RAJIV GANDHI UNVERSITY OF HELATH SCIENCES,BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FORDISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

: ASHA ABRAHAM1ST YEAR M.SC NURSING,

INDIAN COLLEGE OF NURSING, TILAK NAGAR, BYPASS ROAD,

CANTONMENT,

BELLARY – 583104

2. NAME OF THE INSTITUTION : INDIAN COLLEGE OF NURSING, TILAKNAGAR, BYPASS ROAD,

CANTONMENT,

BELLARY – 583104

3. COURSE OF STUDY AND SUBJECT

: DEGREE OF MASTER OF NURSING ,

MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION TO COURSE

: 15-06-2012

5. TITLE OF THE TOPIC : “A STUDY TO EVALUATE THE

EFFECTIVENESSOF

STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE

REGARDING PREVENTION OF

DEEP VEIN THROMBOSIS

AMONG ORTHOPAEDIC

PATIENTS IN SELECTED

HOSPITALS AT BELLARY

KARNATAKA.”

6. BRIEF RESUME THE INTENDED WORK

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. Early detection and treatment are the main intervention of disease control 1.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are manifestations of a

single disease entity, namely, venous thromboembolism (VTE). The earliest known reference to

peripheral venous disease is found on the Eber papyrus, which dates from 1550 BC and

documents the potentially fatal hemorrhage that may ensue from surgery on varicose veins. In

1644, Schenk first observed venous thrombosis when he described an occlusion in the inferior

vena cava. In 1846, Virchow recognized the association between venous thrombosis in the legs

and PE. DVT is the presence of coagulated blood, a thrombus, in one of the deep venous

conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and

swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become

fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing

potentially life-threatening PE 2.

VTE is the most frequent serious complication following hip and knee replacement

surgery. It is the most common cause for re-hospitalization in this patient group. The most

common type of VTE is deep vein thrombosis (DVT), occurring in veins deep within the

muscles of the leg and in the pelvis. Some of the recognized factors that increase the risk of DVT

include major surgery (such as hip or knee replacement), cancer, inherited abnormalities in the

blood-borne proteins involved in coagulation, and hospitalization for a major medical illness 3.

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.

DVT is mostly preventable and national and international consensus groups on venous thrombo

prophylaxis have all recommended that hospital patients should be assessed for clinical risk

factors and an overall risk of thromboembolism. Patients should then receive prophylaxis

according to their risk categories4. The complication of deep vein thrombosis includes:

thromboembolism, embolism, pulmonary embolism, post-phlebitic syndrome and pulmonary

thromboembolism. Thromboembolism remains a major preventable cause of postoperative

mortality and morbidity in the Western world; very little attention has been given to this

condition in the Indian patients 5.

Orthopedic patients will have impairment in mobility results from prescribed restriction

of movement in the form of bed rest, physical restriction of movement or impairment of motor

skeletal function. In orthopedic patients the treatment of choice following surgery or injury are

varying in rest and motion. The effect of immobilization leads to many complications related to

different systems in our body. The patients with acute medical condition in hospital may be for

few days but patients with orthopedic condition may be for many days. When patients are

immobilized following trauma there is high risk for deep vein thrombosis and post operative

stiffness due to limited range of motion 6. The risk of deep vein thrombosis is increased in a

number of circumstances. The surgery heightens the body's tendency for coagulation or clotting.

In addition, when the leg is manipulated during surgery there may be irritation to the walls of the

major blood vessels in the leg. Finally, during and after surgery the lower extremity is not used as

much and, therefore, the normal blood flow rate is decreased. The leg muscles usually help

venous blood return to the heart when they are used.

Prevention of deep vein thrombosis is very important among orthopedic clients. Many

healthcare providers are under the false impression that this life-threatening illness is not a

problem in their hospital or among their patients. All patients who are admitted should be

screened for their risk for deep vein thrombosis. Some common risk factors for deep vein

thrombosis are orthopedic surgery, pelvic surgery, prolonged surgery, immobilization,

coagulation disorders, cancer, sepsis etc 7. Based on the presence or absence of these risk

factors, which carry varying weight age, patients can be stratified into high, moderate and low

risk for deep vein thrombosis. Those at high or very high risk should receive prophylaxis—both

mechanical and pharmacological Mechanical measures such as elastic graduated compression

stockings, intermittent pneumatic compression and venous foot pumps should be used in bed-

ridden patients and those undergoing surgery .Pharmacological prophylaxis involves the use of

heparin in low doses which are associated with no or little increase in the risk of clinically

important bleeding and do not warrant monitoring the coagulation profile. It should be continued

for at least seven days or until the patient is ambulant. Patients at high risk of bleeding and those

with contraindications to heparin should receive mechanical prophylaxis only.

