| | |

| |The time used versus time available for weaning ratio represents a new way of reporting the weaning status and process at an |

| |organizational level. Although various patient and systemic factors were linked to weaning activity, the most important factor |

| |was whether the intensive care unit nurse’s made use of time available. It showed that weaning frequently was given low priority |

| |despite being an essential part of care of the mechanically ventilated patients.6 It is vital for intensive care nurses to |

| |deliver high quality care to the critically ill patient using relevant technologies but also incorporating psychosocial care |

| |measures. This balance is often one of the largest challenges facing by nurses in the intensive care environment. For this |

| |reason, intensive care nurses need to determine the unique interventions that will positively impact on the mechanically |

| |ventilated patient and assist in the patient’s progression toward desired outcomes.7 |

| | |

| | |

| |Our geographical isolation often results in difficulty recruiting experiences critical care nurses. This combined with global |

| |nursing shortage, results in hiring and educating new graduates or nurses with no critical care experience. Even experienced |

| |critical care nurses have belief that there is an increased risk of error if a standardized approach is not followed.8 |

| | |

| | |

| |Critical care nurses’ skill level is dependent upon their knowledge, experience of, and exposure to, critically ill patients.9 |

| |Nurses can improve patient recovery by skilled and timely reduction of sedation as well as weaning from ventilation. The skilled |

| |critical care nursing will reduce the risk of complications, the number of critical care bed days and improve patient outcomes. |

| |Nurses’ is key provider of information to patients, relatives and other members of the interdisciplinary team. |

| |R O Y A L C O L LE O F N U R S I N G |

| | |

| | |

| |NEED FOR STUDY |

| | |

| |Mechanical Ventilation (MV) is one of the core components of supportive therapy for critically ill patients and is often |

| |lifesaving. But its application may lead to numerous types of lung injury, known as ventilator-induced lung injury (VILI).10 |

| |Caring for a patient who needs MV requires sound knowledge of MV and pulmonary physiology. Understanding the basics of MV can |

| |make all the difference for your patient. Critical care nurses assume an increasingly important role in the early identification |

| |of complications. Critical care nurses can identify subtle changes in a patient’s clinical status and initiate appropriate |

| |nursing interventions rapidly and effectively. |

| | |

| | |

| |Translating research into practice is essential in providing care that promotes both cost-efficient and effective health care |

| |delivery. Nurses practicing in the intensive care unit are in need of education that can build research self-efficacy and promote|

| |understanding and the ability to apply research findings. The critical reading of research publications plus course with |

| |intensive care unit nurses showed that using a course along with mentors may increase the research self-efficacy of practicing |

| |nurses.11 |

| | |

| | |

| |Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational |

| |interventions, including weaning protocols, may 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. Revalidation of protocols for ventilation practices in other clinical contexts may be |

| |needed.12 Critical care nurses are responsible for the majority of the decision episodes that resulted in a change to ventilator |

| |settings, ranging in complexity from the simple titration of FIO2 to a decision to commence weaning. |

| | |

| | |

| |Mechanical ventilator weaning is a process of continuous communication between nurses and physicians, constituting a process of |

| |experimentation where actions are not always preceded by articulated goals. The process of weaning is dependent upon mutual |

| |adjustment among decision makers but this process is hampered by the lack of common understanding of implicit norms for action.13|

| |Nurses lack formal competencies in relation to mechanical ventilation, and the formal competencies do not increase as the |

| |qualifications increase, but there is an acceptance that nurses' informal competencies increase with experience. Critical care |

| |education for nurses is not mandatory, and the education is viewed by many as a reward rather than a prerequisite for work in |

| |critical care. |

| | |

| |Competence is currently assumed on successful completion of a nursing qualification. It is recognized that not all nurses |

| |function at the same level of expertise and knowledge, and therefore there is always a risk of nurses acting in ignorance. If |

