RAJIV GANDHI UNIVERSITY OF HEALTH SCEINCES BENGALURU

KARNATAKA.

PROFORMA FOR REGISTRATION OF

1. NAME AND ADDRESS OF THE CANDIDATE

: Mr. SHAFI SHAMSUDIN

I YEAR M.SC NURSING,

GAT CAMPUS,R.R.NAGAR,

BENGALURU-560098

2. NAME AND ADDRESS OF THE COLLEGE

: GLOBAL COLLEGE OF NURSING,

GAT CAMPUS,R.R.NAGAR,

BENGALURU-560098

3. COURSE OF STUDY AND SUBJECT

: I YEAR M.SC.NURSING,

MEDICAL-SURGICAL NURSING.

4 DATE OF ADMISSION 01-06-2011.

5 TITLE OF THE TOPIC

: Effectiveness of Structured Teaching Programme

on Knowledge regarding Autar Scale among staff

Nurses in Selected Hospitals, Bangalore.

6. BRIEF RESUME OF INTENDED WORK

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INTRODUCTION

The goal of medicines is to promote, preserve and restore health. These goals are

embodied in the word prevention. Successful prevention depends upon knowledge of

causation, identification of risk factors, groups, availability of prophylaxis, early detection

and treatment measures. For applying these measures to appropriate persons or groups

continuous evaluation of development of procedures are applied. Early detection and

treatment are the main intervention of disease control.1

Deep vein thrombosis is a condition in which the blood vessel is blocked by the

embolus carried in the blood stream from the site of formation of clot. Thrombosis usually

develops as a result of venous stasis or slow flowing of blood around venous valve sinuses.

Pulmonary embolism can occur when a fragment of blood clot breaks loose from the wall of

vein and migrate from the heart to the lungs, where it blocks a pulmonary artery or one of its

branches. When the clot is large enough to completely block one or more of the vessels that

supply the lungs with blood, it can result in sudden death.2

Each year Deep Vein Thrombosis occurs in about one in 200 people in general

population ranging from less than one in 300 in those below the age of 40 to one in 500 in

those over 80. 2

In United States more people die each year from Deep Vein Thrombosis than

motor vehicle accidents, breast cancer, and AIDS etc. The American College of Chest

Physicians 2002 reported that in United States each year 3,00,000 to 6,00,000 hospitalizations

are associated with Deep Vein Thrombosis. An estimated 2,00,000 patients die from blood

clots that obstruct blood flow to the lungs. In Canada it is reported that pulmonary embolism

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from DVT causes death of more than 1,00,000 patients each year and it remains a leading

cause of death. 4

6.1 NEED FOR THE STUDY

Deep vein thrombosis (DVT) is a silent killer. It is a serious threat to recovery

from surgery and is the third most common vascular disease, after ischemic heart disease and

stroke.

Thrombo embolism remains a major preventable cause of post operative

mortality and morbidity and very little attention has been given among the Indian patients.

Thrombo embolism is a serious post operative complication. After surgery the patient

experiences a period of enforced bed rest and immobility. It is more prevalent in major

orthopedic surgeries especially total hip and knee replacement, traction and plaster cast

because it further reduces post operative movement and these factors lead to venous stasis

and increased likely hood of thrombosis. 5

The incidence of DVT in India as reported is one percent of the adult

population after the age of forty and is 15 to 20 % in hospitalized patients and the risk of

DVT is 50% in patients undergoing orthopedic surgery particularly involving the hip and

knee. It is 40% in those patients undergoing abdominal or thoracic surgery. 1/100 who

develops DVT dies, usually from the blood clot traveling to the lungs - pulmonary embolism.

According to a study done on 60,000 patients in more than 32 countries, almost one

out of every two hospitalized patients in medical and surgical wards worldwide and in India

was at risk of developing DVT. The study revealed that although the risk of DVT was very

high, only 17 per cent of these patients in India received any prophylaxis. 6

3

The Department of Health has made the prevention of DVT a priority across the

NHS. All patients admitted to hospital should be assessed for their risk of developing a blood

clot and, if necessary, given preventative treatment.