Deep vein thrombosis prophylaxis is effective—it reduces the risk of deep vein thrombosis

by two-thirds. Deep vein thrombosis prophylaxis has been identified as the number one measure

to improve the safety of hospitalized patient. Most mechanical methods of thrombo prophylaxis

aim to reduce venous stasis and thus the propensity for clot formation. They found that

mechanical methods can be used in patients at low risk of venous thromboembolism and in those

with contraindication to pharmacologic therapy 8.

6.1 NEED FOR STUDY:

Deep vein thrombosis or DVT is a blood clot that forms in a vein deep in the body. Blood

clots occur when blood thickens and lumps together. Most deep vein blood clots occur in the

lower leg or thigh. They can also occur in other parts of body. Blood clots in the thighs are more

likely to break off and cause PE than blood clots in the lower legs or other parts of the body.

Major orthopaedic trauma (which includes spine, hip and pelvic-acetabular fractures; multiple

long bone fractures of the lower extremity) is a compelling risk factor for developing of VTE and

its potential sequellae pulmonary embolism. The incidence of VTE and its complications is more

in patients undergoing major orthopaedic surgery than in those undergoing other surgical

procedures. Around 90 per cent of DVT incidence was in the proximal veins of the legs 9.

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

vehicle accidents, breast cancer, and AIDS etc. The APHA and the Centers for Disease Control

and Prevention (CDC) convened 60 of the nation’s leading medical experts and patient advocates

in Washington, D.C. in early 2003 10. DVT is one of the most prevalent medical problems today,

with an annual incidence of 80 cases per 100,000. Each year in the United States, more than

200,000 people develop venous thrombosis; of those, 50,000 cases are complicated by PE.

Lower-extremity DVT is the most common venous thrombosis, with a prevalence of 1 case per

1000 population. In addition, it is the underlying source of 90% of acute PEs, which cause

25,000 deaths per year in the United States (National Center for Health Statistics [NCHS], 2006).

This event, the Public Health Leadership Conference on Deep-Vein Thrombosis, brought into the

spotlight the urgency for increased diligence related to prevention on the part of the healthcare

community – as well as the need to raise awareness of DVT and its complications among the

public 11.

In Canada it is reported that pulmonary embolism from DVT causes death of more than

1, 00,000 patients each year and it remains a leading cause of death 12. The Chinese literature

found an increasing incidence of VTE among the Chinese population, and they placed the

orthopaedic surgery of the lower limbs in the high risk group 13. Similarly among the Japanese

population, the rate of incidence of VTE after arthroplasty surgeries was found to be increasing

over the last four decades, though not equivalent to that in North America and Europe 14.

According to International Consensus Statements (1997; 2002). Incidence of DVT by

patient groups comprises under specialities like general surgery is 25%, orthopedic surgery is 45-

51%, urology is 9-32%, gynecological surgery is 14-22%, neurosurgery including strokes is 22-

56%, multiple trauma is 50%, general medicine is 17% 15. A world wide survey conducted by

WHO, 1999 showed that Deep Vein Thrombosis is a common disease with an average incidence

rate of more than one per thousand. It is also lethal disease owing to pulmonary embolism and

almost 25% of cases may have sudden death. Almost 30% of patient develop serious venous

stasis syndrome within 10 years 16.

A prospective study was conducted to document the incidence of proximal deep vein

thrombosis and pulmonary embolism in 58 consecutive Japanese patients undergoing total hip

arthroplasty or total knee arthroplasty. Patients were routinely examined for proximal deep vein

thrombosis by B-mode ultrasonography before and after surgery. Those patients who had

ultrasonographic findings of deep vein thrombosis were also investigated for pulmonary

embolism by ventilation-perfusion lung scan. The incidence of deep vein thrombosis after total

hip arthroplasty and total knee arthroplasty were 9.1% and 4.0% respectively and the incidence

of pulmonary embolism were 3.0% and 0%, respectively. There were no cases of fatal pulmonary

embolism. The study concluded that the incidence of deep vein thrombosis and pulmonary

embolism in Japanese patients may have increased over the last few decades 17.

Thromboprophylaxis after trauma is still not widely practiced in India, the cause of which

can be attributed to lack of awareness, underestimation of the problem, fear about

thromboprophylaxis complications and most importantly the popular belief among surgeons that

Indian have low incidence of DVT contrary to previous belief, most of the recent studies show

increasing incidence of VTE among Indian and Asian population and it is almost equivalent to

that reported in Caucasians 18.