| |nurses do not have adequate knowledge on which to base decision-making, patients in ICU may be exposed to unsafe practices |

| |leading to complications, increased length of ICU stay, increased morbidity and mortality and the possibility of litigation, as |

| |nurses are accountable for all their actions. |

| | |

| |There appeared to be lack of knowledge of nurses working in ICU/CCU with regard to weaning from mechanical ventilation. Nurses’ |

| |knowledge regarding weaning a patient from mechanical ventilation needs to be up to date in order to facilitate the process. As |

| |mechanical ventilation is a cornerstone of managing the critically ill patient and in view of the fact that it has numerous |

| |complications as discussed earlier, it is imperative that nurses caring for these patients are in possession of an adequate level|

| |of knowledge regarding MV and weaning modalities to ensure patient safety and optimum treatment. Prompt weaning from mechanical |

| |ventilation will also contribute to decreased length of stay in the ICU. If these casual observations are taken into account, it |

| |is obvious that the area of weaning the critically ill patient from mechanical ventilation needs further exploration. |

| |REVIEW OF LITERATURE |

| |INTRODUCTION |

| |REVIEW OF LITERATURE IS A KEY STEP IN THE RESEARCH PROCESS. LITERATURE REVIEW IS AN EXTENSIVE, EXHAUSTIVE AND SYSTEMATIC |

| |EXAMINATION OF PUBLICATIONS, RELEVANT TO THE RESEARCH PROJECT. IT IS AN IMPORTANT SOURCE FOR DEVELOPMENT OF RESEARCH PROBLEM AND |

| |PROVIDES INFORMATION OF WHAT HAS BEEN DONE PREVIOUSLY. IT HELPS THE RESEARCHER TO BE FAMILIAR WITH THE EXISTING STUDIES AND ALSO |

| |PROVIDES BASIS FOR RESEARCH. THE MAJOR GOALS OF REVIEW OF LITERATURE ARE TO DEVELOP A STRONG KNOWLEDGE BASE TO CARRY OUT RESEARCH|

| |AND NON-RESEARCH ACTIVITY. THE REVIEW OF LITERATURE FOR THE PRESENT STUDY WILL BE DONE ON CARE OF MECHANICALLY VENTILATED |

| |PATIENTS AMONG NURSES FROM PUBLISHED ARTICLES, TEXTBOOKS, REPORTS, NEWSPAPERS, PUB-MED AND INTERNET SEARCH. THE REVIEWED |

| |PUBLICATIONS HAVE BEEN ORGANIZED AND PRESENTED AS FOLLOWS. |

| | |

|6.1. |The cost of providing care to critically ill patients in the United States consumes roughly 15% of all health care dollars. |

| |Contributing to this economic burden are patients admitted to the intensive care unit (ICU) who require mechanical ventilation |

| |and patients with complications from their dependence on this technology. In fact, 50% of ICU patients receive mechanical |

| |ventilation.14 |

| | |

| |SECTION A: NURSES KNOWLEDGE REGARDING WEANING |

| | |

| |Successful mechanical ventilation requires a basic understanding of respiratory physiology and ventilator mechanics in addition |

| |to intensive nursing care. The type of breath delivered by a ventilator is determined by the combination of variables set by the |

| |operator. This combination of settings is known as a mode. The choice of appropriate ventilator settings is largely influenced by|

| |underlying disease process and usually requires some trial and error for each patient. Nurses should have knowledge regarding |

| |ventilator terminology and settings, patient setup, monitoring, and some of the common complications associated with mechanical |

| |ventilation.15 |

| | |

| |Critical care nurses have a high level of responsibility and autonomy for mechanical ventilation and weaning practices and |

| |therefore require in-depth knowledge of ventilator technology, its clinical application and the current evidence for effective |

| |ventilation strategies. Lung protective ventilatory strategies are not consistently applied and weaning and extubation continue |

