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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 Name of candidate and Address ABITHA JUSTIN. J
( In block letters ) I YEAR M.Sc. NURSING
MASOOD COLLEGE OF NURSING
DOOR NO.3E-12-1084/1,BIKARNATAKA,
KULSHEKAR POST, MANGALORE-575 005 2 Name of the Institution MASOOD COLLEGE OF NURSING
MANGALORE
3 Course of Study and Subject M.Sc. NURSING,
MEDICAL SURGICAL NURSING
4 Date of Admission to the Course 16.06.2012
5 Title of the Topic
“ A STUDY TO ASSESS THE KNOWLEDGE, ATTITUDE AND PRACTICE OF
STAFF NURSES REGARDING THE RISK FACTORS AND PREVENTIVE
MEASURES OF VARICOSE VEIN IN SELECTED HOSPITALS AT MANGALORE.”
1 6. BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION Varicose veins are swollen, twisted, and sometimes painful veins that have filled with an
abnormal collection of blood. Normally veins have leaflet valves to prevent blood from
flowing backwards (retrograde flow or reflux). Leg muscles pump the veins to return blood to
the heart (the calf muscle pump mechanism), against the effects of gravity.
When veins become varicose, the leaflets of the valves no longer meet properly, and
the valves do not work (valvular incompetence). This allows blood to flow backwards and
they enlarge even more. When a person stand up we can see varicose veins as large, bluish
vessels that may feel like a rope.
This process usually occurs in the veins of the legs, although it may occur in other parts
of the body. Individuals spending most of the day on their feet every working day (e.g.
Nursing staffs, teachers, sales assistants, traffic police etc) are at greater risk of health
problems including varicose veins, poor circulation and swelling in the feet and legs, foot
problems, joint damage, heart and circulatory problems and pregnancy difficulties.
Workers in lower status jobs are for more likely to be required to stand for long
periods. Whether employed in an emergency room or private room nurses tend to spend a
large amount of time on their feet while conversing with patients, consulting doctors and
performing medical procedures. This can put nurses at risk of developing varicose vein.
Varicose veins greatly affect over all nursing wellness.
6.2 NEED FOR THE STUDY
Varicose veins are veins that have become enlarged and tortuous. Veins have leaflet
2 valves to prevent blood from flowing backwards. Varicose veins are most common in the
superficial veins of the legs, which are subject to high pressure when standing. Besides
cosmetic problems, varicose veins are often painful, especially when standing or walking.
Millions of workers spend majority of the working day on their feet and many hours in
static positions. Standing uses 20% more energy than sitting and because human bodies are
not designed to stand at work, prolonged standing, can lead to tiredness, loss of
concentration and increased health risks.
These risks include the swelling of feet and legs, feet and joint damage, varicose
veins, heart and circulatory disorders, lower back problems and pregnancy complications.
Severe varicose veins can have an impact on the lives of the people who work on their feet
especially the teachers, nursing staffs, flight attendants, dental staff, traffic and bar
workers, postal workers, construction workers and bank staff .1
Varicose veins have been recognized as chronic disorder since ancient times.
Hippocrates discussed those 2500 years ago. With increasing population, increased
lifespan and changes in lifestyle and occupation it involves at least 1 out of 5 in the world.
It is in developed countries where attire reveals more than it conceals; patients turn up for
treatment because of cosmetic records. But in our Indian scenario it is complications not
cosmetics reasons bring patient to doctor that is reason why though common varicose veins
remain iceberg phenomenon.2
Varicose Veins are present in 20 to 25% of adult females and 10 to 15 % of men in
western Countries. This disease has attained national and industrial importance in western
world because of its high prevalence. The disease is neglected by Indians. Varicose vein is
3 a common surgical problem. The incidence of varicose veins varies among different
populations. This condition is considered a national health problem in western countries.