The survey conducted by INDORSE (Indian observational survey on prevalence of

venous thromboembolism ‘VTE’ risk and prophylaxis in the acute care hospital unit) in 2009 and

analyzed later on in the year 2010 showed that of the 7481 hospitalized patients from 46

hospitals across 11 states in India, 67 percent were at the risk of Deep-Vein Thrombosis (DVT)

and only 19 percent of these patients were given any kind of prophylaxis (prevention) 19.Data

summarized from the National Institute of Health panel shows the overall incidence of Deep

Vein Thrombosis after elective hip surgery is 45 to 70 percent; clinical pulmonary embolism is

about 20 percent and of fatal pulmonary embolism is 1 to 4 percent 20. The incidence of deep

vein thrombosis in India as reported is one percent of the adult population after the age of 40 and

is 15 to 20% in hospitalized patient and the risk of deep vein thrombosis is 50% in patients

undergoing orthopaedic surgery particularly involving the hip and knee. It is 40% in those

patients undergoing abdominal or thoracic surgery, 1/100 that develop deep vein thrombosis dies,

usually from the blood clot traveled to the lungs which is called as pulmonary embolism.

A study conducted to determine the incidence of DVT in Indian patients undergoing major limb

surgery. Incidence was 60% among patients undergoing total knee arthoplasty 21.

Incidence of Deep Vein Thrombosis in India and globally following surgical

interventions varies and ranges from 59 per cent of post-hip surgeries and 29 per cent of post-

knee surgeries, as per Dr.Ashish Anand, consultant orthopedic surgeon, Wockhardt Hospital 22.

An autopsy study on 1000 medical patients at the Postgraduate Institute of Medical Education

and Research (PGIMER), Chandigarh revealed that pulmonary embolism was present in 159

(16%) of 1000 patients who died in the hospital—it was a fatal embolus in 36 and was a major

contributor to death in 90 patients; in 30 patients, the embolus was an incidental finding at

autopsy as death occurred due to some other cause 23.

The Autar DVT scale (1994, 1996b) was developed to identify patients at risk, so that

the recommended prophylaxis could be promptly initiated. The Autar DVT scale (1994)

comprised seven subscales: increasing age, build and body mass index (BMI), immobility,

special DVT risk, trauma, surgery and high risk disease 24.

Deep vein thrombosis (DVT) poses a threat to hospitalized client's recovery. It is a

preventable disease; the cost of its treatment is considerably more than that of its preventive

measures. Accurate DVT risk assessment facilitates the application of the most appropriate

venous thrombo prophylaxis. The rapid increase in magnitude of complications needs the

attention of health professionals. In order to reduce the immediate and long term dangers of DVT

the investigator feels that early detection and prevention is very necessary. Hence the

investigator planned to impart the knowledge by conducting structured teaching programme to

orthopaedic patients.

6.2 REVIEW OF LITERATURE:

Review of literature is a key step in research process. Review of literature refers to an

extensive, exhaustive and systemic examination of publications relevant to research project 25.

Section 1: Studies related to knowledge on deep vein thrombosis.

Section 2: Studies related to prevention of deep vein thrombosis.

Section 1: Studies related to knowledge on deep vein thrombosis.

A systematic review was conducted to assess the symptomatic in-hospital deep vein

thrombosis and pulmonary embolism following hip and knee arthroplasty among patients

receiving recommended prophylaxis. Data were independently extracted by 2 analysts, and

pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-

effects models. The analysis included 44,844 cases provided by 47 studies. The pooled rates of

symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%)

for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA.

The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee

arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for

pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14%

(95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled

incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for

DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in

TPHA studies. The study concluded that using current VTE prophylaxis, approximately 1 in 100

patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops

symptomatic VTE prior to hospital discharge 26.

A Systematic review and meta-analysis on the rate of postoperative venous

thromboembolism was conducted in orthopaedic surgery in Asian patients without

thromboprophylaxis. The pooled proportion was back-calculated by Freeman-Tukey variant

transformation, using a random-effects model. Twenty-two studies (total population 2454)

published from 1979 to 2009 were included. Using venography, the pooled rates of all-site,

proximal, distal and isolated distal DVT were 31·7, 8·9, 22·5 and 18·8 per cent respectively.

With duplex ultrasonography, the respective rates were 9·4, 5·9, 5·9 and 5·8 per cent. After THA

or HFS, using venography, the pooled rates of all-site and proximal DVT were 25·8 and 9·6 per

cent; with ultrasonography, the respective rates were 10·8 and 7·2 per cent. In TKA groups,

using venography, the pooled rates of all-site and proximal DVT were 42·5 and 8·7 per cent;

with ultrasonography, the respective rates were 9·5 and 5·2 per cent. The overall pooled rates of

symptomatic DVT and symptomatic pulmonary embolism (PE) were 4·5 and 0·6 per cent. No

patient died from PE (pooled rate 0·2 per cent).The study concluded that none of these Asian

patients undergoing orthopaedic surgery died from VTE. Pooled rates of proximal and

symptomatic DVT were lower than in Western reports 27.

