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A DESCRIPTIVE STUDY TO “ASSESS THE KNOWLEDGEAND PRACTICE TOWARDS THE CARDIO PULMONARY

RESUSCITATION AMONG STAFF NURSES WORKINGIN CASUALITY IN A SELECTED HOSPITALS

AT TUMKUR (DIST).”IN A VIEW TO DEVELOP SELF

INSTRUCTIONAL MODULE.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DESSERTATION

Mrs. KANTHI MANI GARAPATIMEDICAL – SURGICAL NURSING

MADHUGIRI SRI RAGHAVENDRA COLLEGE OF NURSINGMADHUGIRI – 572132 TUMKUR DISTRICT

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGLORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJRCTS FOR DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

Mrs. KANTHI MANI GARAPATI

M.Sc., Nursing 1st Year

Madhugiri Sri .Raghavendra College Of

Nursing,

Shankar Matt Road,

Raghavendra Extension,

Madhugiri – 572132, Tumkur district.

2. NAME OF THE INSTITUTION

Madhugiri Sri.Raghavendra College Of Nursing,

Madhugiri.

3. COURSE OF STUDY AND SUBJECTS

M.Sc.,NURSING 1st Year

Medical Surgical Nursing

4. DATE OF ADMISSION TO COURSE

25-5-2010.

5. TITLE OF THE TOPICA descriptive study to assess the knowledge and Practice towards Cardio Pulmonary Resuscitation among staff nurses working in Casuality in a selected hospitals at Tumkur dist.In a view to develop self instructional module.

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6. BRIEF RESUME OF INTENDED WORK:

INTRODUCTION:

Cardiopulmonary resuscitation (CPR) is an emergency

procedure which is attempted in an effort to return life to a person in

cardiac arrest. It is indicated in those who are unresponsive with no

breathing or only gasps. It may be attempted both in and outside of a

hospital.CPR involves chest compressions at a rate of at least 100 per

minute in an effort to create artificial circulation by manually pumping

blood through the heart. In addition the rescuer may provide breaths by

either exhaling into their mouth or utilizing a device that pushes air into the

lungs. The process of externally providing ventilation is termed artificial

respiration.

An administering of an electric shock to the heart, termed

defibrillation, is usually needed to restore a viable or "perfusing" heart

rhythm. Defibrillation is only effective for certain heart rhythms, namely

ventricular fibrillation or pulse less ventricular tachycardia, rather than

asystolic or pulse less electrical activity. CPR may however induce a

shockable rhythm. CPR is generally continued until the person regains

return of spontaneous circulation (ROSC) or is declared dead CPR is

indicated for any person who is unresponsive with no breathing or only

gasps as breathing as it is most likely that they are in cardiac arrest. CPR

training: CPR is being administrated while a second rescuer prepares for

defibrillation.2

In 2010, the American Heart Association and International

Liaison Committee on Resuscitation updated their CPR guidelines. The

importance of high quality CPR (sufficient rate and depth without

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excessively ventilating) was emphasized. The order of interventions was

changed for all age groups except newborns from airway, breathing, chest

compressions (ABC) to chest compressions, airway, breathing (CAB).An

exception to this recommendation is for those who are believed to be in a

respiratory arrest (drowning, etc.)3

A universal compression to ventilation ratio of 30:2 is

recommended for adult and in children and infant if only a single rescuer is

present. If at least 2 rescuers are present a ratio of 15:2 is preferred in

children and infants.In newborns a rate of 3:1 is recommended unless a

cardiac cause is known in which case a 15:2 ratio is reasonable. If an

advanced airway such as an endotracheal tube or laryngeal mask airway is

in placed delivery of respirations should occur without pauses in

compressions at a rate of 8-10 per minute. The recommended order of

interventions is chest compressions, airway, breathing or CAB in most

situations. With a compression rate of at least 100 per minute in all groups.