The rapid increase in magnitude of complications needs the attention of health

professionals. Hence in order to reduce the immediate and long term dangers of DVT the

researcher feels that early detection and prevention is very necessary.

The Autar DVT risk assessment scale was developed to separate risk into no risk,

low, moderate and high risk categories. It is recommended that staff nurses using the Autar

DVT scale should evaluate for themselves the best cut-off score to avoid misinterpretations

and to achieve maximum predictive accuracy15

Though many risk assessment scales are available, Autar scale was found to be more

valid and reliable in the case of deep vein thrombosis. So The investigator planned to

administer structured teaching programme to increase the knowledge level of staff nurses

which will help them in to understand more about deep vein thrombosis and to identify the

highly risk patients to deep vein thrombosis.

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6.2 REVIEW OF LITRATURE

Review of literature is a systematic identification, location, scrutiny and summary of

written materials that contain information on research problems. 8

The literature related to the topic are organized and presented under the following

headings.

1. Incidence and prevalence of Deep Vein Thrombosis.

2. Validity and Reliability Assessment of Autar DVT Scale.

3. Knowledge regarding Deep Vein Thrombosis.

The incidence and prevalence of Deep Vein Thrombosis.

A prospective study conducted on incidence of post operative Venous Thrombo

Embolism in Indian patients who have undergone major lower limb surgery. A total of 104

adult patients were enrolled. Venous Thrombosis was observed in 35.6 percent of the patients

who underwent total hip arthroplasty, 46 percent with total knee arthroplasty and 18.3

percent with fracture fixation involving the proximal femur. In this group 52 percent showed

venographic evidence of Venous Thrombosis. The study has shown that post operative

Venous Thrombo Embolism is common in Indian patients. 5

A prospective study was conducted on risk factor and incidence of Deep Vein

Thrombosis among medically-ill hospitalized patients in northern India. Because of the high

risk of missed diagnosis, only a few studies exist on surgical patients. A study was conducted

on medically ill patient both from medical wards and ICU. A total of 163 patients were

studied. None of the patient had prior history of DVT and was at risk of developing DVT.

None of these patients received anticoagulants prior to the development of DVT. The study

5

revealed the risk of DVT was clearly elevated in hospitalized patient than in non-

hospitalized patient. However a large autopsy based study from India revealed a high

prevalence (16 percent) of pulmonary embolism at autopsy in patients dying of a medical

illness. 9

A study conducted in Father Muller Hospital, Kanganadi, Mangalore to determine

the incidence of deep vein thrombosis (DVT) in postoperative patients after major abdominal,

orthopedics and neurosurgical procedures, which require long term postoperative hospital

stay and to identify the risk factors for DVT in these patients. A total number of one hundred

patients were studied. Out of them, 60 were males and 40 were females. In this study, the

incidence of deep vein thrombosis in postoperative patients was found to be 14 %. The

incidence of DVT in our study (14%) is significant enough to advocate prophylactic

anticoagulant therapy to those who have to undergo major surgical procedures and those who

have risk factors. 10

Validity and Reliability Assessment of Autar DVT Scale

A prospective study was conducted in Ain Shams University (EGYPT) aimed to

assess the validity & reliability of "Autar DVT risk scale". The Autar DVT scale was

developed as a predictive index to assess patients' risk and enable the application of the most

effective prophylaxis. The DVT scale was evaluated through data gathered on 35 patients at

vascular surgery to evaluate its validity, reliability and sensitivity as a screening (or

diagnostic test) and prognostic index. This was carried out between May and October 2008 in

Ain Shams Specialized Hospital using the action research technique. The study showed

agreement between duplex and Autar D.V.T scale, at moderate risk it achieved 60%

sensitivity and 40% specificity while 46.6% and 75% at high risk category respectively. The

6

results of this study have provided some interesting data and insight into an effective risk

assessment of DVT patients and guiding decision making. 12

The Autar DVT risk assessment scale was developed by Autar (1994; 1996).

