Synopsis for Registration of Subject for Dissertation

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

SUBMITTED BY: Ms. STEPHY MARIAM ZACHARIAH I M.Sc. NURSING

OBSTETRICS AND GYNAECOLOGICAL NURSING (2011-2013 BATCH)

FORTIS INSTITUTE OF NURSING #20/5, YELACHENAHALLI, KANAKAPURA ROAD BANGALORE-560078

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE Ms. STEPHY MARIAM ZACHARIAH, 1. CANDIDATE AND 1ST YEAR M.Sc. NURSING, ADDRESS FORTIS INSTITUTE OF NURSING, #20/5, YELACHENAHALLI, KANAKAPURA MAIN ROAD, BANGALORE - 560078. 2. NAME OF THE FORTIS INSTITUTE OF NURSING, 2. INSTITUTION BANGALORE. 3. COURSE OF THE MASTERS DEGREE IN NURSING. 3. STUDY AND THE OBSTETRICS AND SUBJECT GYNAECOLOGICAL NURSING. 4. DATE OF 4. ADMISSION TO 31ST MAY 2011 COURSE 5. TITLE OF THE A STUDY TO ASSESS THE 5. TOPIC EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING URINARY TRACT INFECTION DURING PREGNANCY AMONG PRIMIGRAVIDA MOTHERS IN SELECTED HOSPITALS, BANGALORE.

6.0 BRIEF RESUME OF THE INTENDED WORK INTRODUCTION “ Hundreds of dewdrops to greet the dawn. Hundreds of bees in the purple clover. Hundreds of butterflies on the lawn. But only one Mother wide world over.” - Unknown Author One of the important event in man’s life is birth. Life starts in the womb of mother, when there is a union of single egg and sperm, it is called as conception and it marks the beginning of pregnancy. Conception occurs not as an isolated event but as a part of sequential process. The sequential process includes gamete formation, ovulation, fertilization and implantation in the uterus.1, 2 Pregnancy last, approximately for 10 lunar months, nine calendar months, 40 weeks or 280 days. Duration of pregnancy is computed from the first day of the last menstrual period (LMP) until the day of birth.1 Pregnancy brings both physiological and psychological changes in women. Women are often interested in learning more about the changes occurring during pregnancy, because these changes verify the reality and mark the progress of pregnancy. During pregnancy there is a progressive

2 anatomical and physiological changes, these occurs gradually and are not confined to the reproductive organs alone but eventually effect all the organ systems of woman’s body.3, 4 This is principally a phenomenon of maternal adaptation to the increasing demands of the growing fetus.4 Changes during pregnancy are necessary to be able to provide oxygen and nutrients for her own increased metabolism,3 and also providing a nurturing environment for fetal development and growth.1 The urinary system is chiefly thought of in connection with its elimination function and the production of urine, but it also has important function in connection with the control of water and electrolyte balance and blood pressure.5 In female, urinary tract has an importance associated with its proximity to the reproductive organs. When the woman is not pregnant her uterus lies just behind and partially over the bladder.5 During pregnancy, there is a striking anatomical change seen in the urinary system, it is mainly due to the increased progesterone level as it relaxes the wall of the ureters and allows its dilatation and kinking, and also by the pressure from the enlarging uterus.1 As the pregnancy progresses the kidney increases in weight and length by one cm.5 From the 10th week of pregnancy the renal pelves and the ureters also dilate. The smooth muscle of the wall of ureters undergoes hyperplasia, hypertrophy and muscle tone relaxation. The ureter elongates become tortuous and forms single or double curves. In later part of the pregnancy, the renal pelves and the ureter are dilated more on the right side than on the left side because heavy uterus is displaced to the right by the sigmoid colon. The Glomerular Filtration Rate (GFR) and Renal Plasma Flow (RPF) will also increase. Women’s kidneys must manage the increased metabolic and circulatory demand of the maternal body and the excretion of the fetal waste products.1 In some