Recommended compression depth in adults and children is about 5 cm

(2 inches) and in infants it is 4 cm (1.5 inches. As of 2010 the Resuscitation

Council (UK) still recommends ABC for children. As it can be difficult to

determine the presence or absence of a pulse the pulse check has been

removed for lay providers and should not be performed for more than 10

seconds by health care providers. 3

CPR is only likely to be effective if commenced within 6 minutes

after the blood flow stops, because permanent brain cell damage occurs

when fresh blood infuses the cells after that time, since the cells of the brain

become dormant in as little as 4–6 minutes in an oxygen deprived

environment and the cells are unable to survive the reintroduction of

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oxygen in a traditional resuscitation. Research using cardioplegic blood

infusion resulted in a 79.4% survival rate with cardiac arrest intervals of

72±43 minutes, traditional methods achieve a 15% survival rate in this

scenario, by comparison. New research is currently needed to determine

what role CPR, electroshock, and new advanced gradual resuscitation

techniques will have with this new knowledge.4

In the 19th century, Doctor H. R. Silvester described a method

(The Silvester Method) of artificial respiration in which the patient is laid

on their back, and their arms are raised above their head to aid inhalation

and then pressed against their chest to aid exhalation. The procedure is

repeated sixteen times per minute. A second technique, called the Holger

Neilson technique, described in the first edition of the Boy Scout Handbook

in the United States in 1911, described a form of artificial respiration where

the person was laid on their front, with their head to the side, resting on the

palms of both hands. Upward pressure applied at the patient’s elbows raised

the upper body while pressure on their back forced air into the lungs,

essentially the Silvester Method with the patient flipped over. 3

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6.1 NEED FOR STUDY

Over 750,000 citizens of the US and Europe suffer sudden cardiac

arrest each year, and survival remains dismal: over 75% of victims do not leave

the hospital alive.1,2 Cardiac arrest, requires treatment within minutes to attain

survival. Cardiopulmonary resuscitation (CPR) and electrical defibrillation

remain the two crucial interventions that can be life-saving during cardiac

arrest. Through CPR training offered by the American Heart Association

(AHA) and other organizations, laypersons can provide treatment to cardiac

arrest victims before the arrival of emergency medical personnel. This review

will summarize current knowledge about the importance of CPR in the

treatment of cardiac arrest, and will describe several exciting new technologies

that will make CPR more effective in coming years.3

A number of studies have confirmed that CPR can be life-saving

when provided either by laypersons or medical professionals. In several large

investigations, the prompt delivery of CPR served as a important predictor of

survival—bystander CPR may almost double the chance of survival.5-7 Other

work has shown that the probability of survival from cardiac arrest falls by 10–

15% per minute without treatment, and well performed CPR likely shifts this

curve towards higher probability of survival. Furthermore, recent

investigations have suggested that CPR maintains the heart in a state favorable

for defibrillation.8,9 That is, fatal cardiac arrhythmias common in cardiac

arrest have a greater chance of being successfully terminated by electrical

shock if CPR is performed first. A recent randomized trial in Norway

suggested that in cases of prolonged cardiac arrest, delaying defibrillation in

order to first provide several minutes of CPR significantly improved patient

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survival.10 Not only can prompt CPR make an important impact on outcomes,

but the quality of CPR appears to matter greatly.5

Recent work has also shown that during actual human CPR, shallow

chest compressions have an adverse impact on outcomes.9 Therefore, it is

crucial that CPR be performed in accordance with published guidelines, which

are formulated based on the best available data and updated every five years.3

Given the importance of CPR quality, it is perhaps surprising that the

performance of CPR has only recently been assessed during actual cases of

cardiac arrest. In a number of investigations over the past few years, CPR

quality was found to be lacking during both in-hospital and out-of-hospital

cardiac arrest, both in Europe and the US.11-15 In other words, poor CPR

quality is endemic. In general, chest compressions are delivered too slowly and

in too shallow a fashion, and ventilations are given too rapidly. There are

several reasons why this might be the case despite the best intentions of

providers. 3

First, CPR is deceptively simple to describe and remarkably difficult

to perform, as humans generally do not have a good internal sense of timing to

recognize 100 compressions or 8–12 ventilations per minute, and fatigue often

prevents adequate depth efforts. Second, CPR is taught in the sterile conditions

of a classroom, but performed in the volatile environment of a dramatically ill

person surrounded by anxious onlookers—training can be easily forgotten in

the panic of the moment, especially if that training has not taken place recently.

It is clear from a variety of data that the majority of cardiac arrest patients do

not receive CPR at all until the arrival of medical personnel precious minutes

after the onset of arrest.

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CPR training must be simplified and widely disseminated. Why, for

example, can we not require CPR competence as a prerequisite for a driver’s

license, or provide CPR training to every parent during the hospital stay before

the birth of their child or before they leave the hospital with their newborn.3

Benjamin S Abella, MD, MPhil, is currently Assistant Professor of

Emergency Medicine at the University of Chicago, where he also serves as

Chair of the Hospital CPR Committee. Dr Abella maintains an active research

program in cardiac arrest and resuscitation care, including clinical projects

evaluating cardiopulmonary resuscitation (CPR) quality. Dr Abella is a

recipient of research funding from the National Institutes of Health (NIH),

Laerdal Medical Corporation and Philips Medical Systems, and has consulted

on cardiac arrest topics for a variety of academic and commercial

organizations. He will soon take a position at the University of Pennsylvania,

where he will continue his clinical work and research as a member of the new

Center for Resuscitation Science.3

The AHA has recently developed a product for the self-teaching of

CPR in under 30 minutes called “CPR Anytime”, and such tools may make

such ambitious training goals more feasible.CPR quality must also be

improved. CPR is a crucial intervention that can improve outcomes from the

highly mortal condition of sudden cardiac arrest. This intervention does not

necessarily require special equipment and can be provided by laypersons and

medical personnel alike. However, to be effective, CPR must be provided

according to published performance guidelines. This is an exciting time for

cardiac arrest care, as a body of important new research has led the way toward

the development of novel tools to assist care providers in their attempt to save

lives. 3■

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6.2 REVIEW OF LITERATURE

6.2.1. A study was conducted to assess Attitudes toward the performance of

bystander cardiopulmonary resuscitation in Japan. A sample size of a total of

4223 individuals (male 50%) completed the questionnaire, including high

school students, teachers, emergency medical technicians , medical nurses, and

medical students. The result shows that about 70% of the subjects had

experienced CPR training more than once. Only 10-30% of high school

students, teachers, and health care providers reported willingness to perform

CC plus MMV, especially on a stranger or trauma victim. The study was

concluded with most laypeople and health care providers are unlikely to

perform CC plus MMV, especially on a stranger or trauma victim, but are more

likely to perform CC only.6

6.2.2. A study was performed to assess Medical and nursing students' attitudes

toward cardiopulmonary resuscitation and current practice guidelines. A pilot

questionnaire concerning beliefs and attitudes toward CPR-D was distributed

to 120 fourth year medical students and 120 nursing students. The result shows

that questionnaire was answered by 71 of 120 fourth year students (59.1%),

and 76 of 120 (63.3%) nursing students. Negative attitude toward defibrillation

correlated with perceived organizational attitudes toward practice guidelines.

The study was concluded with Medical students' attitudes mature as hoped for,

but the nursing students need encouragement. More information is needed to

diminish anxiety concerning defibrillation. Negative beliefs and attitudes

toward defibrillation affect the students' attitudes toward practice guidelines.7

6.2.3. A study was conducted on Undergraduate nursing students' to investigate

the extent to which Irish nursing students acquire and retain CPR cognitive

knowledge and psychomotor skills following CPR training. Deterioration in

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both CPR knowledge and skills was found 10 weeks following CPR training.