A prospective study of risk factor profile and incidence of deep venous thrombosis

among medically-ill hospitalized patients at a tertiary care hospital in AIIMS New Delhi, India.

All adults admitted to the medical wards and intensive care unit with level 1 or 2 mobility over a

period of two years (July 2006 to July 2008) at the AIIMS, New Delhi, were prospectively

studied. Patients having DVT at admission or an anticipated hospital stay less than 48 h were

excluded. The presence of clinical risk factors for DVT was recorded and laboratory evaluation

was done for hypercoagulable state. A routine surveillance venous compression Doppler

ultrasonography was performed 12 ± 8 days after hospital admission. Of the 163 patients, 77

(47%) had more than one risk factor for DVT. Five (3%) patients developed DVT; none of them

had symptomatic DVT. None of these patients received anticoagulation prior to the development

of DVT. The mean age of those who developed DVT was 40 ± 13 (25-50) yr; two of five were

male. The incidence rate of DVT was 2.7 per 1000 person-days of hospital stay [95% confidence

interval (CI): 0.87 to 6.27]. None of the factors was found to be significantly associated with the

risk of DVT. In the setting, although many hospitalized medically-ill patients had risk factors for

DVT; the absolute risk of DVT was low compared to the western population but clearly elevated

compared to non hospitalized patients. Large studies from India are required to confirm the

findings 28.

A study was conducted on trends in prevalence of deep venous thrombosis among

hospitalized patients in an Asian institution. Venous thromboembolism (VTE) has long been

considered a disease of secondary importance among Asians because of its perceived low

prevalence. They studied the prevalence and patterns of deep venous thrombosis (DVT) among

hospitalized patients in our tertiary referral centre. Primary and secondary DVT prevalence

among hospitalized patients was 0.453%, a significant rise from reported rates of 0.079% and

0.158% in 1989-1990 and 1996-1997, respectively. Malignancies and orthopaedic surgery were

the most common risk factors for DVT. Further comparisons with the two earlier Singaporean

studies showed no changes in the gender and ethnic background of patients but a higher

proportion of elderly patients (>80 years) was recorded in the current study (11.7% vs. 7.0%, p =

0.04). Statistically significant increases were found in all medical and surgical disciplines except

among obstetrics and gynecology patients. Orthopaedic patients had the highest increase in DVT

rates between the 1989-1990 and 2002-2003 periods (0.082% vs. 0.96%, p<0.01). Doppler

ultrasound scans performed increased from approximately one per 100 admissions in 1996-1997

to one per 30 admissions in 2002-2003. The significant increase in period prevalence of DVT

among hospitalized patients in Singapore could be accounted by methodological differences

between comparative studies, an increase in proportion of elderly patients and most importantly,

a possible shift in perception of the importance of VTE among Asians, resulting in a higher index

of suspicion and lower threshold for performing diagnostic tests 29.

A prospective study of the incidence of deep-vein thrombosis within a defined urban

population was conducted. In a prospective study all positive paleographic within the well-

defined population of the city of Malmo, Sweden, during 1987 were studied in order to

determine the incidence of deep venous thrombosis (DVT). Epidemiological data were analyzed

for the detection of patient groups at increased risk of DVT. The incidence was found to be equal

for both sexes, i.e. 1.6 per 1000 inhabitants and year. Risk factors were found to be in accordance

with earlier studies. The median age for men was 66 years, compared to 72 years for women. At

diagnosis of DVT, 19% of subjects had a known malignancy and within 1 year 5% (19 cases)

developed a new malignancy. Of the men, 29% had postoperative or post-traumatic (fracture)

DVT, compared to 46% of the women. Fewer patients with DVT than expected (39%) belonged

to blood group 0 (31%) (P < 0.005). Pulmonary embolism (PE) was clinically suspected in only

5% of cases, and diagnosis was verified scientifically in 2% of cases. None of these died of PE,

but of 6 patients who were found to have PE at autopsy, four died about 4 weeks after the DVT

was diagnosed 30.