| |to be delayed. Critical care nurses play a vital role in the recognition of patients capable of spontaneous breathing and ready |

| |for extubation. Critical care nurses need to establish a strong knowledge base to promote effective and appropriate management of|

| |patients requiring mechanical ventilation.16 |

| | |

| | |

| |The professional nurses lack knowledge regarding weaning the critically ill patient from mechanical ventilation. The professional|

| |nurses do not have adequate knowledge related to the underlying indications that need to be resolved prior to commencing weaning |

| |in the critically ill patient. Issues pertaining to withdrawal of ventilator support, when weaning should be considered |

| |successful, the role of NIPPV in weaning as well as the endpoints of the final stages of weaning revealed a lack of knowledge.17 |

| | |

| |Knowledge of nurses, both ICU trained and non-ICU trained, working in the ICUs of three public and two private hospitals was |

| |found to be lacking in the three care areas tested in this study, namely pain management, glycaemic control and weaning from |

| |mechanical ventilation. The difference in knowledge between ICU trained and non-ICU trained nurses was statistically significant |

| |but relatively small. A weak correlation was found between level of knowledge and years of ICU experience. 18 |

| | |

| |Internationally, nurse-directed protocolised-weaning has been evaluated by measuring its impact on patient outcomes. |

| |Nurse-directed protocolised-weaning had no effect on nurses’ views and perceptions due to the high level of satisfaction which |

| |encouraged nurses’ participation in weaning throughout. Weaning protocols provide a uniform method of weaning practice and are |

| |particularly beneficial in providing safe guidance for junior staff.19 |

| | |

| |A study was conducted on “evidenced-based practice: use of the ventilator bundle to prevent ventilator associated pneumonia” |

| |among critical care nurses regarding knowledge about the use of the ventilator bundle to prevent ventilator associated pneumonia.|

| |The study concluded that, education sessions designed to inform nurses, about the ventilator bundle and its use to prevent |

| |ventilator-associated pneumonia, have a significant effect on participants, knowledge and subsequent clinical practice.20 |

| | |

| | |

| |An overall total of 3986 decisions on mechanical ventilation and weaning were identified, a median of 6 decisions per patient per|

| |day of mechanical ventilation. Among the recorded decisions, 2538 (64%) were made exclusively by nurses, 693 (17%) were made |

| |exclusively by medical staff, and 755 (19%) were made by collaboration. In the collaborative decisions, the patient’s bedside |

| |nurse discussed the situation with a medical colleague and nursing input was considered and used in the decision making |

| |process.21 |

| | |

| |SECTION B: MECHANICAL VENTILATION ASSOCIATED COMPLICATIONS |

| | |

| |Ventilator-associated pneumonia (VAP) is considered to be an important cause of infection related death and morbidity in |

| |intensive care units. The educational program involving respiratory therapists and nurses and a self-study module with |

| |pre-intervention and post-intervention assessments, lectures, fact sheets, and posters was conducted. A focused education |

| |intervention resulted in sustained reductions in the incidence of VAP, duration of hospital stay, cost of antibiotic therapy, and|

| |cost of hospitalization.22 |

| | |

| | |

| | |

| | |

| |Previous experimental studies have shown that injurious mechanical ventilation has a direct effect on pulmonary and systemic |

| |immune responses. Evidence from experimental studies suggests that lung over distension during mechanical ventilation causes or |

| |exacerbates lung injury referred as ventilator-induced lung injury (VILI). The current study supports pathway for the |

| |overexpression and release of pro-inflammatory cytokines during ventilator-induced lung injury. The study also suggests that |

| |injurious mechanical ventilation may elicit an immune response that is similar to that observed during infections.23 |

| | |

| | |

| |Dyssynchrony may result because mechanical ventilators lack the simultaneous responsiveness needed for interaction with the |

| |dynamic conditions of patients. Patient ventilator dyssynchrony (PVD) can prolong mechanical ventilation and hospital stay, and |