The result shows that the students' knowledge and skills were improved over

their pre-training scores, which clearly indicated a positive retention in CPR

cognitive knowledge and psychomotor skills. The study was concluded with

findings present strong evidence to support the critical role of CPR training in

ensuring that nursing student’s progress to competent and confident responders

in the event of a cardiac related emergency.8

6.2.4. A study was performed on nurses' knowledge of and experience in

cardiopulmonary resuscitation and on nurses' knowledge of the guidelines for

cardiopulmonary resuscitation and emergency cardiovascular care. A sample

size of Three hundred and four nurses at Asahikawa Medical College Hospital

were asked to fill in questionnaires. The results show that more than 80% of

the nurses are much interested in CPR. Most of the nurses had received

education and training in CPR as students or after graduation. The results of

this survey demonstrate the need to provide more education (on CPR) to

nursing staff.9

6.2.5. A survey was conducted on cardio-pulmonary resuscitation knowledge

of the nursing staff in the .Asahikawa Medical College Hospital. A sample size

of 66 nursing staffs on cardio-pulmonary resuscitation (CPR) and compared

the results with that of 53 students of the Department of Nursing. The result

shows that the "Ability" defined as an indicator of capability of practicing CPR

of the nursing staffs was 17% and that of the student nurses was 0%. The study

was concluded with that the CPR knowledge of both the nursing staffs and the

student nurses was not sufficient, indicating the necessity of CPR education for

both nursing staffs and student nurses.10

6.2.6. A study to examine the efficacy of self-instruction on nurses'

competence. With a sample size of 20 undergraduate nursing students. The

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result shows that the self instructional was evaluated positively by the student

nurses. The study was concluded with that CPR teaching methods need to be

evaluated and refined in order to improve practice. 11

6.2.7. A descriptive and exploratory study was conducted to develop an

educational practice of Problem-Based Learning in CPR/BLS with the sample

size of 24 students in the third stage of the Nursing Undergraduate Course in a

University in the Southern region of Brazil. The results showed that Problem –

Based Learning allows the educator to evaluate the academic learning process

in several dimensions, functioning as a motivating factor for both the educator

and the student, because it allows the theoretical-practical integration in an

integrated learning process.12

6.2.8. A cross sectional study was conducted to evaluate the knowledge of

nurses on cardiopulmonary resuscitation. Nurses were assigned to groups 1 (33

nurses, in units equipped with a heart monitor and a cardiac defibrillator) and 2

(23 nurses, in units without this equipment). Nurses in group 1 showed better

knowledge on the recognition of electrocardiographic recordings, and 91% of

them recognized the ventricular fibrillation algorithm. Among nurses in group

2, 85% had knowledge on issues relative to basic care. The results showed that

training in CPR generates positive results. The study was concluded with that

Continued and systematic education strategies are essential to ensure better

performance of the nursing team.13

6.2.9. This study was conducted to analyze the sustainable effects of

cardiopulmonary resuscitation (CPR) reeducation on nurses' knowledge and

skills. A experimental design was used for a single sample group of 47 nurses

working for a general hospital. The result shows that Nurses' skills between the

first and second time dropped but they improved between the second and third

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time owing to the effects of reeducation. The study was concluded with that

reeducation of CPR clearly affects nurses' knowledge and skills.14

6.2.10. A study was performed to evaluate Hospital HCWs' attitudes towards

Cardio pulmonary resuscitation (CPR) and ICU admission. A sample of 4903

health care workers including doctors, nurses of 5 Italian hospitals. The result

shows that a great variation in responses among health care givers, depend on

profession (RN/MD), on working area and experiential working characteristics.

The study was concluded with importance of communication among HCW, in

order to reach the best decision for every patient, and the great need of

continuous educational programs which could compensate for lack of

experience and help to create/maintain a strong bioethical and patient-oriented

attitude.15

6.2.11. The study was conducted to assess the involvement of nurses in 'do not

resuscitate’ decision-making on acute elder care wards and their adherence to

such decisions in the case of an actual cardiopulmonary arrest. The result

shows that 54.3% of respondents reported that cardiopulmonary resuscitation

was 'never' started on their ward, 'rarely' on 39.5% and 'sometimes' on 6.2%.

For patients without 'do not resuscitate' status, nurses started cardiopulmonary

resuscitation 'rarely' or 'sometimes' on 22.2% of all wards, and 'often' or

'always' on 77.8%.the study was concluded with the need to make appropriate

'do not resuscitate' decisions and to avoid rash decision-making in cases of

actual cardiopulmonary arrest, nurses should be involved early in 'do not

resuscitate 'decision-making.16

6.2.12. A study was conducted to explore facets involved in the retention of the

cognitive knowledge and psychomotor skills of cardiopulmonary resuscitation.