According to Callam, prevalence of varicose veins is 10-15% in men and 20-25% in
women. We do not have statistical data of varicose veins in India but incidence in India is
on the rise.3
Current statistics reveal that nearly 2.7 million people worldwide, suffer from
varicosities and the toll is ever increasing. Where India is concerned, experts are
witnessing a growing prevalence of varicosities especially among women. Nearly, 20-15
per cent of women and 10-15 per cent of men suffer from varicose veins in India. 4
The extrapolated prevalence rate of varicose vein in India providing warning in about
47,928,177 in statistics.
Researcher, during her clinical practice as a staff nurse found her colleague with the
problem of varicose vein. Due to that colleague negligence and ignorance of varicose vein
it ends up in long lasting leg ulcer.
The list of occupational hazards just seems to be increasing. Varicose veins have
become a serious threat to the lives of millions of people across the globe and is said to be
ignored by people living across India. “There is an urgent need to spread awareness about
varicose veins in India. Many people suffer from it, but most tend to ignore it and that is
not good as it can lead to complications in the advanced stage”. 5
Lot of awareness campaigns on varicose veins in the US are going on and but in
India there is a lack of education on this subject as the common man doesn’t know what
4 the problem is all about and what can happen if it is not treated on time.
Though there is a high prevalence of varicose vein in India, very few studies have
been conducted in India. Nurses are under the risk of development of varicose vein since
they are forced to stand for long time for giving care. Lack of rest and exercise for calf
muscles may lead to varicose vein. Researcher found the importance of doing this study
based on the literature, statistical values and also based on her personal experience she had
while she was doing her clinical practice as a staff nurse.
6.3 THE REVIEW OF LITERATURE
A literature is a body of text that aims to review the clinical points of knowledge on a
particular topic of research
(ANA,2000)
5 Literature related to the risk factors and prevention of varicose vein
A Cross sectional study has been done in order to investigate the relationship
between the demographic and occupational fact. This study was conducted through on 203
nurses in Amol hospitals. Questionnaire was used to collect the required information. It
was completed through interview and physical examination based on the standard CEAP
forms. 145 of the subjects were female. 73.9% of the nurses had varicose with different
levels (CI95%: 77- 65). Female gender, age, BMI (OR =1.21), regular exercise (OR
=0.31), family history, weight, and overtime between job factors (OR =1.01), years of
service, standing (OR =2.3) and sitting in the ward had significant relationship with the
varicose intensity. The result of the study shows that the necessary training to reduce
disability and treatment expenses to adjust risk factors and prevention of inducing varicose
is essential according to the high number of the nurses who have lower varicose veins with
different intensities and the effect of lots of demographic and occupational factors.
A descriptive study was conducted to identify the incidence of Varicose veins in
relation to occupation and working hours during January 2009 to April 2010. In this study
retrospective cohort design applied, among 58 patients who were diagnosed with varicose
veins.70.69% cases involved in mainly standing occupations while only 29.31% patients
belonged to mainly sitting occupations. The male female ratio among the varicose vein
patients was found to be 4:1.On an average, the patients who got the disease had worked
standing or walking for 9.33 hours/day. The maximum incidence was seen in the age group
of 30-39 years with as many as 17 cases out of 58 cases studied. The study concluded that
a definite co relation between varicose veins and standing occupations, and taking care of
6 the factors responsible for the disease will go a long way in increasing the productivity and
efficiency of workers. People who work more than 9.33 hours per day standing or walking
are more likely to develop the disease. 7
A pilot study was done to find out the occupational health problems among hospital
nurses. He administered questionnaire on a study group of 300 nurses and on a reference
group of 250 school teachers to determine the health problems associated with the nursing
profession. Sensitivity to penicillin and other substances was found to be the most common
health problem associated with nursing. Nearly 60% of the nurses were hospitalized for
over three days for various types of illnesses as compared with 11% of teachers, the most