An epidemiological study based on postoperative screening with centrally adjudicated

bilateral venography was conducted on Deep-vein thrombosis rates after major orthopedic

surgery in Asia. A prospective epidemiological study in 19 centers across Asia (China, Indonesia,

South Korea, Malaysia, Philippines, Taiwan, and Thailand) in patients undergoing elective total

hip replacement (THR), total knee replacement (TKR) or hip fracture surgery (HFS) without

pharmacological thromboprophylaxis were performed. The primary endpoint was the rate of

DVT of the lower limbs documented objectively with bilateral ascending venography performed

6-10 days after surgery using a standardized technique and evaluated by a central adjudication

committee unaware of local interpretation. Overall, of 837 Asian patients screened for this

survey, 407 (48.6%, aged 20-99 years) undergoing THR (n = 175), TKR (n = 136) or HFS (n =

96) were recruited in 19 centers. DVT was diagnosed in 121 of 295 evaluated patients [41.0%,

(95% confidence interval (CI): 35.4-46.7)]. Proximal DVT was found in 30 patients [10.2% (7.0-

14.2)]. Total DVT and proximal DVT rates were highest in TKR patients (58.1% and 17.1%,

respectively), followed by HFS patients (42.0% and 7.2%, respectively), then THR patients

(25.6% and 5.8%, respectively). DVT was more frequent in female patients aged at least 65

years. Pulmonary embolism was clinically suspected in 10 of 407 patients (2.5%) and objectively

confirmed in two (0.5%).The study concluded that the rate of venographic thrombosis in the

absence of thromboprophylaxis after major joint surgery in Asian patients is similar to that

previously reported in patients in Western countries 31.

A quantitative cross sectional survey was conducted in Canada to investigate the

patient’s awareness and knowledge of thromboprophylaxis as well as patients satisfaction with

thromboprophylaxis. The researcher used 48 participants receiving pharmacological

thromboprophylaxis as samples. Among them 81.2% reported hearing of either deep vein

thrombosis, pulmonary embolism or both conditions. Of the patients who had heard of deep vein

thrombosis and or pulmonary embolism, 74.2% knew immobility was a risk factor but had

limited knowledge about symptoms and treatment modalities. The research findings suggest that

patients require further information on deep vein thrombosis during their hospitalization to

enhance their involvement in deep vein thrombosis prevention and recognition. The study also

highlights the need to strengthen the nurses role in providing patient education regarding deep

vein thrombosis32.

A study was conducted to estimate the risk factors for clinically relevant

pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or

knee arthroplasty. During the 10-yr study period, 116 of 9,791 patients undergoing primary

hip or knee arthroplasty at the authors' institution who experienced pulmonary embolism or

deep venous thrombosis within 30 days of surgery were matched at a 1:1 ratio with patients

undergoing the same surgery with the same surgeon who did not experience an adverse

event. Medical records were reviewed, with data abstracted using a standardized data

collection form. Increased body mass index (P = 0.031; odds ratio = 1.5 for each 5-kg/m2

increase) and American Society of Anesthesiologists physical status classification of 3 or

greater (P = 0.005; odds ratio = 2.6) were found to independently increase the likelihood of

pulmonary embolism or deep venous thrombosis. In addition, use of antithrombotic

prophylaxis was found to decrease the likelihood of these thromboembolic events (P =

0.050; odds ratio = 0.2 for aspirin or subcutaneous heparin, and odds ratio = 0.4 for warfarin

or low-molecular-weight heparin). In patients undergoing primary elective lower extremity

arthroplasty, obesity, poor American Society of Anesthesiologists physical status

classification, and lack of thromboprophylaxis are independent risk factors for clinically

relevant thromboembolic events 33.

Section 2: Studies related to prevention of deep vein thrombosis.

A comparative, descriptive study was conducted on graduated compression stockings

among hospitalized post operative patients in USA. The researcher selected 142

hospitalized post operative patients; 37 had thigh length and 105 had knee length stockings.

They assessed the usage of the stockings and also asked the patients to rate the comfort of

stockings and explain their purpose. The results showed that the patients were unaware

about the purpose and usage of stockings. The researcher recommended that nurses ensure

that graduated compression stockings are properly sized and used, that education of patients

regarding the stockings be improved 34.

A multi centre study was conducted on deep venous thrombus prophylaxis among

orthopaedic patients at New Delhi .The aim of the study was to determine the ideal

prophylaxis for deep vein thrombosis. The researcher grouped 30 patients in group 1 were

not given any thromboprophylaxis while 100 patients in group 2 were put on mechanical

prophylaxis. The result showed that 7 patients in group 1 developed deep vein thrombosis

while no patient in group 2 had this complication. The researcher concluded that mechanical

prophylaxis may be a safe tool in preventing deep vein thrombosis and nurses should

provide effective educational programmes in relation to mechanical prophylaxis 35.

A study was conducted in Scotland to determine the optimum type of exercise for promoting

venous return. Studies of both active and passive movements were carried out on 40 limbs in 20

subjects (18 men and two women) with a median age of 27 years (20-54).They assessed the

ankle dorsiflexion and plantar flexion, subtler inversion, eversion and a combination of all

movements .The active combined movements produced the higher velocities with an increase of

38% mean and 58% in peak flow velocities, which were significantly greater than the peak and

mean flow rates produced by passive movements. The active combined exercises would

therefore be the most effective in eliminating stasis and could contribute to the prevention of

deep vein thrombosis 36.