3 women, marked changes can be observed in the urinary system mainly due to the hormonal effect and this tends to result in a slow down or stasis of urinary flow.5 Bladder irritability, nocturia, urinary frequency and urgency (without dysuria) are the other commonly reported aliments in early pregnancy. Urinary frequency results initially from increased bladder sensitivity and later by the compression of the bladder.1 Urinary tract infection is caused by the pathogenic micro-organisms in the urinary tract.6 It is the second most common bacterial disease and the most common bacterial infection in women.7 As the uterus grows, because of its increased weight can block the drainage of urine from the bladder causing a stagnation of urine later causes infection.8 Due to urinary stasis or stagnation certain consequences occur, that is a lag occur between the time urine if formed and when it reaches the bladder and also stagnation or stagnated urine is an excellent medium for the growth of the micro- organisms, in addition the urine of pregnant women contains more nutrients including glucose, thereby increasing the pH (making the urine more alkaline). This makes the pregnant woman more susceptible to urinary tract infection.1Escherichia coli are the most common pathogen causing a urinary tract infection. Several factors cause urinary tract to be relevant complication of the gestational period, aggravating both the maternal and perinatal health outcome. Studies have suggested that if urinary tract infections are untreated it can lead to complication such as pyelonephritis, low birth weight babies, premature delivery and occasionally still birth. So a thorough knowledge regarding urinary tract infection is needed to be provided among primigravida mothers.

4 6.1 NEED FOR THE STUDY Urinary tract infection is more common during pregnancy because of changes in the urinary tract.8 The hormonal and mechanical changes increase the risk of urinary stasis and vesico-urethral reflux. These changes, along with an already short urethra (approximately 3-4 cm in females) and difficulty with hygiene due to a gravid uterus, increase the frequency of urinary tract infections (UTIs) in pregnant women may lead easy ascent of the micro-organisms into the bladder.9 It is estimated that 10 to 20% of all women suffer acute infection. At least one-third of women develop urinary tract infection before the age of 24 years. Urinary tract infection complicates upto 20% of pregnancies and is responsible for 10% of all antepartum admissions.6 Urinary tract infection is more commonly seen in primigravida than multiparous. Previous history of urinary tract infection increases the chance of recurrent infection by 50%, presence of asymptomatic bacteriuria increases the chance by 25%, and abnormality in the renal tract is found in about 25%. About 2-10% of young women are susceptible to asymptomatic bacteriuria in pregnancy on routine screening. But if not detected early and treated promptly, this infection complicates 1-3% of all pregnancies.10 A retrospective study on urinary tract infection during pregnancy was conducted in the service of Gynaecology and Obstetrics of Military Hospital of Instruction, at Mohammed V. Rabert, Morocco. During the study period, microscopic urinary examination was performed on 147 patients. Overall, 45 patients had featured of urinary tract infection. There were 19 patient with acute pyelonephritis (28.9%), 58 patient had uncontrolled diabetes mellitus of whom, 13 patient had urinary tract infection and five other patient had

5 premature birth. In the case with urinary tract infection, the organism grown was gram negative, in all with Escherichia Coli being the commonest seen in 14 to 23 patient (60.8%). The results showed that urinary tract infection needs to be detected and treated promptly because treatment has shown its effectiveness in preventing pregnancy related complication. Routine screening for asymptomatic bacteriuria should be practiced regularly.11

Another study was conducted to find out about maternal urinary tract infection whether it is independently associated with adverse pregnancy outcome. It was a retrospective population based study. The result of the study was, out of 1,99,093 deliveries, 2.3% (n=4742) had urinary tract infection during pregnancy and delivery. Patients with urinary tract infection had significantly higher rates of intra-uterine growth retardation, pre- eclampsia, caesarean deliveries and pre-term deliveries.12

Studies have shown that urinary tract infection in pregnancy may result in maternal and fetal morbidity. The pregnant woman should be educated, about the physiological changes during pregnancy which may be one of the risk factors for development of urinary tract infection and also its prevention. Regular antenatal care should be taken to minimize the complications of pregnancy, and to ensure a healthy maternal and fetal outcome.10