A sample size of 73 RNs from three general hospitals. The result shows that

cognitive knowledge was adequately retained but that skills were not. The

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study was concluded with need for certification as a CPR instructor, the

number of years certified, and time since last certification were significantly

related to skill scores. Findings prompt questions of appropriateness of the

usual certification procedures for hospital-based RNs.17

6.2.13. The study was conducted to describe the basic cardiac life-support

(BLS) skills of nurses and nursing students to assess the influence of

resuscitation teaching and other group characteristics on performance. A study

sample of 298 people (34 men and 264 women) .The results showed that 36%

first assessed the patient's response, 67% opened the airway but only 3%

determined pulse less ness before starting to resuscitate. Twenty-one percent of

the participants compressed correctly for at least half of the test and 33%

Ventilated correctly at least half of the time. The study was concluded with the

skills of the participants of the study cannot be considered adequate in terms of

an adequate and prompt assessment of the need for resuscitation, and a 50%

success rate in artificial ventilation and chest compression.18

6.2.14. A study was conducted to assess nurses' ability to initiate and maintain

effective cardiopulmonary resuscitation in actual cardiac arrests. The results

indicated that in the majority of cases nurses effectively managed all

components of CPR. In particular the results suggest that nurses' actual

management of cardiac arrests in a contextual environment differs markedly

from results shown by research using simulated settings. The study was

concluded with that the need for an evaluation of the use and effects of

cognitive and metacognitive instructional strategies in CPR training courses on

transfer of skills and knowledge to practice.19

STATEMENT OF THE PROBLEM

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A descriptive study to “assess the knowledge and practices towards the Cardio

Pulmonary Resuscitation among staff nurses working in Causality in a selected

hospitals” at Tumkur Dist, in a view to develop an instructional module.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge of staff nurses regarding Cardio Pulmonary Resuscitation .

2. To assess the practice of Staff Nurses regarding Cardio Pulmonary Resuscitation .

3. To determine the association between the knowledge of Staff Nurses regarding Cardio Pulmonary Resuscitation with selected variables.

4. To develop an instructional module to correlate the knowledge and practice about Cardio Pulmonary Resuscitation.

6.4. VARIABLES UNDER STUDY:

Dependant : Knowledge, Practice.

Independent: Self Instructional Module.

Extraneous: Age, sex, education , experience, standards of educational

institution, policies of hospital, attendance of professional development

programme , availability of resources, exposure to mass media.

6.5. OPERATIONAL DEFINITIONS:

*ASSESSMENT To evaluate the knowledge and practice of

CPR.

*KNOWLEDGE in this study “Knowledge” refers to the correct

response from the respondent ( staff nurses

who are working in Causalities) on CPR.

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*PRACTICE In this study “Practice” refers to the actual

application of knowledge and skills on CPR.

*C P R Cardiopulmonary resuscitation (CPR) is an

Emergency procedure which is attempted in

an effort to return to a person in cardiac arrest.

*CASUALTY A section of an institution that is staffed and

equipped to provide rapid and varied

emergency care, especially for those who are

stricken with sudden and acute illness

or who are the victims of severe trauma.

*STAFF NURSES A nurse is a healthcare professional who, in

Collaboration with other members of a health

care team, is responsible for: treatment, safety,

and recovery of acutely or chronically ill

individuals, health promotion and

maintenance within families, communities and

populations.

*HOSPITALS An institution that provides medical, surgical,

or psychiatric care and treatment for the sick

or the injured.

*INSTRUCTIONAL MODULE A self-contained instructional unit that

includes one or more learning objectives,

appropriate learning materials and methods,

and associated criterion-reference measures.

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6.6. ASSUMPTIONS:

6.6.1 Staff nurses who are not working in Casualties may have deficit

knowledge regarding Cardio Pulmonary Resuscitation

6.6.2. Staff nurses who are not working in Casualties may have deficit

practice regarding Cardio Pulmonary Resuscitation

6.6.3. Self instructional module will enhance the knowledge regarding

Cardio Pulmonary Resuscitation.

6.6.4. Self instructional module will guide knowledge regarding

assessment of a patient , need for CPR , to perform CPR in

correctly on time.

7. MATERIALS AND METHODS:

The purpose of the study is to assess the knowledge and practices on CPR among staff nurses working in Casualties.

7.1. SOURCE OF DATA:

Research approach : Descriptive approach

Research design : Non experimental design

Setting of the study : Selected hospitals at Tumkur dist

Population : Staff nurses

Sampling technique :Convenient sampling technique.

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Sample size : 100 staff nurses

Sample criteria *Inclusion criteria

- Nurses who are working in selected hospitals at Tumkur dist.

- Staff nurses who can understand Kannada and English.

- Staff nurses who are willing to participate in the study.

*Exclusive criteria

- Staff nurses who are not working in selected hospitals at Tumkur dist.

- Staff nurses who cannot understand Kannada and English.

- Staff nurses who are not willing to participate in the study.

7.2. METHOD OF DATA COLLECTION:

Tools of data collection : structured questionnaire

Part A : Proforma for collecting the data on demographic Variables.

Part B : Sstructured questionnaire to assess the knowledge and practices on CPR.

Data analysis and interpretation :

Data will be analyzed through descriptive and inferential method and statistics.

Duration of the study – 6 weeks

Does the study requires any investigations or interventions

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-NO –

Has ethical clearance has been obtained from your institution in case of the above.

Yes ethical clearance will be obtained from,

- The research committee of Madhugiri Sri Raghavendra College of Nursing.

- The authorities of selected communities, Madhugiri.

- The informed consent from the staff nurses who are willing to participate in this study.

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8. LIST OF REFERENCES:

1. Suzanne C.Smeltzer, Brenda Bare, Text book of Medical – Surgical Nursing. Page no: 810-812.

2.. Lewis, Heikemper, etal. Text book of Medical – Surgical Nursing, assessment and management of clinical problems. Page no 1845 – 1849.

3. www.wellness.com,www.googlesearch.com,www.popmed,medlife. Com.

4. B T Basavantappa, Text book of Medical – Surgical Nursing, Page no: 605-616.

5. A Journal of Nightingale Nursing Times, Volume -6,8; September 2010, Nov 2010.

6. Taniguchi T, Omi W, etal.“Department of Emergency and Critical Care Medicine” 2007 Oct;75(1):82-7. Epub 2007 Apr 8.

7. Niemi-Murola L, Mäkinen M,etal. Department of Anaesthesia and Intensive Care Medicine, 2007 Feb;72(2):257-63. Epub 2006 Nov 28.

8. Madden C.”Department of Nursing, Waterford Institute of Technology,” 2006 Apr;26(3):218-27. Epub 2005 Nov 28.

9. Masui. “Asahikawa Medical College Hospital” 2003 Apr;52(4):427-30.

10. Nagashima K, Suzuki A, Takahata O, Sengoku K, Fujimoto K, Yokohama H, Iwasaki H.”Department of Anesthesiology,” Asahikawa Medical College, Asahikawa 078-8510.

11. Davies N, Gould D. “Faculty of Health”, South Bank University, 103 Borough Road, London, 2000 May;9(3):400-10.

12. Sardo PM, Dal Sasso GT. Escola Superior de Saúde da Universidade de Aveiro (ESSUA),2008 Dec;42(4):784-92.

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13. Bertoglio VM, Azzolin K,etal. Hospital Moinhos de Vento, Rio Grande do Sul, Brasil. 2008 Sep;29(3):454-60.

14. Oh SI, Han SS. Gyeonggi Provincial Medical Center Pocheon Hospital, 2008 Jun;38(3):383-92.

15. Zamperetti N, Mazzon D,etal. Department of Anesthesia and Intensive Care Medicine, 2007 Mar;73(3):119-27.

16. De Gendt C, Bilsen J,etal. End-of-Life Care Research Group, Vrije Universiteit Brussel, 2007 Feb;57(4):404-9.

17. Lewis FH, Kee CC,etal. 1993 Jul-Aug;24(4):174-9.

18. Nyman J, Sihvonen M. Helsinki Polytechnic, Tukholmankatu 10, 2000 Oct;47(2):179-84.

19. Boyde M, Wotton K. Princess Alexandra Hospital, Brisbane, 2001 Sep-Oct;17(5):248-55.

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9. SIGNATURE OF THE CANDIDATE……………………………….

10. REMARKS OF THE GUIDE.

11. NAME AND DESIGNATION OF GUIDE.

11.1. SIGNATURE……………………………………………………

11.2. HEAD OF THE DEPARTMENT.

11.3. SIGNATURE……………………………………………………..

12. REMARKS OF THE CHAIRMAN / PRINCIPAL

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12.1. SIGNATURE………………………………………………….....