A randomized controlled study was conducted on the effect of sequential foot

compression on prevention of VTE after total knee arthroplasty on 48 patients in India. Two

common prophylactic measures were used, in which controlled group used with low molecular

weight heparin, where as the other group received foot compression therapy for 7 days after

surgery. Results revealed that lower limb swelling and pain were significantly reduced for the

foot compression group (78%) in relation to the controlled group (50%).ultrasound and

venography demonstrated as significantly VTE in this group .Study emphasized on foot

compression therapy as an important prophylactic method in venous stasis 37.

6.3 STATEMENT OF THE PROBLEM:

“A study to evaluate the effectiveness of structured teaching programme on knowledge regarding

prevention of deep vein thrombosis among orthopaedic patients in selected hospitals at Bellary

Karnataka”.

6.4 OBJECTIVES OF THE STUDY:

1. To assess the pre-intervention knowledge of orthopaedic patients regarding prevention of deep

vein thrombosis by pre-test knowledge scores.

2. To develop and conduct structured teaching programme regarding prevention of deep vein

thrombosis among orthopaedic patients.

3. To assess the post intervention knowledge of orthopaedic patients regarding prevention of

deep vein thrombosis by post-test knowledge scores.

4. To evaluate the effectiveness of structured teaching programme by comparing the pre-test and

post-test knowledge scores of orthopaedic patients.

5. To determine the association between the mean pre test knowledge scores of orthopaedic

patients regarding prevention of deep vein thrombosis and selected socio-demographic variables.

6.5 RESEARCH HYPOTHESIS:

H1: The mean post test knowledge scores of orthopaedic patients regarding prevention of

deep vein thrombosis will be significantly higher than their mean pre test knowledge scores.

H2: There will be a significant association between the mean pre test knowledge of

orthopaedic patients regarding prevention of deep vein thrombosis and the selected socio

demographic variables.

6.6 VARIABLES UNDER STUDY:

INDEPENDENT VARIABLES

In this study, the independent variable refers to the structured teaching programme

regarding prevention of deep vein thrombosis.

DEPENDENT VARIABLES

In this study, the dependent variable refers to the knowledge among orthopaedic patients

regarding prevention of deep vein thrombosis.

ATTRIBUTE VARIABLE

In this study, the attribute variable refers to the variables such as age, sex, educational

qualification, occupation, socio economic status, religion, sources of information etc.

6.7 OPERATIONAL DEFINITION:

1. Evaluate: In this study, it refers to the findings of the value of a structured teaching

programme on knowledge regarding prevention of deep vein thrombosis among orthopedics

patients in selected hospital.

2. Effectiveness: In this study, it refers to the desired changes brought about by structured

teaching programme as measured in terms of significant knowledge gain in post test and graded

as adequate, moderately adequate knowledge.

3. Structured teaching programme: In this study, it refers to systematically organized

teaching strategy design for a group of orthopedics patients that enhances the knowledge

regarding prevention of deep vein thrombosis.

4. Knowledge: In this study, it refers to the correct response from respondents regarding

prevention of deep vein thrombosis as elicited through structured interview schedule.

5. Prevention: In this study, it refers include the primary and secondary measures adopted by

orthopedics patients to control and reduce the deep vein thrombosis.

6. Deep Vein Thrombosis: A condition in which a blood clot (thrombus) forms in a vein, which

in some cases then breaks free and enters the circulation as an embolus, finally lodging in and

completely obstructing a blood vessel ,e.g.- in lungs causing a pulmonary embolism. The term

encompasses both DVT and PE.

7. Orthopedics Patients: In this study it refers to adults who are undergoing open reduction

or hip/knee replacement surgeries or immobilized due to any other orthopaedic conditions.

6.8 ASSUMPTIONS:

The study assumes that

1. The orthopaedic patients are prone to develop deep vein thrombosis.

2. The orthopedics patients may not have adequate knowledge regarding prevention of deep

vein thrombosis.

3. Structured teaching programme is an accepted teaching strategy that can enhance the

knowledge of orthopedics patients regarding prevention of deep vein thrombosis.

6.9 DELIMITATIONS:

1. Study is limited to those adult orthopaedic patients who are undergoing open reduction or

hip or knee replacement surgeries or immobilized due to any other orthopaedic

conditions.

2. Orthopedics patients who are available at the time of data collection.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

1. The data will be collected from the adult orthopedics patients who are undergoing open

reduction or hip or knee replacement surgeries or immobilized due to any other

orthopaedic conditions in selected hospitals of Bellary, Karnataka.

7.2 METHOD OF COLLECTION OF DATA:

7.2.1 RESEARCH DESIGN:

The research design selected for the present study is quasi-experimental with “one group

pre-test and post-test design”.