Even though care is taken during pregnancy, the mothers may not be able to cope with the physiological changes which may indirectly lead to certain pathological problems which have to be diagnosed at any early stage or may lead to complication. Perinatal outcome depends on the early recognition and management of problems. Identification of the existence of risks, together with appropriate and timely intervention can help prevent

6 disabling conditions both during the neonatal period and in the future development stages.2

In the light of above facts and with the experience of researchers it is significant to assess the knowledge regarding urinary tract infection during pregnancy and to impart knowledge regarding urinary tract infection during pregnancy to primigravida mothers.

6.2 REVIEW OF LITERATURE A review of literature on the research topic makes the researcher familiar with the existing studies and provides information which helps to focus on a particular problem, lays a foundation upon which to base new knowledge. It creates accurate picture of the information found on the subjects.13

6.2.1 Reviews related to urinary tract infection during pregnancy.

6.2.2 Reviews related to effectiveness of structured teaching programme. 6.2.1 REVIEWS RELATED TO URINARY TRACT INFECTION DURING PREGNANCY: A cross-sectional study was conducted on urinary tract infection among pregnant women in Al-Mukall district in Yemen. The samples were all pregnant women attending Al-Mukalla maternity hospital for the period from January to June 2002. The samples of urine were been collected from 137 pregnant women. It was found that, 41 (30%) were positive for urinary tract infection, while 96 (70%) were negative. The distribution of urinary tract infection among the infected women was according to age group, parity, trimester and number of pregnancy. Bacteriuria was commonest in the age group of 15-24 years (53.7%). There was an increase in frequency of

7 bacteriuria with progress of pregnancy with 48.8% of infection in women in 3rd trimester of pregnancy and of infected women 75.6% had one to three children.14 A descriptive study was conducted on risk factors of urinary tract infection in pregnancy. The study was a conducted in the Obstetrics and Gynaecology Department of Isra University Hospital, Hyderabad from first January to 30th August 2008. Total 232 women were selected out of which 108 (46.5%) reported urinary symptoms which were due to pregnancy, while 10 (4.3%) were due to underlying urinary tract infection. Most common urinary symptoms in these women were abnormal voiding pattern 85 (40.3%) followed by irritative symptoms and voiding difficulties. Illiteracy, history of sexual activities, low socio-economic group, history of urinary tract infection and multiparity were found to be risk factors for urinary tract infection in these women.15 A study was conducted to find out whether urinary tract infection in pregnancy as a clinical problem. It was a retrospective study, done in 1664 pregnant women with different trimesters who attended the Obstetrics and Gynaecology out-patient department of Rafalullah Community Hospital for their antenatal checkup from July to December 2009. Most of them were between the age group of 16 to 25 years. After taking proper history, clinical examination and laboratory investigation, a number of 200 (33%) pregnant women were diagnosed as a case of urinary tract infection, of them100 (50%) were primigravida mothers, 60 (30%) were second gravida mothers and 40 (20%) were third gravida mothers.10 A cross-sectional study was conducted to find out frequency and risk factors of asymptomatic bacteriuria during pregnancy. Out of 3000 houses in

8 Satellite Town and Behari colony, Bahawalpur only 1200 houses were selected by systemic random sampling. In them 580 women who fulfilled the inclusion criteria were interviewed and tested for bacteriuria. Out of them, four per cent were below 20 years, 4.6% were between 20-30 years and 5.4% women aged above 30 years (p=0.103). Regarding parity 3.18% of primigravida and 6.04% multigravida had bacteriuria (p=0.0039). Regarding socio-economic status, 6.45% from lower class and 2.5% from middle and upper class were the sufferer (p=0.0039). Prevalence was 6.64% among uneducated and 3.06% among educated women (p=0.0039). As for past history, 35.7% of women had an episode previously (p=0.001). It was found that asymptomatic bacteriuria is a common infection during pregnancy, having a strong association with multiparity; lower socio-economic status and illiteracy.16 6.2.2 REVIEWS RELATED TO EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME: An experimental study was conducted on effectiveness of structured teaching programme on sex awareness among adolescent girls in a selected rural area, Chennai, India. The purpose of the study was to assess the knowledge in sex awareness, evaluate the effectiveness of structured teaching programme and to associate the knowledge of adolescent girls with that of the demographic variable. The data were collected from 80 randomly selected samples. There were 40 samples allocated for experimental group and remaining 40 samples for the control group, the overall knowledge mean value in experimental design was 48.69 with standard deviation of 17.41 where as in control group the mean value was only 5.36 with the standard deviation of 11.94. After structured teaching programme the paired ‘t’ value was 17.69 with the p<0.001 which is highly significant which says there is

9 an improvement in the knowledge in sex awareness among adolescent girls. Hence the structured teaching programme was effective.17 An experimental study was conducted on effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health. The study was to find out the effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health. A total of 200 Adolescent school students were included in this study. The mean (+/- SD) pretest score of the experimental group on knowledge of reproductive health was 39.83 (+/- 16.89) and of the control group was 39.47 (+/- 0.08). The same of experimental group after administration of the structured teaching program (84.60+/-10.60) and of the control group with conventional teaching method (43.93+/-10.08) was statistically significant (p<0.001). Similarly, the post-test scores of knowledge of the groups on responsible sexual behaviour and their attitude towards reproductive health were better in the experimental group than in the control group (p<0.001). The knowledge of adolescent school students on reproductive health is inadequate. The use of structured teaching program is effective in improving knowledge and attitude of the adolescents on reproductive health.18

10 6.3 STATEMENT OF PROBLEM A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING URINARY TRACT INFECTION DURING PREGNANCY AMONG PRIMIGRAVIDA MOTHERS IN SELECTED HOSPITALS, BANGALORE. 6.4 OBJECTIVES OF THE STUDY

1.To assess the demographic profile of primigravida mothers.

2.To assess the knowledge of primigravida mothers regarding urinary tract infection.

3.To find out the effectiveness of structured teaching programme on knowledge regarding urinary tract infection among primigravida mothers.

4.To find out the association between the post-test knowledge score of primigravida mothers regarding urinary tract infection and selected demographic variables. 6.5 OPERATIONAL DEFINITIONS 6.5.1 ASSESS In this study it refers to, ‘measure the knowledge of the primigravida mothers regarding the urinary tract infection during pregnancy’.

11 6.5.2 EFFECTIVENESS In this study it refers to, ‘gain of knowledge among primigravida mothers regarding urinary tract infection during pregnancy as determined by the significant difference in post-test scores with the pre-test scores’. 6.5.3 STRUCTURED TEACHING PROGRAMME In this study it refers to, ‘a detailed, well planned teaching strategy to enhance awareness among primigravida mothers regarding urinary tract infection during pregnancy’. 6.5.4 KNOWLEDGE In this study it refers to, ‘the correct response from primigravida mothers regarding urinary tract infection during pregnancy as elicited through self-administered questionnaire before and after the structured teaching programme’. 6.5.5 PRIMIGRAVIDA In this study it refers to, ‘a woman, who became pregnant for the first time’. 6.5.6 URINARY TRACT INFECTION In this study it refers to, ‘infection caused by pathogenic micro- organism in the urinary tract’.

12 6.6 HYPOTHESIS

H0 : There is no significant difference between pre and post-test knowledge scores of the primigravida mothers regarding urinary tract infection.

H0.1 : There is no significant association between the post-test knowledge score of the primigravida mothers regarding urinary tract infection and selected demographic variables.

H1 : There is a significant difference between pre and post-test knowledge scores of the primigravida mothers regarding urinary tract infection.

H1.1 : There is a significant association between the post-test knowledge scores of the primigravida mothers regarding urinary tract infection and selected demographic variables.

6.7 VARIABLES IN THE STUDY Independent variable : Structured teaching programme regarding urinary tract infection during pregnancy.

Dependent variable : Knowledge of the primigravida mothers regarding urinary tract infection during pregnancy.

Demographic variables : Refers to age, education, religion, family type, occupation, income of the family, place of residence and source of previous knowledge regarding urinary tract infection.

7.0 MATERIALS AND METHODS 7.1.1 Source of data : Primigravida mothers in selected hospitals, Bangalore.

7.1.2 Research approach : An evaluative research approach.

13 7.1.3 Research design : A Quasi-experimental research design with one group pre-test and post-test.

7.1.4 Research setting : Selected hospitals, Bangalore.

7.1.5 Population : Population of the study is primigravida mothers. 7.1.6 Sample : Primigravida mothers in selected hospitals, Bangalore.

7.1.7 Sampling technique : Non probability purposive sampling technique will be adopted to select the subject. 7.1.8 Sample size : 60 primigravida mothers

7.1.9 SAMPLING CRITERIA Inclusion criteria : Primigravida mothers who are willing to participate in this study.

Primigravida mothers who are : available during the period of data collection.

Exclusion criteria : Primigravida mothers who are already infected with urinary tract infection.

Who cannot read and write English : and Kannada.

7.2.1 TOOL FOR DATA COLLECTION Data collection tool contain items on the following aspects. Part 1: Contain the items of demographic characteristics of primigravida mothers comprising of age, education, religion, family type, occupation,

14 income of the family, place of residence and source of previous knowledge regarding urinary tract infection. Part 2: Knowledge assessment questionnaire regarding urinary tract infection during pregnancy. 7.2.2 METHOD OF DATA COLLECTION The data required for the study will be collected by the investigator among 60 primigravida mothers who fulfills the inclusion and exclusion criteria using structured questionnaire on knowledge regarding urinary tract infection during pregnancy. 7.2.3 METHOD OF DATA ANALYSIS The investigator will analyze the data obtained by using descriptive and inferential statistics. The plan of data analysis as follows: Descriptive statistics Mean, Mean %, Median and Standard deviation will be used. Inferential statistics  Student’s paired t-test will be used for measuring the significant mean difference between pre and post-test score.  Chi square [χ 2] for list for measuring association between knowledge level and selected demographic variables. The result will be statistically significant whenever P≤ 0.05 level of significance.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON OTHER HUMAN OR ANIMALS?

15 Yes, the knowledge of primigravida mother on urinary tract infection during pregnancy will be assessed by using a self-administered questionnaire. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE INSTITUTION?

1. The ethical clearance is obtained from the research committee of Fortis Institute of Nursing.

2. Written permission will be obtained from the concerned authorities of selected hospitals.

3. Informed consent will be obtained from the samples who are involved in the study before collecting the data.

16 8.0 LIST OF REFERENCES

1. Lowdermilk Leonard Deitra, Perry Shannon E. Maternity and womens health care. 9th ed. China: Mosby Elsevier; 2007. P.313, 316, 335, 345-6.

2. Wong Donna L, Perry Shannon E. Maternal and child nursing care. 1st ed. United States of America: Mosby; 1998. P.58, 79

3. Pillittery Adele. Maternal and child health nursing, care of the child bearing and child rearing family. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2007. P. 213.

4. Dutta D C. Textbook of obstetrics including perinatology and contraception. 6th ed. Calcutta: New Central Book Agency (P) Ltd; 2004. P.46.

5. Fraser Diane M, Cooper Margaret A. Myles textbook for midwives. 14th ed. Edinburgh: Churchill Livingstone; 2003. P. 123,129,198-201, 331-2.

6. Lewis Sharon L, Heitkemper Margaret Melean, Dirksen Shannon Ruff, O’Brien Patricia Graber, Bucher Linda, Mani Mrinaline, etal. Lewis’s medical-surgical nursing assessment and management of clinical problems. 1st ed. Delhi: Reed Elsevier India (Pvt) Ltd; 2011. P.1161-73.

7. Smeltzer Suzanne C, Bare Brenda G. Brunner and suddarth’s textbook of medical-surgical nursing. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2004. P.1310.

8. Urinary Tract Infection during Pregnancy. Available at: URL: http://www.americanpregnancy.org/pregancycomplications/utiduringpre g.html

9. Johnson Emilie Katherine. Urinary tract infections in pregnancy.

Available from: URL: http://emedicine.medscape.com/article/452604- overview

17 10. Rahman M A, Talukder S I, Khatoon M R, Arman R. Urinary tract infection in pregnancy: a clinical problem. Dinajpur Med Col J 2010 Jul; 3 (2):59-62. Available from: URL: http://www.dinajmc.org/journal/djmcjv3i2/07djmcjv3i2AzizarUTI.pdf

11. Abdelaali Bahadi, Driss El Kabbaj, Hicham Elfazazi, Rachid Abbi, Moulay Rachid Hafidi, etal,. Urinary tract infection in pregnancy. Saudi Journal of Kidney Diseases and Transplantation 2010; 21(2): 342-4. Available from: URL:http://www.sjkdt.org/article.asp?issn=1319- 2442;year=2010;volume=21;issue=2;spage=342;epage=344;aulast=baha di

12. Mazor Dray, Lew A, Schlaeffer F, Sheiner E. Maternal Urinary Tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med 2009 February; 22(2): 124-8. Available from: URL: http://www.ncbi.nih.gov/pubmed/19085630

13. Polit Denise F, Beck Cheryl Tatano. Nursing research generating and assessing evidence for nursing practice. 8th ed. New Delhi: Wolters Kluwar (India) Pvt Ltd; 2008. P.105.

14. Al-Haddad A M. Urinary tract infection among pregnant women in al- mukalla district, yemen. Eastern Mediterranean Health Journal 2005; 11(3):505-10. Available from: URL:http://www.emro.who.int/publications/emhj/1103/PDF/32.pdf

15. Haider G, Zehra N, Munir A A, Haider A. Risk factors of urinary tract infection in pregnancy. J Pak Med Assoc. 2010 Mar; 60(3): 213-6.

Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed/20225781

18 16. Fatima N, Ishrat S. Frequency and risk factors of asymptomatic bacteriuria during pregnancy. J Coll Physicians Surg Pak. 2006 Apr; 16(4): 273-5. URL: http://www.ncbi.nlm.nih.gov/pubmed/16624191

17. Dhital A D, Badhu B P, Paudel R K, Uprety D K. Effectiveness of structured teaching program in improving knowledge and attitude of school going adolescents on reproductive health. Kathmandu University

Medical Journal. 2005 Oct-Dec; 3(4): 380-3. Available from: URL: http://imsear.hellis.org/handle/123456789/46616

18. Shanmugasundaram S. Effectiveness of structured teaching programme on sex awareness among adolescent girls in a selected rural area, Chennai, India. Academy Health Meet. 2005; 22: abstract no. 3105. Available at: URL: http://gateway.nlm.nih.gov/MeetingAbstracts/ma? f=103622568.html

9 SIGNATURE OF THE Ms. STEPHY MARIAM CANDIDATE ZACHARIAH 10 REMARKS OF THE GUIDE It is feasible; it brings awareness among primigravida women.

11 NAME AND DESIGNATION Mrs. SABITHA SIBBALA OF ASSOCIATE PROFESSOR 11.1 THE GUIDE 11.2 SIGNATURE Mrs. SABITHA SIBBALA

11.3 CO-GUIDE Mrs. GOWRI SAYEE ASSOCIATE PROFESSOR

11.4 SIGNATURE Mrs. GOWRI SAYEE

11.5 HEAD OF THE Mrs. GOWRI SAYEE DEPARTMENT ASSOCIATE PROFESSOR.

11.6 SIGNATURE Mrs. GOWRI SAYEE

12 REMARKS OF THE Study is feasible, adds to the PRINCIPAL knowledge base of nursing. Develops an awareness regarding causes and prevention of UTI among pregnant women. 12.1 SIGNATURE Prof. SHRIDHAR K V.