| |is common yet underappreciated in critically ill patients. Sedation is a common solution for managing dyssynchrony, but it may |

| |not always be the best answer for all types of dyssynchrony. We can describe the biochemical markers of PVD, through direct |

| |observations and continuous data recordings of heart rate, respiratory rate, end tidal carbon dioxide, and oxygen saturation. |

| |Collaborative teamwork will resolve the identification and treatment of PVD.24 |

| | |

| | |

| | |

| |Nosocomial pneumonia (NP), also known as hospital-acquired pneumonia, is a lower respiratory tract infection that was not present|

| |or incubating on admission to hospital. In critical care units (CCUs) NP is the most common nosocomial infection, with prevalence|

| |rates ranging from 10% to 70%. Ventilator support is a well-known risk factor for NP; the incidence of NP is 6 to 20 times higher|

| |in patients treated with continuous ventilatory support. Several important deficits in nosocomial pneumonia knowledge were |

| |identified indicating a need for critical care nurses to have greater exposure to nosocomial pneumonia prevention education, |

| |guidelines, and research.25 |

| |STATEMENT OF PROBLEM |

| |A study to assess the knowledge regarding weaning the critically ill patient from mechanical ventilation among ICU nurses at |

| |selected hospital in Bangalore. |

| | |

| |OBJECTIVES |

| |-To assess the knowledge regarding weaning the critically ill patient from mechanical ventilation among ICU nurses. |

| |-To develop structured teaching program along with protocol regarding weaning the critically ill patient from mechanical |

| |ventilation among ICU nurses. |

| |-To compare the pre-post knowledge score of weaning the critically ill patient from mechanical ventilation among ICU nurses. |

| |-To associate demographic variables with pre-post knowledge score of ICU nurses with selected demographic variables. |

| | |

| |HYPOTHESIS |

| |H1:- There will be significant difference in pre-test and post-test knowledge score of ICU nurses on weaning the critically ill |

| |patient from mechanical ventilation. |

| | |

| |H2:-There will be significant association between pre-post knowledge score among ICU nurses with selected demographic variables |

| |(such as; age, qualifications, years of work experience, trainings). |

| | |

| |OPERATIONAL DEFINITIONS |

| |ASSESS |

| |Assess refers to the process of detecting knowledge of ICU nurses regarding weaning the critically ill patient from mechanical |

| |ventilation. |

| | |

| |KNOWLEDGE |

| |It refers to correct responses of ICU nurses to the knowledge part of self - administered questionnaire and express as knowledge |

| |score. |

| |NURSES |

| |The word refers to the nursing staff working in ICU ward and acquires knowledge on the given topics. |

|6.2. |MECHANICAL VENTILATOR |

| |Mechanical ventilators are devices that provide ventilation (respirations) for the patient who are unable to breathe effectively |

| |on their own. |

| | |

| |ASSUMPTIONS |

| |-Structured teaching program on weaning the critically ill patient from mechanical ventilation among nurses will improve the |

| |quality and safety of client care. |

| |-ICU nurses should be able to co-relate nursing care of mechanically ventilated patients with complications. |

| |DE-LIMITATIONS |

| |The study is delimited to: |

| |-Nurses working in ICU ward in selected hospital in Bangalore. |

| |-Nurses who are willing to participate. |

| |-The duration of study is one month. |

| | |

| |PROJECTED OUTCOME |

| |The pre-set study will help nurses to understand about the ventilator settings and nursing management regarding weaning |

| |mechanically ventilated patient. |

| | |

| |MATERIALS AND METHODS |

| |SOURCE OF DATA |

| |The primary data will be collected from nurses working ICU ward in selected hospital. |

| |7.1.1. RESEARCH DESIGN |

| |The research design adopted for this quasi- experimental study is one group pre-test and post-test design. |