common illness being typhoid fever. Recurrent sore throat, backache and varicose veins
were more common in nurses and in fact, most of the illnesses were developed after
joining the nursing profession. A considerable proportion of injuries, which involved leave
for over three days, was seen among the nursing staff. The differences in prevalence rates
of these diseases and disabilities are statistically significant. 8
A survey was carried out to determine the prevalence of varicose veins among
railway men doing identical work of sweepers in the North and South of India showed that
the overall prevalence was significantly higher among sweepers of South Indian (25.08%)
than among sweepers of North India (6.8%). Further a study was conducted to test the
cause-and-effect relationship. The study suggested that prevalence of varicose veins is
related to patterns of diet and eating and thus this disease may be prevented.9
A study was undertaken to assess the prevalence of varicose vein in different
7 Occupations. It was found difficult to obtain precise figures for the incidence of these
conditions, but any physician who treats adult patients knows the extreme frequency of
their occurrence .In a survey of 1,000 young industrial employees, it was found that
10%had definite varicose veins. In a older group of departmental store employees, all over
40 ,the incidence had risen to 40%among the men and 70%among the women.10
Over a two year period all admitted patients to a government tertiary level
district hospital of varicose veins were evaluated for demographics, clinical manifestations,
treatment and outcome. This study reveals that the disease is more prevalent during the
active adult life in their 3rd and 4th decades and males were more affected. The
occupations needing prolonged standing and use of violent muscular efforts is found to be
a contributing or precipitating factor for varicose veins. Hereditary factors may play an
important role in the development of varicose veins. 25% of patients had a family history
of varicose veins occurring in close relatives. Majority of patients presented to the hospital
for complications of the disease (60%) rather than for cosmetic purposes. The commonest
symptoms in the study were prominent swellings in the lower limb and pain. Majority of
the patients had combined valvular incompetence (71%). The most common post-operative
complication observed was wound infection (25%).11
A cross sectional study was conducted among teachers in 12 schools in Ahmadabad
which revealed that 77% of the 138 teachers suffered from varicosity or enlargement of the
veins of legs. Among these 107 nearly 84 people suffered from spider webs, the first stage
of varicose veins. While 23 had severely established varicose veins which means they
suffered from severe aches, swelling and heaviness in the legs. This study concluded that
8 varicose veins is a condition that makes walking and standing extremely difficult and
painful and if treated early at the stage of spider veins they are preventable. 12
A prospective randomized study was conducted on Prolonged standing at work and
hospitalization due to varicose veins among the Danish population with representative
random sample of 9653 working age adults interviewed by telephone (response rate
90%).Reported that respondents (2939 were men’s and 2708 were women’s). Risk ratios
for VV were estimated by log-linear Poisson regression models separately for men and
women with adjustment for smoking status, body mass index (BMI), heavy lifting, and, for
females only, number of children at baseline During 12 years of follow up, 40
hospitalizations due to VV were observed among the men and 71 among the women. For
employees with jobs that require prolonged standing or walking compared to all other
employees, the relative risk was 1.75 (95% CI 0.92 to 3.34) for men and 1.82 (95% CI 1.12
to 2.95) for women. The pooled estimate of the relative risk was 1.78 (95% CI 1.19 to
2.68). The etiological fraction of prolonged standing or walking at work was estimated as
22.5% for men and 22.6% for women. This prospective study confirms that prolonged
standing at work constitutes an excess risk of hospital treatment due to varicose veins and
accounts for more than one fifth of all cases of working age.13
A cross-sectional study was conducted in Finland to assess whether smoking,
alcohol drinking and dietary factors are linked with varicose veins, A middle-aged general
population of 4903 was studied, and prevalence rates at entry and five-year incidence of
varicose veins were assessed. Lifestyle habits were recorded at entry and at the end of the
follow-up. New varicose veins were significantly more common in individuals with regular
9 alcohol intake, incidence odds ratio (OR) 1.5 (95% confidence interval [CI]: 1.05-2.3) in a
multivariate analysis (of 2202 individuals). The association was particularly strong in
women. Smokers had a higher incidence of varicose veins compared with non-smokers,
OR 1.3 (95% CI: 0.9-1.8). Having daily meals of meat implied less new varicose veins
than having 0-2 weekly meals of meat, and was concluded Alcohol was likely to increase
the risk of varicose veins in women and smoking in both genders.14
A cross-sectional community based study was conducted to the issue of working
conditions and their health ramifications in Israel with special emphasis on occupations
requiring prolonged standing. This review article discusses the physiological and medical
aspects of prolonged standing in the workplace. Searching the literature, 19 studies were
found which specifically examined the effect of prolonged standing versus prolonged
sitting at work. Most of these studies suggested that prolonged standing may result in the
development and aggravation of chronic venous insufficiency. The conclusion states that
there is an association between prolonged standing and venous insufficiency. It was found
to be more pronounced in women than in men.15
A cross sectional study was conducted on the effect of standing in the workplace
and the development of chronic venous insufficiency of the superficial venous system in
the legs. Revealed that mechanical hydrostatic pressure generated by long periods of
standing at the workplace is a major etiologic factor in the development of chronic venous
insufficiency of the superficial venous system in the legs. Both varicose veins and working
while standing are very common, so it is not surprising to find a high percentage of
varicose veins amongst those who work standing up. Ambulatory venous pressure while
sitting is about 60-80 mm of water, as opposed to 20 mm while walking, and the number is
10 only slightly higher (about 100) while standing. Recent work by J. Bergan and his group
demonstrated (in laboratory animals) that increased venous pressure will lead to the
disappearance of the valve leaflets. This can explain the high frequency of venous reflux
amongst young people (13%) and the even higher frequency (35%) found amongst the
elderly population. It has been explained that hydrostatic pressure along with muscle
pumps failure and venous out flow obstruction is an important contributor of the increased
venous pressure. thus it concludes that standing as an important and significant factor in
the development of this complex disease process.16
Dr. Rajmohan Nambiar in Singapore also noted that 67%of varicose vein patients
had involved in profession of prolong standing.17
6.4 STATEMENT OF PROBLEM
“A study to assess the knowledge, attitude and practices of staff nurses regarding the
risk factors and preventive measure of varicose vein in selected hospitals at Mangalore.”
6.5 OBJECTIVES
1.To assess the knowledge of staff nurses regarding risk factors and preventive
measures of varicose vein
2.To assess the attitude of staff nurses regarding risk factors and preventive measures
of varicose vein
3.To assess the practice of staff nurses regarding risk factors and preventive measures
11 of varicose vein
4.To find out the correlation between knowledge and attitude of staff nurses
regarding risk factors and preventive measures of varicose vein
5.To find out the correlation between knowledge and practice of staff nurses
regarding risk factors and preventive measures of varicose vein
6.To find out the association between knowledge, attitude and practice regarding risk
factors and preventive measures of varicose vein with selected variables
6.6 OPERATIONAL DEFINITION Knowledge: it is defined as the information known by the staff nurses regarding risk factors and preventive measures of varicose vein. Attitude: it refers to the opinion of staff nurses regarding risk factors and preventive
measures of varicose vein.
Practice: Measures followed by the staff nurses to prevent the occurrence of varicose
vein during their clinical practice.
Varicose vein: Varicose vein are the veins that have become enlarged and tortuous.
Risk factors: a risk factor is a variable associated with an increased chance of
varicose vein.
Prevention: It refers to precautionary measures taken by the staff nurses to avoid the
occurrence of varicose vein.
12 Staff nurses: In this study staff nurse is a person who is having diploma or basic
degree in nursing from a recognized university or board registered under a state
nursing council and is working in a selected hospital at Mangalore.
6.7 VARIABLES
Dependent Variables: Demographic variables
Independent Variable: Knowledge, attitude and practice
6.8 ASSUMPTION
The study based on the following assumption
The staff nurses may have a chance of occurrence of varicose vein because of the need of
standing in their profession.
Staff nurses may have some knowledge regarding risk factors and preventive measures of
varicose vein.
Staff nurses may be willing to express their knowledge, attitude and practice regarding
risk factors and preventive measures of varicose vein.
6.9 DELIMITATION
Study is limited only in selected hospitals in Mangalore.
Staff nurses who were present at the time of the study only participated in the study.
Age group between 25 -40 yrs.
Study period limited only 4 weeks
6.10 HYPOTHESES
13 1. H1 - There is significant correlation between knowledge and attitude
regarding risk factors and preventive measures of varicose vein among staff nurses.
2. H2- There is significant correlation between knowledge and practice
regarding risk factors and preventive measures of varicose vein among staff nurses.
3. H3 – There is a significant association between knowledge, attitude and
practice with selected demographic variables.
MATERIALS AND METHODS
7.1.1 SOURCE OF DATA:
Data will be collected from the staff nurses in selected hospitals at Mangalore.
7.1.2 RESEARCH DESIGN:
Descriptive design.
7.1.3 SETTING :
The study will be conducted in selected hospitals at Mangalore.
7.1.4 POPULATION:
The population of study consists of staff nurses in selected hospitals at Mangalore.
The sample of the study is the staff nurses who have an experience of 3 years and above as
staff nurse.
14 7.2 METHOD OF DATA COLLECTION
7.2.1 SAMPLING PROCEDURE:
Simple random sampling procedure will be used to select the staff nurses of selected
hospitals at Mangalore.
7.2.2 SAMPLE SIZE:
The sample size will be approximately 60 staff nurses in the age group of 25-40yrs of
selected hospitals at Mangalore.
7.2.3 INCLUSION CRITERIA:
1. Staff nurses who are working in selected hospitals at Mangalore.
2. Staff nurses who have an experience of 3 years and above.
3. Staff nurses with age group of 25-60 yrs.
4. Staff nurses who are willing to participate in the study.
5. Staff nurses present at the time of data collection.
7.2.4 EXCLUSION CRITERIA
1. Staff nurse who are not willing to participate.
2. Staff nurses who is having less than 3 years of experience.
3. Staff nurses who are already having varicose vein.
4. Staff nurses who are not available during the period of data collection.
15 7.2.5 DEVELOPMENT OF TOOL
Instrument Used
Self administered questionnaire, attitude scale, and check list.
Description Of The Tools
Appropriated structured knowledge questionnaire to assess the knowledge and likert
type of attitude scale to assess the attitude and practice of staff nurses regarding risk
factors and preventive measures of varicose vein constructed and validated by experts and
it will be used to collect the needed data.
7.2.6 DATA COLLECTION METHOD
A prior formal permission will be obtained from the selected hospital authorities of
Mangalore for collecting the required data.
Objectives of the study will be explained to the participants and a formal written
consent will be taken from the subjects.
Structured questionnaire will be administered to collect the data regarding knowledge
about risk factors and prevention of varicose vein.
Attitude scale will be administered to assess the attitude and practice of risk factors and
prevention of varicose vein
Duration of data collection is 4 weeks
7.2.7 DATA ANALYSIS PLAN
Descriptive and inferential statistics will be used
16 Mean median and mode will be used to explain demographic variables
Chi square test to associate the knowledge score with selected demographic variables
To correlate between knowledge attitude and practice by using Karl Pearsons moment
correlation.
7.3 DOES THE STUDY REQUERE ANY INVESTIGATION TO BE CONDUCTED
ON PATIENTS OF OTHER HUMANS OR ANIMALS?
Yes. The study requires to analyses the knowledge, attitude and practice of regarding
the risk factors and preventive measures of varicose vein of selected hospitals at Mangalore
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTE
IN CASE OF 7.3?
Yes. Ethical clearance is obtained on 08.11.2012 from the ethical committee of
Masood College of Nursing.
17 REFERENCES
1. Neill R.Standing problem. Hazard magazine (online). 2005 Aug10. (cited 2011Oct
24): URL http://www.hazards.org/standing/index.htm
2. Mukunda NK. Clinical evaluation and management of lower limb varicose vein: a
study at KIMS. Unpublished doctoral dissertation submitted to Rajiv Gandhi
University of Health Sciences:2006.
3. S.P Despandae, G.C Gupta , P.D. Banodea East and Central African Journal of
Surgery ,15(2) July-Aug ,2010, pp:65.
4. Express Health Care Jan 2011.
URL: http://www.expresshealthcare.in/201101/knowledge01.shtml
5. Cox , Sara ,Jane Awareness of varicose vein among general public.
URL: http://www.timeswellness.com/
18 6. Rahul Khilnani ,Killer disease – zero awareness , Mumbai mirror (news paper on
the internet) 2010 Jan 23rd , para 1-4.
URL:
http://www.mumbaimirror.com/article/9/2010012320100125184545283b3363c3a/k
iller-disease-zero-awareness.html
7. Amir Mohammad. The incidence of varicose vein in relation to occupation and
working hours (cited 2011 Nov 11).
URL: http://www.slideshare.net/amir9935varicose-veins-4776270
8. G.Samarawickrama Apilot study of occupational health problems among hospital
Nurses ,Asia Pac J Public Health 1987:1(1) 47-52.
9. Malhotra SL.An epidemiological study of varicose vein Indian rail road workers
from the south and north of India with special reference to causation and
prevention of varicose vein.Int J Epid 2011 Oct 23;1(2):177-183
10. Merle scott ,W.J. Post phebitic and varicose vein stasis clinical results of treatment
by pulsatile air pressure principle 1951;147(13):1195-1201
11. Pramod Mirji shailesh Emmi , Chhaya Joshi study of clinical features and
management of varicose vein of lower limb journal of clinical and diagnostic
19 Research 2011 Nov 5(7);1416-1420
12. Sharma R. New worry for teachers: varicose vein. The Times of India(internet)
2010 Nov 29 (cited 2011 Oct 24)
URL: http://www.epaper.timesofindia.com/repository/ml
13.F Tüchsen, H Hannerz, H Burr, N Krause. Prolonged standing at work and
hospitalisation due to varicose veins: a 12 year prospective study of the Danish
population, Occupational and Environmental Medicine, 2005;62:847-850
14. Ahti TM, Mäkivaara LA, Luukkaala T, Hakama M, Laurikka JO.. “Lifestyle factors
and varicose veins: does cross-sectional design result in underestimate of the risk?”
Phlebology. 2010 Aug;25(4):201-6.
15.Shai A, Karakis I, Shemesh D. Possible ramifications of prolonged standing at the
workplace and its association with the development of chronic venous insufficiency,
Harefuah 2007 Sep;146(9):677-85, 734.
16.Bass A., The effect of standing in the workplace and the development of chronic
venous insufficiency, Harefuah. 2007 Sep; 146(9):675-676, 734-735.
17.Nambiar Rajmohan The incidence of varicose vein in Singapore.(1968) Singapore
Medical Journal 9(3):167-169
20 Signature of the candidate
21 Remarks of the guide
Name and designation of (in block letters)
11.1 Guide MRS. WILMA D’ SOUZA PROFESSOR
MASOOD COLLEGE OF NURSING
MANGALORE.
11.2 Signature
11.3 Co-guide (if any) MRS. LAVINA JULIA PEREIRA PROFESSOR MASOOD COLLEGE OF NURSING MANGALORE
11.4 Signature
12.1 Head of the department MRS. LAVINA JULIA PEREIRA PROFESSOR MASOOD COLLEGE OF NURSING
MANGALORE
12.2 Signature
1 3.1 Remarks of the Chairman and Principal
13.2 Signature
22