Founded on Virchow’s triad in the genesis of DVT and comprising seven subscales of

thrombogenic risk factors, the DVT risk calculator was validated on a small orthopedic

population. Although positive outcomes were reported, the small yet well formed study did

not permit generalisability of findings and wider application across the boundaries of

practice. Further to revalidate the DVT scale for its universal application and finding and

generalisability by Ricky Autar, Principal Lecturer of De Montfort University, England, 150

patients were randomly recruited from Orthopedic, Surgical and Medical specialties. Data

from two patients, who could not be followed up, were excluded for evaluation of the

predictive accuracy of the DVT scale. Overall, 115 patients out of the 148 (78%) were

correctly classified and predicted. This predictive accuracy of the DVT risk calculator was an

underestimation of its efficacy as it was masked by the administration of prophylaxis to a

large number of high risk patients. As a result of the findings and the availability of new and

compelling research evidence, the Autar DVT scale was revisited and revised for

maximization of its predictive validity. 3

A study was conducted in College of Nursing, USA to test the validity and reliability

of the Autar Scale. Hospital-acquired deep vein thrombosis (DVT) and pulmonary embolisms

(PE) are preventable problems that can increase mortality. Three phases were undertaken in

developing and testing the DVT risk assessment tool. Investigation and clarification of risk

and predisposing factors for DVT were identified from the literature, expert nursing

knowledge, and medical staff input. Second, item development and weighting

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were undertaken. Third, parametric testing for content validity measured the differences in

mean assessment tool scores between a group of patients who developed DVT in the hospital

and a demographically similar group who did not develop DVT. Interrater reliability was

measured by having three different nurses score each patient and compare the differences in

scores among the three. The DVT group had significantly higher scores on the DVT

assessment scale than did those who did not experience DVT. Interrater reliability showed a

strong correlation among the scores of the three nurses. Providing a valid and reliable tool for

measuring the risk for DVT or PE in hospitalized patients will enable nurses to intervene

early in patients at risk. Basing DVT risk assessment on the evidence provided in this study

will assist nurses in becoming more confident in recognizing the necessity for interventions

in hospitalized patients and decreasing risk. Nurses can now evaluate patients at risk for DVT

or PE using the risk assessment tool. 13

Knowledge regarding Deep Vein Thrombosis

Deep vein thrombosis (DVT) constitutes a serious threat to patients' general recovery.

The Autar DVT risk assessment scale was developed to separate risk into no risk, low,

moderate and high risk categories. Founded on Virchow's triad in the genesis of DVT, the

scale is composed of seven categories of risk factors. When the scale was tested on a

trauma/orthopaedic unit a cut-off score of 16 yielded 100% sensitivity, 81% specificity and a

correlation coefficient of 0.98. The DVT scale is designed to allow application in diverse

clinical specialties. It is recommended that staff nurses using the Autar DVT scale should

evaluate for themselves the best cut-off score to achieve maximum predictive accuracy15.

8

A quantitative, cross-sectional survey design was used, and 48 participants

receiving pharmacological thromboprophylaxis participated. Most hospitalized patients

(83%) were aware that were receiving injections to prevent blood clots and 81.2% reported

hearing of either DVT, PE or both conditions. Of the participants who had heard of DVT

and/or PE, 74.2% knew immobility was a risk factor but had limited knowledge of symptoms

and prevention modalities. Participants reported hearing about VTE more frequently from

friends, family or the media than from healthcare providers, including nurses. Participants

were satisfied with pharmacological thromboprophylaxis but were less satisfied with the

information received on VTE. Findings suggest that patients require further information on

VTE during their hospitalization to enhance their involvement in VTE prevention and

recognition, and that the provision of written, patient-directed information could begin to

address that lack of involvement. This study also highlights the need to strengthen the

nurses' role in providing patient education about VTE.16

STATEMENT OF THE PROBLEM

“A study to evaluate the effectiveness of Structured Teaching Programme on

Knowledge regarding Autar Scale among staff nurses in Selected Hospitals,

Bangalore”.

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6.3. OBJECTIVES OF THE STUDY

1. To assess the regarding Autar Scale among staff nurses in Selected Hospitals,

Bangalore.

2. To evaluate the effectiveness of structured teaching programme on Autar scale

among staff nurses by comparing the pre & post test score.

3. To find out the association between knowledge on Autar scale among the staff

nurses with their selected demographic variables.

6.4 Hypothesis:

H1 – There will be significant difference in knowledge regarding Autar scale among

staff nurses before and after administration of STP.

H2 – There will be significant relationship between knowledge on autar scale among

staff nurses and their selected demographic variables.

6.5 OPERATIONAL DEFINITIO

Evaluate: It refers to assess the structured questionnaire regarding autar scale among

staff nurses

Effectiveness: It determines the extent to which structured teaching programme has

improved the knowledge regarding Autar scale among stuff nurses as assessed by

structured questionnaire.

Structured Teaching Programme: It refers to the systematically organized group

instructions and discussions on use of Autar scale

Autar scale : Autar scale is using to assess and identify the patients those who are prone

to develop deep vein thrombosis. The Autar scale (1994) comprised seven subscales:

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increasing age, build and body mass index (BMI), immobility, special DVT risk, trauma,

surgery and high risk disease. The score of Autar scale in DVT is as follows: 1) <6 = No

risk, (2) >10 = Low risk (<10 per cent),(3) 11-14 = Moderate risk (11-40 per cent),(4)

>15 = High risk (>41 per cent).

DVT (deep vein thrombosis): Blood clotting in the veins of the inner thigh or leg. Blood

clots can break off (as emboli) and makes their way to the lung where they have the

potential of causing respiratory distress and respiratory failure

Knowledge: it refers to response of staff nurses to the questionnaire regarding autar scale.

Staff Nurses: Nurses who have completed Basic B.Sc nursing or diploma in nursing and

presently working in the selected hospitals, Bangalore.

7. MATERIALS AND METHODS:

7.1 Sources of data:

The staff nurses who are working in selected hospitals, Bangalore.

7.2 Method of Data Collection: Data will be collected by using structured questionnaire.

7.2.1 Definition of the study subject: Staff nurses in a selected hospitals of Bangalore.

7.2.2 Inclusion & Exclusion Criteria:

a) Inclusion criteria:

Nurses who are,

1. willing to participate in the study.

2. present at the time of the study.

b) Exclusion Criteria:

1. Nurses who have previously attended seminar or work shop on Autar scale.

7.2.3Research Design : Pre experimental, one group pre- test

post –test design.

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7.2.4. Setting : Selected hospitals in Bangalore.

7.2.5. Sampling technique : Convenient sampling technique.

7.2.6

a) Sample Size : 60 Staff Nurses

b) Duration of study : 4 weeks

c)

7.2.7. Tools for Research : The investigator will collect the data by using

structured questionnaire. It consists of two parts.

Part A : Socio Demographic Variables

Part B : Assess the knowledge regarding autar scale.

7.2.8. Collection of data : The investigator himself will collect data

from staff nurses by using structured

questionnaire.

7.2.9 Method Of Data analysis:

1. The researcher will use descriptive and in

ferential statistics to analyse the data.

2. The analysed data will be presented in the form

of tables, figures and graphs wherever necessary.

7.3 Does the study require any investigations or interventions to be conducted on

patients or other humans or animals? If so, please describe briefly.

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No

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, permission has been obtained from the concerned authorities and

subject.