7.2.2 RESEARCH APPROACH:

An evaluative research approach

7.2.3 RESEARCH SETTING:

1. The study will be conducted on adult orthopedics patients who are undergoing open

reduction or hip or knee replacement surgeries or immobilized due to any other

orthopaedic conditions in selected hospitals of Bellary, Karnataka.

7.2.4 POPULATION:

1. The population included in the present study is the adult orthopedics patients who are

undergoing open reduction or hip or knee replacement surgeries or immobilized due to

any other orthopaedic conditions in selected hospitals of Bellary, Karnataka.

7.2.5 SAMPLE SIZE:

1. The total sample size consists of 50 orthopedics patients who are undergoing open

reduction or hip or knee replacement surgeries or immobilized due to any other

orthopaedic conditions in selected hospitals of Bellary, Karnataka.

7.2.6 SAMPLING TECHNIQUE:

Non–probability, purposive sampling technique will be used.

7.2.7 DURATION OF THE STUDY:

4 – 6 weeks.

7.2.8 SAMPLING CRITERIA:

Inclusion Criteria

1. Orthopedics patients who are willing to participate in the study.

2. Both male and female adult orthpaedics patients who are undergoing open reduction or

hip or knee replacement surgeries or immobilized due to any other orthopaedic conditions

in selected hospitals of Bellary, Karnataka.

. 3. Orthopedics patients who are available at the time of data collection.

4. Orthopedics patients who can understand and speak kanada and Hindi and English.

Exclusion Criteria

1. Orthopedics patients who are not willing to participate in the study.

2. Orthopedics patients who are not available at the time of data collection.

3. Orthopedics patients who are illiterate.

7.2.9 TOOLS OF DATA COLLECTION:

Data collection tools are structured knowledge questionnaire, which contain items on the

following aspects.

Part-I: Demographic variables such as age, sex, educational qualification, occupation, socio

economic condition, religion, source of information regarding prevention of deep vein

thrombosis.

.Part-II: It consists of structured knowledge questionnaire regarding prevention of deep vein

thrombosis.

7.2.10 COLLECTION OF DATA:

1. The investigator herself collects the data from the adult orthpaedics patients who are

undergoing open reduction or hip or knee replacement surgeries or immobilized due to any other

orthopaedic conditions in selected Hospitals at Bellary.

2. Structured knowledge questionnaire is used to assess the knowledge by taking pre-test on deep

vein thrombosis and its prevention.

3. Conduct the structured teaching programme for adult orthopedics patients who are undergoing

open reduction or hip or knee replacement surgeries or immobilized due to any other orthopaedic

conditions in selected Hospitals, Bellary

4. Same structured knowledge questionnaire schedule for the pre test will be used for post- test

to assess the effectiveness of structured teaching programme.

7.2.11 DATA ANALYSIS METHODS:

The investigator will use descriptive and inferential statistics

Paired‘t’ test will be used to test the significant difference in the knowledge scores

between pre- test and post- test score.

Chi–Square test is used to determine the knowledge scores with demographic variables.

The data analyzed will be presented in the form of table, diagrams and graphs based

findings.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER

HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE, BRIEFLY.

YES, the study requires administration of structured interview schedule and structural teaching

programme to adult orthpaedics patients who are undergoing open reduction or hip or knee

replacement surgeries or immobilized due to any other orthopaedic conditions in selected

hospitals, Bellary. Karnataka.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION IN CASE OF?

Prior to the study informed consent will be obtained from the institution authorities to

conduct the study in the selected hospitals.

Subject privacy, confidentially and anonymity will be guarded.

Scientific objectivity of the study will be maintained with honesty and impartiality.

8. LIST OF REFERENCES:

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2000. P: 137-8.

2. Deep vein thrombosis risk stratification in emergency medicines. Kaushal (Kevin) Patel.

MD; Chief Editor: Barry E Brenner. MD. PhD. FACEP. Nov. 6 2012.

3. Thrombosis Advisor. How Thrombosis Develops; Thrombosis - a common and

potentially life-threatening condition 2012, Bayer Pharma AG.

4. Ricky Autar. The Management of Deep Vein Thrombosis. The Autar DVT Risk

Assessment Scale. Available from URL:

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

5. Smitha Kumar. A study to find out the effectiveness of nursing interventions in

preventing the complications of immobility among orthopaedic patients in selected

hospitals at Tumkur an unpublished research under Rajiv Gandhi University of Health

Sciences, 2008-2010.

6. Black M Joyce, Jane Hokanson Hawks, Medical Surgical Nursing, 7 th edition,

St.Louis: Elsevier publishers, 2007, 1535-40.