| |RESEARCH APPROACH |

| |The research approach is evaluative approach. |

| |7.1.2. SETTING |

| |The study will be conducted in selected hospital at Bangalore |

| |7.1.3. POPULATION |

| |The population selected in this study include ICU nurses working in selected hospital in Bangalore. |

| | |

| |METHOD OF COLLECTION OF DATA |

| |7.2.1. SAMPLING PROCEDURE |

| |The sampling technique adopted for this study is purposive. |

| |7.2.2. SAMPLE SIZE |

| |The sample size is 60. |

| |7.2.3. INCLUSION CRITERIA |

| |The criteria for sample selection are nurses: |

| |-Who are present at the time of data collection |

| |-Who are willing to participate in the study |

| |-Who are working in ICU ward |

| |7.2.4. EXCLUSION CRITERIA |

| |The criteria for excluding sample are nurses: |

| |-Who are not willing to participate in the study |

| |-Who are on leave at time of data collection |

| |-Who are not working in ICU ward |

| |7.2.5. INSTRUMENT INTENDED TO BE USED |

| | |

| |SELECTION OF TOOL |

| |This consists of three parts: |

| | |

| |Part-1:- Consist of demographic variables such as age, qualifications, socio-economic status, years of work experience, training |

| |etc. |

| | |

| |Part-2:- Self-administered questionnaire will be used to assess the knowledge. |

| | |

| |The content of Self-administered questionnaire will be: |

| |-Basic knowledge regarding weaning critically ill patient from mechanical ventilation. |

| |-Advanced knowledge regarding weaning critically ill patient from mechanical ventilation. |

| |-Applied knowledge regarding weaning critically ill patient from mechanical ventilation. |

| | |

| |Part-3:- Structured teaching program regarding ventilator settings and nursing management regarding weaning mechanically |

| |ventilated patient. |

| | |

| | |

| | |

| | |

| | |

| |SCORING PROCEDURE |

| |For Knowledge Assessment |

| |For Answers |

| |If answer is yes 1 |

| |If answer is no 0 |

| | |

| |SCORING INTERPRETATION |

| | |

| |LEVEL OF KNOWLEDGE |

| |RANGE |

| | |

| |Adequate knowledge |

| |75-100% |

| | |

| |Moderate knowledge |

| |51-74% |

| | |

| |In adequate knowledge |

| |50% and below |

| | |

| | |

| |7.2.6. DATA COLLECTION METHOD |

| |Prior permission will be obtained from the superintendent of the hospital before conducting the study. Questionnaire will be |

| |distributed to the nurses between 10 am-3pm. Data will be collected 15 samples per day. The duration will be 4 weeks. |

| | |

| |Phase-1:- With prior informed consent pre-test will be conducted among nurses regarding care for mechanically ventilated |

| |patients. |

| | |

| |Phase-2:- The researcher will conduct structured teaching program among nurses regarding care for mechanically ventilated |

| |patients. |

| | |

| |Phase-3:- After 3-5 days of conducting structured teaching program among nurses working in intensive care unit, post-test on |

| |knowledge will be conducted among nurses regarding care for mechanically ventilated patients. |

| |2.7.7. PILOT STUDY |

| |6 Samples will be selected and study will be conducted to find out feasibility. |

| |2.7.8. DATA ANALYSIS PLAN |

| |The data obtained will be analysed in view of the objective of the study using analytic and inferential statistics. |

| | |

| |The plan for data analysis is as follows: |

| |-Means, median and modes, standard derivation is used for assessing the knowledge score. |

| |-Chi-square test to find out the association between knowledge with selected demographic variables. |

| |-Frequencies and percentage of distribution will be presented in tables, figures and graph. |

| | |

| |DOES THE STUDY REQUIRED ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? |

| |NO |

| | |

| |WAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION? |

| |Yes, ethical clearance will be been obtained from the research committee of nightingale college of nursing. |

| |Consent will be taken from the medical superintendent and permission will be taken from the study subjects before the collection |

| |of data. |

| | |

| | |

| | |

| | |

| | |

| | |

| |REFERENCES |

| | |

| |1. Burns, S. M. Mechanical ventilation of patients with acute respiratory distress syndrome and patients requiring weaning: The |

| |evidence guiding practice. Critical Care Nurse. 2005; 25 (4): 14-24. Accessed Date: 06/11/ 2011. |

| | |

| |2. McLean E, Jensen A, Schroeder G, Gibney T, Skjodt M. Improving adherence to a mechanical ventilation weaning protocol for |

| |critically ill adults: Outcomes after an implementation program. American Journal of Critical Care. 2006; 15 (3): 299-309. |

| |Accessed Date: 06/11/2011. |

| | |

| |3. MacIntyre N, Cook J, Ely W, Epstein K, Fink B, Heffner E, Hess D, Hubmayer D, Scheinhorn J. Evidence-based guidelines for |

| |weaning and discontinuing ventilator support; a collective task force facilitated by the American College of Chest Physicians. |

| |The American Association for Respiratory Care and the American College of Critical Care Medicine. 2001, 120:375S-395S. Accessed |

| |Date: 09/11/2011. |

| | |

| |4. Grap M, Strickland D, Tormey L, Keane K, Lubin S, Emmerson J, et al. Collaborative Practice: Development, implementation and |

| |evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care. 2003; 12 (5): |

| |454-460. Accessed Date: 12/11/2011. |

| | |

| |5. Krishnan A, Moore D, Robson C, Rand C, Fessler H. A prospective, controlled trial of a protocol-based strategy to discontinue|

| |mechanical ventilation. American Journal Respiratory Care. 2004; 169 (10): 673-678. Accessed Date: 07/11/2011. |

| | |

| |6. Hansen S, Fjaelberg M, Nilsen B, Lossius M. Mechanical ventilation in the ICU- is there a gap between the time available and |

| |time used for nurse-led weaning? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2008. Available from: |

| |. Accessed Date: 08/11/2011. |

| | |

| |7. Coyer M, Wheeler K, Wetzig M, Couchman A. Nursing Care of Mechanically Ventilated Patient: What does the evidence say? |

| |Intensive and Critical Care Nursing. 2007; 23, 71—80. Available from: . Accessed Date:|

| |08/11/2011. |

| | |

| |8. Kress J, Pohlman A, Hall J. Sedation and analgesia in the intensive care unit. American Journal of Respiratory Critical Care |

| |Medicine. 2002:166, 1024-1028. Accessed Date: 13/11/2011. |

| | |

| |9. Galley J, Riordan B. Guidance for nursing staff in critical care. Royal college of Nursing. February 2003. Available from: |

| | Accessed Date: 05/12/2011. |

| | |

| |10. Lian X. Know the facts of mechanical ventilation. Men in nursing. December 2008; 10-16. Available from: |

| | Accessed Date: 06/11/2011. |

| | |

| |11. Britt Swenson. Research Education for Clinical Nurses: A Pilot Study to Determine Research Self-efficacy in Critical Care |

| |Nurses. Journal of continuing Education in Nursing. 2009 October; 40 (10): 454-461. DOI: 10.3928/00220124-20090923-05. Accessed |

| |Date: 18/11/2011. |

| | |

| |12. Rose L, Nelson S, Johnston L, Presneill J. Decisions Made By Nurses During Mechanical Ventilation and Weaning in Australian |

| |Intensive Care Unit. American Journal of Critical Care. 2007 September; 16 (5), 434-443. Accessed Date: 06/11/2011. |

| | |

| |13. Ingrid E. A descriptive, comparative study of nurses’ decisions and interventions related to mechanical ventilator weaning |

| |[PhD thesis]. Copenhagen: University of Copenhagen; 2003. Available from: University of Copenhagen Library E. Reserve. Accessed |

| |Date: 04/12/2011. |

| | |

| |14. Marine LP. The ICU Book. 3rd edition. Lippincott’s William & Wilkins: Wolters Kluwer, New Delhi; 2007. |

| | |

| | |

| | |

| |15. Clare M, Hopper K. Mechanical Ventilation: Ventilator Settings, Patient Management, and Nursing Care. Compendium. April 2005;|

| |256-268. Available from: Accessed Date: 08/11/2011. |

| | |

| |16. Rose L. Clinical application of ventilator modes: ventilator strategies for lung protection. Australian college of critical |

| |care nurses. May 2010; 23(2): 71-80. Available from: PMID: 20378369. Accessed Date: 03/12/2011. |

| | |

| |17. Demingo P. Professional nurses’ knowledge regarding weaning the critically ill patient from mechanical ventilation |

| |[M.Sc.Nursing Thesis]. South Africa: Nelson Mandela Metropolitan University; November 2009. Available from: |

| | Accessed Date: 06/11/2011. |

| | |

| |18. 14. Perrie HC. Knowledge of intensive care nurses in selected care areas commonly guided by protocols [M.Sc.Nursing Thesis]. |

| |Johannesburg: University of Witwatersrand; 2006. Available from: Accessed Date: |

| |04/12/2011. |

| | |

| |19. Blackwood B, Wilson J. The impact of nurse directed protocolised weaning from mechanical ventilation on nursing practice: A |

| |quasi-experimental study. International Journal of Nursing Studies. February 2007; 44 (2) 209-226. DOI: |

| |10.1016/j.ijnurstu.2005.11.031. Accessed Date: 19/11/2011. |

| | |

| |20. Tolentino-DelosReyes AF, Ruppert SD, Shiao SY. Evidenced-based practice: use of the ventilator bundle to prevent ventilator |

| |–associated pneumonia. American Journal of Critical care 2007; 16(1):20-27. Accessed Date: 08/11/2011. |

| | |

| |21. Lisa Beck, Chad Johnson. Implementation of a nurse-driven sedation protocol in the ICU. Canadian Association of Critical Care|

| |Nurses. 2008. Available from: Accessed Date: 25/11/2011. |

| | |

| | |

| | |

| |22. Anucha A, Uyaporn P, Thongphubeth K, Chanart Y, David K, Jeanee E, et.al. Effectiveness of an educational program to reduce |

| |ventilator associated pneumonia in a tertiary care centre in Thailand: A 4 year study. Infectious diseases society of America. |

| |August 2007; 45: 704-11. Available from: DOI: 10.1086/520987. Accessed Date: 08/11/2011. |

| | |

| |23. Cook J, Meade M, Perry G. Qualitative studies on the patient’s experience of weaning from mechanical ventilation. American |

| |College of Chest Physicians. December 2001; 120: 469S-473S. Available from: Accessed Date:|

| |09/11/2011. |

| | |

| |24. Karen G, Mary J, Cindy L, Curtis N, Paul A. Patient-Ventilator Dyssynchrony: Clinical Significance and Implications for |

| |practice. American Association of Critical Care Nurse. 2009; 29, 41-55. Available from: |

| | |

| |Accessed Date: 12/11/2011. |

| | |

| |25. Lam K, Mclain K, Wilson J, Geok K. Critical care nurses’ knowledge in preventing nosocomial pneumonia. Australian journal of |

| |advanced nursing. September 2006; 24 (3) 19-25. Accessed Date: 03/12/2011. |

| | |

| | |

| | |

|6.3. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.4. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.5. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.6. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.7. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.8. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|6.9. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|7. | |

| | |

|7.1. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|7.2. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|7.3. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|7.4. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|8. | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|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 DEPARTMENT | |

| |11.6. SIGNATURE | |

|12. |12.1. REMARKS OF THE PRINCIPAL | |

| |12.2. SIGNATURE | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download