Informed written consent will be obtained from the participants prior to

the study

Privacy, Confidentiality & anonymity will be guaranteed.

Scientific objectivity of the study will be maintained with honesty and

impartiality.

LIST OF REFERENCES:

13

1. Park J E, Textbook of preventive and social medicine, Jabalpur, Bharat

Publisher 2000. p137-8.

2. Brunner and Suddharth’s text book of Medical Surgical Nursing 10th edition,

Lippincott Philadelphia 2004. Pg 405-7

3. Ricky Autar, The Management of Deep Vein Thrombosis_The Autar DVT Risk

Assessment Scale. Available from URL:

http://bjhltx.com/learning/themanagementofdvt_theautar.pdf

4. American college of chest physicians 2002. Prevention of thrombo embolism

chest108; p312-34.

5. Agarwala S, Bhagwat A.S, Modhe J, Deep Vein Thrombosis in Indian patients

undergoing Major limb surgery India J Surg, 2003.65: p159-62.

6. Avaliable From URL:http://www.expresshealthcare.in/200904/market23.shtml

7. Avaliable from URL

:http://www.nhs.uk/conditions/deep-vein-

thrombosis/Pages/Introduction.aspx

8. Polit and Hangler P. Nursing Research Principles and methods, Philadelphia

Lippincott, 1999. P69-71.

9. Surendra K Sharma, Varun Gupta “A prospective study of risk factor profile

and incidence of deep venous thrombosis among medically ill hospitalized

patients in Northern India” , AIIMS, New Delhi, Feb 20, 2009.

10. George C, Rao BSS Shenoy D H, Hegde B R. “The Incidence of Deep Vein

Thrombosis in post operative patients in a large south Indian tertiary care

centre” Father Muller Hospital, Kanganadi, Mangalore-2.

Vol 4, issues 5, Oct 2010, pg3120- 3127. Available in

URL:http://jcdr.in/article_fulltext.asp?issn=0973

14

11. Agarwala S, Bhagwat AS, Wadhwani R. Pre and postoperative DVT in Indian

patients - Efficacy of LMWH as a prophylaxis agent. Indian J Orthop

[serialonline]200524];39:55-8.Available from:

http://www.ijoonline.com/text.asp?2005/39/1/55/36900

12. Dr.SusanM Dosouky, Dr. Eman T Elshamma,Validity and Reliability

Assessment of Autar Scale. Available in URL:

http://www.ijar.lit.az/pdf/3/2010(1-8).pdf

13. Mc Caffrey R, Bishop M, Development and testing of a DVT risk assessment

tool:Providing evidence of Validity and Reliability. Available in URL:

www.ncbi.nlm.nih.gov/pubmed/17355406

14. Awareness of Deep Vein Thrombosis APHA Conference, 1986. Dec. P 105-8

15. Autar, R.Calculating patients' risk of deep vein thrombosis, 17-Oct-

2011,Avaliable from URL: http://hdl.handle.net/10755/170279

16. Stephanie   Le Sage , Marianne   McGee ,Jessica D.   Emed Journal of Vascular

Nursing,Volume 26, Issue 4 , Pages 109-117, December 2008

9 SIGNATURE OF CANDIDATE

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10 REMARKS OF THE GUIDE Study is satisfactory and recommended.

11.1 NAME AND DESIGNATION OF GUIDE Mrs. SUGANTHI. J,

Asst.Prof

Medical Surgical Nursing Dept

11.2 SIGNATURE

11.3 CO-GUIDE ( IF ANY ) Mr. GOPALAKRISHNAN, (HOD),

Assoc.Prof

Medical Surgical Nursing Dept

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT Mr. GOPALAKRISHNAN, (HOD),

Assoc.Prof

Medical surgical Nursing Dept

11.6 SIGNATURE

12.1 REMARKS OF THE PRINCIPAL The topic selected by the researcher is relevant and forwarded

12.2 SIGNATURE

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