7. Piovella F, Wang CJ, Lu H, L ; AIDA investigators. Deep-vein thrombosis rates

after major orthopaedic surgery in Asia. An epidemiological study based on postoperative

screening with centrally adjudicated bilateral venography, J Thromb Haemost 2005;

3:2664–70.

8. Kapoor V K. Venous thromboembolism in India, Volume23; 2010.

9. National Institutes of Health and Human services USA Gov.Oct.28, 2011.

10. Hirsh J, Hoak J. Management of deep-vein thrombosis and pulmonary embolism. A

statement for healthcare professionals from the Council on Thrombosis (in consultation

with the Council on Cardiovascular Radiology), American Heart Association.Circulation.

1996; 93:2212-2245.

11. Silverstein MD, Heit JA. Trends in the incidence of deep vein thrombosis and pulmonary

embolism: a 25- year population-based study. Arch Intern Med, Mar 23 1998:

158(6):585-93.

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

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

13. Lee LH. Deep venous thrombosis rates after major orthopaedic surgeries in Asia.

An epidemiological study based on post operative screening with centrally adjusted

bilateral venography. J Thromb haemostat. 2005; 3.

14. Sudo A, Sano T. The incidence of Deep vein thrombosis after hip and knee surgery

artrhroplastics in Japanese patients. A prospective study. Orthop surg. 2003;11: 174-7.

15. APHA Deep-Vein Thrombosis Omnibus Survey. Conducted by Wirthlin Worldwide

2002.

16. WHO 1999, Incidence and Prevalence of venous thrombosis IAMA, India.

17. Deep vein thrombosis after hip and knee arthroplasties. Journal of Orthopaedic Surgery

2003: 11(2): 174–177Vol. 11 No. 2, December 2003 175.

18. Pellois A, Cohen AT. Epidemiology of post –operative venous thrombolism in Asian

countries. Int J Angiol. 2004; 13: 101-8.

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20. Prevention of Deep Vein Thrombosis and pulmonary embolism, NIH consens

conference. 1986 Mar 24-26; 6(2): p 1-8.

21. www.hindu.com/2009/03/19/stories/2009031959630300.htm .

22. AADS Research. Dept Arthoplasty and Total Hip Replacement Procedure. 2001; June:

p.1990-9.

23. Cohen AT, Tapson VF, Bergmann JF. ENDORSE Investigators. Venous

thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE

study): A multinational cross-sectional study. Lancet: 2008; 387–94.

24. . Dr. Susan M 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

25. BT Basavanthappa. Nursing Research. New Delhi. Jaypee publication. 2005. P.No.49.

26. Burnand B ; IMECCHI Group. Symptomatic in-hospital deep vein thrombosis and

pulmonary embolism following hip and knee arthroplasty among patients receiving

recommended prophylaxis: a systematic review. JAMA. 2012 Jan 18;307(3):294-303. doi:

10.1001/jama.2011.2029.

27. Kanchanabat B . Systematic review and meta-analysis on the rate of postoperative venous

thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis.

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28. Surendra K. Sharma. A prospective study of risk factor profile & incidence of deep

venous thrombosis among medically-ill hospitalized patients at a tertiary care hospital in

northern India. Departments of Medicine, Radio-diagnosis and Hematology. All India

Institute of Medical Sciences New Delhi, India. Received February 20, 2009.

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patients in an Asian institution. Department of Haematology, Singapore General Hospital,

Outram Road, Singapore 169608. Thromb Haemost. 2009 Jun;101(6):1095-9.

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An epidemiological study based on postoperative screening with centrally adjudicated

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9. SIGNATURE OF THE STUDENT :

10. REMARKS OF THE GUIDE : The research topic selected by

the student is quite appropriate and felt

need of the hour to improve the

knowledge by effective structured

interventions programme among the

patients.

11. NAME AND DESIGNATION OF :

11.1 GUIDE NAME AND ADDRESS : Smt. B Revathi

M.Sc (N), M.Phil

Medical Surgical Nursing

Indian College of Nursing

Bellary.

11.2 SIGNATURE OF GUIDE :

11.3 CO – GUIDE (IF ANY) : Mr. Anvarsab U Naregal

M.Sc (N),

Medical Surgical Nursing,

Indian College of Nursing.

Bellary.

11.4 SIGNATURE :

11.5 HEAD OF THE DEPARTMENT : Smt. B Revathi

M.Sc (N), M.Phil

Medical Surgical Nursing

Indian College of Nursing

Bellary.

11.6 SIGNATURE :

12.1 REMARKS OF THE PRINCIPAL: The research topic selected by the

candidate is relevant as it focuses

on the methods and prevention of

deep vein thrombosis which in

turn will reduce the morbidity and

mortality rate of the nation.

12.2 SIGNATURE OF THE PRINCIPAL: