Rajiv Gandhi University of Health Sciences s119

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

Mrs. ANCY THOMAS I YEAR M. Sc NURSING CHILD HEALTH NURSING (2010 –12 BATCH)

SRI SHANTHINI COLLEGE OF NURSING #188/B, PARVATHI NAGAR, OPP: SUB REGISTRAR OFFICE, LAGGERE MAIN ROAD, LAGGERE, BANGALORE-560058 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION 6. BRIEF RESUME OF THE INTENDED WORK

NAME OF THE Mrs. ANCY THOMAS CANDIDATE AND 1st YEAR M.SC NURSING, 01 ADDRESS SRI SHANTHINI COLLEGE OF NURSING #188/B,PARVATHI NAGAR, OPP:SUB REGISTRAR OFFICE, LAGGEREMAINROAD, LAGGERE,BANGALORE -560058. SRI SHANTHINI COLLEGE OF NURSING , NAME OF THE #188/B,PARVATHI NAGAR, 02 INSTITUTION OPP:SUB REGISTRAR OFFICE,LAGGERE MAIN ROAD, LAGGERE, BANGALORE -560058.

COURSE OF THE MASTER DEGREE IN NURSING 03 STUDY AND SUBJECT CHILD HEALTH NURSING

DATE OF ADMISSION 04 TO COURSE 30/06/2010

TITLE OF THE THE EFFECTIVENESS OF STRUCTURED TOPIC TEACHING PROGRAMME REGARDING 05 PREVENTION OF HYPOTHERMIA IN NEONATES INTRODUCTION

“ As a mother my job is to take care of what is possible and trust god with the

impossible.”

-Ruth Bell

Graham

Thermoregulatory needs of the newborn play a vital role in neonatal care, particularly in first several hours of life. The infants are at risk for hypothermia in the first days to weeks of life, due to evaporative, convective, and radiant heat losses during resuscitation. Evaporative and convective heat loss depends on air speed and humidity of the air (Hey & Maurice 1968). Newborns can become hypothermic (subnormal body temperature) very soon after birth, even in the summer when we don’t expect it.1

Neonatal hypothermia is associated with an increased mortality risk for 28 days.

There are few Hospital-based data on specific risk factors for neonatal hypothermia.

Hypothermia is well recognized as a factor influencing newborn health.1

The newborn infant exhibits immature thermoregulation, as compared with the older child or adult and therefore needs to be protected from extremes of cold and heat.

World Health Organization (WHO) provided the following definitions of normothermia and hypothermia:

 Normal range: 36.5–37.5 °C

 Potential cold stress: 36.0–36.5°; cause for concern

 Moderate hypothermia: 32.0–36.0°; danger, immediate warming of the baby

needed  Severe hypothermia: less than 32.0°; outlook grave; skilled care urgently needed.2

6.1 NEED FOR THE STUDY

There is a general agreement that perinatal hypothermia should be avoided in all newborns, with the possible exception of those who have sustained a significant hypoxic- ischemic insult. In 2006, the American Academy of Pediatrics' and American Heart

Association's Neonatal Resuscitation Program (NRP) textbook recommended, 'the goal

(of the first postnatal temperature) should be an axillary temperature of approximately

36.5 °C'. The NRP text also noted that 'temperature must be monitored closely because of the slight but described risk of hyperthermia...(which) during or after ischemia is associated with progression of cerebral injury...The goal is to achieve normothermia and avoid iatrogenic hyperthermia'.3 Continuous temperature monitoring should be initiated as soon as possible after the birth of the preterm infants in order to document and achieve normothermia.4 Since low delivery room temperatures can predispose to hypothermia, the

NRP text recommended, 'when delivery of a preterm baby is anticipated, the temperature of the room should be increased', and to 'pre-heat the radiant warmer by turning it on well before birth, use a head cap, and ...if the baby is born at less than 28 weeks gestation, consider placing him, below the neck, in a reclosable polyethylene bag, without first drying the skin. The bag can be a standard 1-gallon, food-quality, polyethylene bag purchased in a grocery store.5

Another way to improve temperature regulation in the delivery room is to actively share American Society of Heating, Refrigerating and Air-conditioning Engineers

(ASHRAE)6 and WHO recommendations for delivery room temperatures with hospital leaders and managers of Labor and Delivery services.2 The ASHRAE handbook recommends single room labor-delivery-recovery-postpartum temperature of 75 2 °F, standard patient room temperature of 75 2 °F, recovery room temperature of 75 2 °F and nursery temperature of 75 3 °F. The guidelines further state that Delivery Room temperature should never be below 68 °F. Recommendations from the American Institute of Architects (AIA), WHO and Recommended Standards for Newborn ICU Design are in agreement with the ASHRAE document. Prevention of hypothermia is also enhanced by use of weighing scales built into warmers and appropriate attention to adequate warming mechanisms of transport incubators. However, of paramount importance is staff education in this area on the problem of neonatal hypothermia and the use of preventive strategies, especially in the extremely low birth weight infant.6

Neonatal hypothermia is widely recognized as an important contributing factor to neonatal morbidity, especially in low and middle income countries and has been associated with mortality risk in newborns and young infants aged 0-2 months . The

World Health Organization (WHO) has included thermal care (including the prevention of neonatal hypothermia) as a component of essential care in newborn among a package of basic interventions recommended universally for all babies . However, in low-resource settings, adequate thermal care of newborns is difficult to achieve and hospital-based studies in South Asia and Sub-Saharan Africa have demonstrated a high incidence of primary hypothermia, especially in the first 24 h after birth.2

All the above studies/ articles show that prevention of hypothermia is very necessary to prevent the complications in the newborn. So the researcher has taken this study to educate the post natal mothers so that they will have adequate knowledge regarding the prevention of hypothermia in the neonates. 6.2 REVIEW OF LITERATURE:

The review of literature will be discussed in the followings:

A prospective observational study of post-delivery care and neonatal body temperature, carried out at Kathmandu Maternity Hospital, was followed by a randomized controlled intervention study using three simple methods for maintaining body temperature. There were 500 infants in the initial observation study and 300 in the intervention study. In the observation study, 85% (420/495) of infants had temperatures <

36 degrees C at 2 h and nearly 50% (198/405) had temperatures < 36 degrees C at 24 h

(14% were < 35 degrees C). Most of the infants who were cold at 24 h had initially become cold at the time of delivery (only seven infants had been both well dried and wrapped). In the intervention study, all infants were dried and wrapped before random assignment to one of the three methods: the "kangaroo" method, the traditional "oil massage" or a "plastic swaddler". All three were found to be equally effective. Overall,

38% (114/298) of the infants had temperatures < 36 degrees C at 2 h and 18% (41/231) at

24 h (when none was < 35 degrees C).7

A study was conducted to identify the incidence, rate and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran, 900 neonates were randomly selected. Body temperature was measured repeatedly at different time points after birth. More than 50% became hypothermic soon after birth. Multiple regression analysis showed that low birth weight, low gestational age environmental temperature, low Apgar score, multiple pregnancy and receiving cardiopulmonary resuscitation were significantly associated with hypothermia. These findings suggested that there is an urgent need to sensitize and educate all levels of staff dealing with neonates in our country.8

A study was conducted on Successful implementation of evidence-based Routines in Ukrainian maternities to describe the process of change and assess compliance and effect on maternal and infant outcome when the WHO package Effective Perinatal Care

(EPC) was implemented at maternities in Ukraine. Baseline data were collected for 652,

742 and 302 deliveries and 420, 381 and 135 infants, respectively, in Donetsk, Lutsk and

Lviv. Follow-up data included 4,561, 9,865 and 7,227 deliveries and 3,829, 8,658 and

6,401 infants. EPC procedures were successfully implemented and adherence to the protocols was excellent. For most variables, the change occurred during the first three months but was well sustained. The use of partogram increased fourfold in Donetsk and from 0% to 60% in Lviv. Induction and augmentation of labor decreased to less than 1% and less than 5%, respectively. Cesarean section rate dropped significantly in two of the maternities. The proportion of hypothermic infants decreased from 60% (Donetsk), 85%

(Lutsk) and 77% (Lviv) to 1% in all three maternities during the first three months and was stable throughout the study period. Admission to Neonatal Intensive Care Unit decreased significantly in two of the maternities and there was no effect on early neonatal mortality.9

A study was conducted on the Introduction of neonatal care in a rural Bangladesh hospital: an analysis of the first year's operation.A neonatal care unit was introduced into a rural hospital in Bangladesh. Emphasis was on simple care to prevent hypothermia, hypoglycaemia and infection, and on involving mothers in caring for their infants as much as possible. The mean birth weight was found to be only 2.44 kg, so that the level of low birth weight requiring special care was fixed at 2.0 kg. At this level, during the first year of operation, 193 low birth weight babies were attended, approximately 20% of total deliveries. Of these, 80% were above 1.5 kg and had a mortality of 25%. Those below 1.5 kg fared worse, and 83% either died or were discharged against medical advice. The main problems were an initial lack of enthusiasm from the nursing staff, high incidence of sepsis (related to poor hygiene of mothers) and difficulty in persuading mothers to keep very low birth weight babies in hospital. However, with minimal expenditure and equipment, appropriate neonatal care saved the lives of many low birthweight infants. Establishing breastfeeding and educating the mothers reduced the subsequent high mortality of low birth weight infants in the first year of life.10

A study was conducted on Cling wrap, an innovative intervention for temperature maintenance and reduction of insensible water loss in very low-birthweight babies nursed under radiant warmers: a randomized, controlled trial.The aim of study was to assess the value of polythene film ('cling wrap') to improve thermal control and reduce postnatal weight loss in preterm, very low-birthweight babies was investigated. Consecutively born babies with birthweights between 750 and 1500 g were stratified by birthweight (<1250 g, 1251-1500 g) and randomised either to the cling wrap (CW) or no cling wrap (NCW) group. The baby bassinette of the RW was covered with cling wrap up to the level of the neck in the CW group for the 1st 7 days. The primary outcome variables were the incidence of hypothermia (axillary temperature < or = 36 degrees C) after initial stabilisation during the first 7 days and cumulative weight loss (percentage of birthweight) at 48 hours of age.The results show that Of 51 babies, 26 were randomised to the CW and 25 to the NCW group. None of the babies in the CW group developed hypothermia in the 1st 7 days but 36% in the NCW group (p = 0.001) did. Babies who were hypothermic on admission took less time to reach normal temperature in the CW group. Cumulative weight loss in the 1st 48 hours was 5.0 + 5.6% in the CW group and

8.6 + 7.0% in the NCW group (p = 0.06).11 A study was conducted on the use of self-heating gel mattresses eliminates admission hypothermia in infants born below 28 weeks gestation. A retrospective audit was conducted to evaluate the effectiveness of self-heating acetate gel mattresses at resuscitation of infants born at or below 28 weeks to prevent hypothermia at birth. All infants born at or below 28 weeks gestation during 18 months before and 18 months after self-heating acetate gel mattresses were introduced during resuscitation were included.

The results show one hundred five babies were born when acetate gel mattresses were not used, and 124 were born during the period when they were. Four (3.3%) babies were hypothermic (temperature <36 degrees C) at admission when the mattresses were used compared to 21 (22.6%) babies who were hypothermic during the period it was not (p <

0.001). Hyperthermia (temperature >37 degrees C) rose from 30.1% prior to use of gel mattresses to 49.6% when they were used (p = 0.004). This shows that self-heating acetate gel mattresses are highly effective in reducing admission hypothermia in infants born at or below 28 weeks gestation.12

STATEMENT OF THE PROBLEM:

A study to assess The Effectiveness of Structured Teaching Programme regarding Prevention of Hypothermia in Neonates among the Post Natal Mothers in selected Hospitals of Bangalore. 6.3 OBJECTIVES:

1. To assess the knowledge regarding prevention of hypothermia in neonates among

the post natal mothers in term of pre test score.

2. To assess the knowledge regarding prevention of hypothermia among the post

natal mothers in term of post test score.

3. To assess the effectiveness of structured teaching programme by comparing pre

test and post test level of knowledge score.

4. To determine the association between post test knowledge score and socio

demographic variables such as age, education, religion, occupation, parity, family

income per month, types of family etc.

6.4 HYPOTHESIS:

H1 The mean post test knowledge score of post natal mothers is significantly

higher than the mean pre test knowledge score by paired‘t’ test at 0.01

level.

H2. There is significant association between the knowledge with selected

demographic variables such as age, education, religion, occupation, parity, family

income per month, types of family by Chi square(χ2)test at 0.05 level. 6.5. VARIABLES:

INDEPENDENT VARIABLES:

Structured Teaching Programme regarding the prevention of

hypothermia in neonates among the post natal mothers.

DEPENDENT VARIABLES:

Knowledge level of the post natal mothers regarding the prevention of hypothermia in neonates.

EXTRANEOUS VARIABLES:

Demographic variables such as age, education, religion, occupation, parity, family

income per month, types of family .

6.6. OPERATIONAL DEFINITIONS:

EFFECTIVENESS:

It refers to significant increase in the knowledge as determined by significant

difference in pre test and post test knowledge score.

STRUCTED TEACHING PROGRAMME:

It is a structured teaching programme or material preparing in English and kannada regarding the prevention of hypothermia in neonates.

PREVENTION:

It refers to the measures taken to prevent the baby from the subnormal temperature,36.5 degree celsius. HYPOTHERMIA:

It refers to the temperature below 36.5 degree Celsius.

NEONATES:

It refers to the baby whose age is from 0 to 28days of life.

POST NATAL MOTHERS:

It refers to the mothers who have just given birth to a baby.

HOSPITAL:

It refers to an institution which provides care , diagnosis and treatment of the sick,

injured and those persons who need nursing and medical care.

6.7. ASSUMPTION:

Post natal mothers may not have adequate knowledge about prevention of

hypothermia in neonates.

Post natal mothers have interest to know about the prevention of

hypothermia in neonates.

6.8. DELIMITATION:

The study is delimited to the post natal mothers present in selected

hospitals of Bangalore.

7. MATERIALS AND METHODS:

7.1. SOURCE OF DATA:

Data will be collected from post natal mothers present in selected hospitals

of Bangalore. 7.2 METHOD OF COLLECTION OF DATA:

7.2.1. RESEARCH DESIGN:

A Quasi Experimental research design.

7.2.2. RESEARCH APPROCH:

An evaluative Survey research approach.

7.2.3. SETTING OF THE STUDY:

This study will be conducted in selected hospitals of Bangalore.

7.2.4 .POPULATION:

The population of present study consists of post natal mothers who are present in selected hospitals of Bangalore.

7.2.5. SAMPLE SIZE:

The total sample of the study consists of 75 post natal mothers.

7.2.6. SAMPLING TECHNIQUE:

Non Probability–convenient sampling.

7.2.7.SAMPLING CRITERIA:

INCLUSION CRITERIA:

Post natal mothers

 Who are present in selected hospitals.

 Who can understand Kannada or English.

 Who are willing to participate in the study.

EXCLUSION CRITERIA:

Post natal mothers

 Who are not willing to participate in the study.

 Who are not able to speak and write Kannada or English.

7.2.8. DATA COLLECTION TOOL:

The researcher develops a structured knowledge questionnaire. It consists of part-I and part-II.

Part- I: selected Demographic variables such such as age, education, religion, occupation, parity, family income per month, types of family .

Part-II: knowledge questionnaires regarding prevention of hypothermia.

7.2.9. DATA ANALYSIS METHOD:

The data analysis will be done through descriptive statistics and

Inferential statistics.

 DESCRIPTIVE STATISTICS:

Frequency, Mean percentage, standard deviation of demographic

variables.

INFERENTIAL STATISTICS:

▪paired “t” test to compare the pre and post test knowledge score of 0.01

level.

▪ Chi square (χ2) test will be used to find the association between the

selected demographic variables and knowledge score of health workers. 7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR

ANIMALS?

7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

YOUR INSTITUTION:

Permission will be obtained from :

 The research committee of Sri Shanthini College of Nursing.

8. LIST OF REFERENCE:

1. http:// kinne.net/coldkids.htm

2. World Health Organization (WHO). Thermal protection of the newborn: a practical

guide 1997.

www.who.int/reproductivehealth/publications/MSM_97_2_Thermal_protection_of_t

he_newborn/index.htm Accessed 8/13/07.

3. Kattwinkel J (ed). Textbook of Neonatal Resuscitation. 5th edn, American Academy

of Pediatrics: Elk Grove Village, IL, 2006, Lesson 8 6.

4. Knobel RB, Wimmer JE, Holbert D. Heat loss prevention for preterm infants in the

delivery room. J Perinatol 2005; 25: 304–308. | Article | PubMed |

5. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat Loss Prevention in the

delivery room: a randomized controlled trial of polyethylene occlusive skin

wrapping in very preterm infants. J Pediatr 2004; 145: 750–

753. | Article | PubMed | ISI |

6. Handbook: HVAC Applications. American Society of Heating, Refrigerating and

Air-Conditioning Engineers, Inc. (ASHRAE): Atlanta, GA, 2003

7. Johanson RB, Spencer SA, Rolfe P, Jones P.Effects of post delivery care on neonatal

body temperature.Acute Pediatrics 1992 Nov:81(11)

http://www.ncbi.htm.nih.gov/pubmed

8. Zaveri F, Kazemnegiad A, Ganjali M, Babaei G, Nayai F. Incidence and risk factors

of neonatal hypothermia at referral hospitals in Tehrain.Neonatal hypothermia 2000

Jun 5: 23(12 http://www.ncbi.htm.nih.gov/pubmed 9. Begleud A, Lefeme- Cholay H. Succesful implementation of evidence based routines

in Ukranian maternities.Acute obstretic/ gynaecology.2010:Jan 2: 89(2)

10. Hort K.P. Introduction of neonatal care in a rural Bangladesh hospital: analysis of

the first year’s operation.1985: Dec 5(4) http://www.ncbi.htm.nih.gov/pubmed

11. Kaushal M, Agarwal R, Sufal A. Clingwrap, an innovative intervention for

temperature Maintainance and reduction of insensible water loss in very low birth

weight babies nursed under radiant warmers.2009: Jan12(29)

12. Ibrahim C.P. Yoxall CW.Use of self heating gel mattresses eliminates admission

Hypothermia in infants born below28 weeks gestation. 2010: Jul15 (169).

http://www.ncbi.htm.nih.gov/pubmed 9. SIGNATURE OF THE STUDENT :

10. REMARKS OF THE GUIDE : The study will help the post natal mothers to improve their knowledge regarding prevention of hypothermia in neonates.

11. NAME AND DESIGNATION OF

11.1 GUIDE : Mrs. Vasantakumari Associate Professor,

11.2 SIGNATURE :

11.3 HEAD OF THE DEPARTMENT : Mrs. Vasantakumari Associate Professor,

11.4 SIGNATURE :

12. REMARKS OF PRINCIPAL : The researcher selected the appropriate topic to help the post natal mothers how to prevent hypothermia in neonates.

12.1. SIGNATURE :