SYNOPSIS FOR REGISTRATION OF SUBJECT

FOR DISSERTATIONSUBMITTED TO:

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

IN PARTIAL FULFILLMENT

OF

M.Sc. (N) IN MEDICAL SURGICAL NURSING

SUBMITTED BY:

Mrs. MANJULA. S.

I YR M.Sc. (N)

UNDER THE GUIDANCE OF:

Mrs. JESSY JACOB

ASSOCIATE PROFESSOR

MEDICAL SURGICAL NURSING

NARAYANA HRUDAYALAYA COLLEGE OF NURSING

NO: 258/A, BOMMASANDRA INDUSTRIAL AREA

ANEKAL TALUK, BANGALORE-99

1 NAME OF THE CANDIDATE AND ADDRESS

Mrs. MANJULA. S 1st YEAR M. Sc. NURSING, NARAYANA HRUDAYALAYA COLLEGE OF NURSING, BOMMASANDRA INDUSTRIAL AREA, BANGALORE – 99.

2 NAME OF THE INSTITUTION NARAYANA HRUDAYALAYA COLLEGE OF NURSING.

3 COURSE OF STUDY AND SUBJECT 1ST YEAR M. Sc. NURSING (MEDICAL SURGICAL NURSING)

4 DATE OF ADMISSION TO COURSE 18/06/2009

5 TITLE OF THE TOPIC EFFECTIVENESS OF A STRUCTURED

TEACHING PROGRAMME ON

KNOWLEDGE REGARDING PREVENTION

OF DEEP VEIN THROMBOSIS AMONG

ORTHOPEDIC PATIENTS.

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PROBLEM STATEMENT

A STUDY TO ASSESS THE EFFECTIVENESS OF A STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF DEEP VEIN

THROMBOSIS AMONG ORTHOPEDIC PATIENTS IN A SELECTED HOSPITAL,

BANGALORE

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:- Venous thrombosis is the term used for the formation of blood clot in venous

system. Vascular system is a vast network through which blood circulates in the body.

Approximately 75% of total blood volume is contained in the veins. Venous disorders

are characterised by stasis, coagulability of blood and vessel wall injury1.

Deep vein thrombosis (DVT) is a condition in which blood clot is formed in

the veins due to venous stasis. A worldwide survey conducted by WHO showed that

Deep vein thrombosis is a common disease and leads to pulmonary embolism.

Survivors may experience serious and long term complications2.

World statistics revealed that 25% to 40% of patients over the age of 40 years,

operated for one or more hours develop deep vein thrombosis, therefore knowledge

on prevention is essential. There is also associated clinical morbidity in post

thrombotic syndrome5.

6.1: NEED FOR THE STUDY:

Deep vein thrombosis is more prevalent in patients who have undergone

surgeries, which reduce movement and enforce bed rest and immobility. Deep vein

thrombosis is a major source of morbidity and mortality in healthy patients, who have

undergone surgeries.

Postoperative orthopedic patients are at risk and prone to develop Deep vein

thrombosis. Deep vein thrombosis of the lower limb is often asymptomatic1.

Trends in nursing care are challenging with the scientific and technological

growth. Nurses must acquaint themselves with changing trends. Nurses have major

responsibility as a teacher in educating patients5.

Hence the researcher would like to conduct a study to assess the effectiveness

of a structured teaching programme on knowledge regarding prevention of deep vein

thrombosis among postoperative orthopedic patients.

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6.2: REVIEW OF THE LITERATURE

Based on the objectives of the study the review of the literature had been arranged under

the following sections.

SECTION A: Incidence of deep vein thrombosis among orthopedic patients.

SECTION B: Risk factors for deep vein thrombosis in postoperative patients.

SECTION C: Prevention of deep vein thrombosis in orthopedic patients.

SECTION D: Knowledge of orthopedic patients regarding deep vein thrombosis

SECTION A: Incidence of Deep vein thrombosis among orthopedic patients

A study was conducted to identify the incidence of post operative deep vein

thrombosis in a population undergoing major lower limb surgeries. A total of 104

adult patients were enrolled, venous thrombosis was observed in 35.6% of patients

who underwent total hip replacement, 46% with total knee replacement and 18.3%

with fixation involving femur and tibia bone. In this group overall 52.1% showed

venographic evidence of venous thrombo-embolism. The study has shown that post

operative deep vein thrombosis is common in Indian population7.

There are few studies on the incidence of deep vein thrombosis complicating

total knee arthroplasty in Asians. The incidence of proximal deep vein thrombosis in

these studies ranges from 0.8% to 14.5%. Since the age distribution in this study is

similar to that in other studies, age is therefore not considered a contributing factor to

deep vein thrombosis in Asian compared to western patients8.

Trauma patients are at high risk for thrombotic events due to increased hyper

coagulability and decreased function of the fibrinolytic system. Increased

hypercoagulability results from venous stasis due to immobilization, direct endothelial

damage to vessels and specific alterations in the clotting mechanism including

increased tissue factor release. Increased incidence of deep vein thrombosis and

pulmonary embolism is observed in patients with single extremity and multiple

extremity trauma4.

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SECTION B: Risk factors for Deep vein thrombosis in postoperative Patients

The thromboembolic risk factor classification stratifies total knee arthroplasty

into the highest risk category with a proximal deep vein thrombosis rate of 10% to

20%, symptomatic pulmonary embolism rate of 5% to 10%, and a fatal pulmonary

embolism rate of 1% to 5%7.

A study was conducted to evaluate the risk factors for the development of

thromboembolic disease and to examine the issue of routine thrombo prophylaxis.

Six hundred and two patients were included in this study. Risk factors identified for

postoperative thromboembolic disease were a history of rheumatoid arthritis, a recent

history of air travel, previous deep vein thrombosis or pulmonary embolism and limb

immobilization. The study concluded that the incidence of thromboembolic disease

after foot and ankle surgery could be higher than that of previously reported,

particularly if a patient has certain risk factors6.

A multi centered study was done among patients with clinically evident

thromboembolic disease to evaluate potential risk factors. Factors found to correlate

with an increased incidence of deep vein thrombosis were non weight bearing status

and immobilization after surgery8.

A study was conducted in Italy among patients in cardiac rehabilitation, to

estimate rate of deep vein thrombosis in relation to different thrombo prophylaxis

strategies. Two hundred and seventy patients admitted in 3 rehabilitation centers after

coronary artery bypass graft, were included in the study, deep vein thrombosis was

detected in 47 patients (17.4%), the rate of proximal and isolated deep vein

thrombosis was 2.6% (7 cases) and 14.8% (40 cases) respectively. Clots were found

in contra lateral to sapheneous vein site in half of all deep vein thrombosis case. The

study showed that in patients undergoing cardiac rehabilitation after coronary artery

bypass graft surgery are at risk for deep vein thrombosis8.

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SECTION C: Prevention of Deep vein thrombosis in orthopedic patients

Deep vein thrombosis prevention can be as simple as doing regular stretching

exercises. Mobility is the best method to prevent deep vein thrombosis. When the leg

muscles are inactive, blood collects in the legs and lower extremities. Regular

mobility and stretching exercises help to maintain proper blood circulation. Mobility

and stretching exercises are particularly important for those who have had recent

surgery, especially hip or knee surgery, which carries a high risk of deep vein

thrombosis formation. Mobility may be impaired by surgery, but the right exercises

will help to prevent blood clots5.

According to short term postoperative prophylaxis strategy, heparin is

administered in early post operative period. The rate of deep vein thrombosis was 2%

and 8% in patients with and without heparin respectively4.

Prophylactic anti-platelet therapy for one to three weeks in high risk surgical

and medical patients is associated with 39% reduction of venous thrombosis and 64%

reduction of pulmonary embolism6.

Compression stockings will prevent post operative DVT among orthopedic

and general surgery patients at moderate risk2.

A systematic review in 87 patients who have undergone general surgery and

94 patients who undergone orthopedic surgery, revealed that low molecular weight

heparin was effective as standardised heparin in prevention of deep vein thrombosis

and pulmonary embolism7.

The prophylaxis in deep vein thrombosis includes anticoagulation and

physical measures in the prevention of deep vein thrombosis. Prophylactic anti-

platelet therapy for one to three weeks in high risk surgical and medical patients is

associated with 39% reduction of venous thrombosis and 64% reduction of pulmonary

embolism.

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SECTION D: Knowledge of orthopedic patients regarding Deep vein thrombosis

A survey was conducted among postoperative orthopedic patients to assess

knowledge regarding deep vein thrombosis. Differing levels of knowledge was present

between patients. Only small sub set of patients had informed about DVT symptoms and

consequences9.

Deep vein thrombosis is a common postoperative complication associated with

significant morbidity and mortality. Prophylaxis rates are high as 50% following

orthopedic surgery and 25% following general surgery. There is evidence to support

significant association between increased age, obesity, past history of thromboembolism

and orthopedic surgery with higher rates of postoperative deep vein thrombosis. An

accurate knowledge is important in preventing postoperative deep vein thrombosis4.

6.3: OBJECTIVES OF THE STUDY:

To assess the knowledge regarding prevention of deep vein thrombosis before and after structured teaching programme among orthopedic patients.

To identify association between knowledge and selected demographic variables.

To determine the effectiveness of structured teaching programme on knowledge regarding prevention of deep vein thrombosis.

6.4: OPERATIONAL DEFINITIONS:

Effectiveness: It refers to Change in knowledge score as a result of structured teaching programme as measured by questionnaire.

Structured Teaching Programme: It refers to Planned teaching regarding prevention of deep vein thrombosis.

Knowledge: It refers to the understanding regarding various aspects of deep vein thrombosis. Such as meaning, causes, signs and symptoms and prevention.

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Orthopedic Patients: It refers to adults who are undergoing open reduction or hip/knee replacement surgeries or immobilized due to any other orthopedic conditions.

Deep Vein Thrombosis: It refers to formation of blood clot in deep veins of legs due to immobility among orthopedic patients.

6.5: ASSUMPTIONS:

1. Orthopedic patients are prone to develop deep vein thrombosis.

2. Orthopedic patients have some knowledge regarding deep vein thrombosis.

3. The planned teaching programme will improve the knowledge of orthopedic patients regarding prevention of DVT.

6.6: HYPOTHESIS

H1: The mean post test knowledge score of patients will be significantly higher than

their mean pre test knowledge score at 0.05level of significance.

H2: There will be a significant positive association between knowledge and selected

demographic variables at 0.05level of significance.

6.7: DELIMITATIONS

1 The study delimited to patients who are admitted in Sparsh hospital.

2 Data collection is delimited for a period of 6 weeks.

3 Generalisation of finding will be delimited to population studied.

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7. MATERIALS & METHODS

7.1 Sources of data

• Patients who are undergoing a planned open reduction or hip/knee replacement surgeries or immobilized due to any other orthopedic conditions.

7.2 METHODOLOGY

7.2.1 Research approach : This study will incorporate an evaluative approach.

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

7.2.3 Sample : Patients who are undergoing a planned open reduction or hip/knee replacement surgeries or immobilized due to any other orthopedic conditions and are admitted in Sparsh Hospital, Bangalore.

7.2.4 Sample size : 30

7.2.5 Sampling Technique : Simple Random sampling

7.2.6 Sampling Criteria :

Inclusion criteria:

• Patients who are willing to participate in the study.

• Patients who are undergoing a planned open reduction or hip/knee replacement

surgeries or immobilized due to any other orthopedic conditions.

• Patients who can understand English, Kannada, Telugu, Tamil or Hindi

Exclusion Criteria

• Patients who are unable to comply with the requirements of the study

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7.2.7 Variable

Independent variable : Structured teaching programme

Dependent variable : Knowledge regarding prevention of deep vein thrombosis.

7.2.8 Setting

• Sparsh Hospital

7.2.9 Data collection technique

Obtain formal administrative permission.

Obtain informed consent from patients.

Select sample using simple random sampling.

Assess the knowledge by using structured questionnaire (pretest).

Provide structured teaching programme.

Reassess the knowledge by using the same structured questionnaire (posttest).

DESCRIPTION OF TOOLS:

Section- A

Demographic profoma : Age, gender, education, economic status, occupation and previous history of orthopedic surgery,

Section -B

Structured Questionnaire : Regarding prevention of deep vein thrombosis

7.2.10 Data Analysis:

Descriptive Statistics – frequency, percentage, mean, standard deviation.

Inferential Statistics : Chi-square

- t test

- One way analysis of variance

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7.3. Does the study require any investigation or interventions to be

conducted on patients or other humans or animals? If so, please

describe briefly.

Yes the study requires the assessment of knowledge regarding prevention of deep vein

thrombosis by using structured questionnaire (pretest and posttest) structured teaching

will be given after pretest.

7.4 Has ethical clearance been obtained from your institution?

Ethical clearance is obtained from the institution and hospital.

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8. REFERENCES

1. Smeltzer S, Bare B. Medical Surgical Nursing. 10th Edition: Lippincott William and Wilkins publishers; 2008: 1104 – 1109.

2. http:\\www.orthobluejouranl.com; Jennifer and Christopher, department of orthopedics, Brown University.

3. Lewis SM, Heitkemper MM, Driksen SR. Medical Surgical Nursing, Missouri, mosby by publication; 2008: 648 – 650

4. Brady L.P ; A Multifaceted approach to prevention of VTE vascular Nursing; 2004 : 261 – 269

5. http://www.bmj.com/prodigy/dvt/view.

6. Russel S. C Prophylaxis of postoperative deep vein thrombosis and pulmonary & embolism surgery 2002: 89 – 104

7. Clagett G.P. & Reisch, J.S. Prevention of venous thromboembolism in general surgical patients.

8. Journal of orthopedic surgery orthopedics, Vol. 27, 2005: 11(2): 184–189.

9. http://www.ncbi.nim.nih.gov.pubmed.

10. Orthopedic nursing, national association of orthopedic nurses, the leader in practice and education.vol-28,nov 4;167-174

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9. Signature of Candidate :

10. Remarks of the Guide :

11. Name & Designation of

a. Guide : Mrs. Jessy JacobAssociate Professor, Medical Surgical Nursing,Narayana Hrudayalaya College of Nursing.

b. Signature :

c. Co-Guide (if any) :

d. Signature :

e. Head of Department : Mrs. PriyalathaHOD of Medical Surgical NursingNarayana Hrudayalaya College of Nursing

f. Signature :

12. 12.1 Remarks of the Chairman & Principal

12.2 Signature:

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