Rajiv Gandhi University of Health Sciences s164

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM FOR THE PREVENTION OF URINARY TRACT INFECTION IN PATIENTS WITH INDWELLING CATHETER ADMITTED IN SELECTED HOSPITALS IN KOLAR

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

MISS DALIAMOL M.A A.E.& C.S. PAVAN COLLEGE OF NURSING KOLAR- 563101(KARNATAKA)

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

N 1. AME OF THE CANDIDATE & MISS. DALIAMOL M.A 6. ADDRESS AE&CS PAVAN COLLEGE OF NURSING KOLAR- 563101 KARNATAKA

2. NAME OF INSTITUTION PAVAN COLLEGE OF NURSING , KOLAR

3. COURSE OF STUDY AND THE MSC (N) MEDICAL- SUBJECT SURGICAL NURSING

4. DATE OF ADMISSION TO COURSE 31/05/2007

5. TITLE OF THE TOPIC:

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM FOR THE PREVENTION OF URINARY TRACT INFECTION IN PATIENTS WITH INDWELLING CATHETER ADMITTED IN SELECTED HOSPITALS IN KOLAR.

BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Bone can break, muscle can atrophy, glands can leaf,

even the brain can go to sleep without immediate

danger to survival. But should the kidneys fails……

neither bone, muscle, gland nor brain could carry on

(Lewis)

This statement underlines the importance of kidneys to our life. Adequate function of kidney is essential to maintenance of a healthy body. If the kidney fails to function and the care is not to given, death is inevitable within 2-3 weeks. (1)

The urinary system is the structure which precisely maintain chemical environment of the body, performs various excretory, regulatory and secretary function.

Urinary tract infection incidence can be possible indicator of the quality of the catheter in the hospital care. Urinary tract infection are one of the most common nosocomial infections accounting for approximately 20-40 % of all hospital acquired infection and

80%of this are associated with use of urinary catheter. Most of the studies advised that between 10%-30% patients with short term catheter will develop bacteriuria .Indwelling catheters are part of disposable system consisting of catheter tubing, drainage bag are common tool used in the management of patient. They are used in 15%-25% of all hospital patients, to monitor urine out put or to provide bladder drainage. The indications for the use of catheter are Benign Prostatic Hypertrophy, Urinary incontinence, Urinary retentions, Quadriplegia, Paraplegia, Neurogenic bladder and Coma.

3 Malcingi U,Moro ML, Carpie D, Ramella conducted a study on

Urinary tract infection in prevention among catheterized patients. The incidence of catheter associated Urinary tract infection becomes higher with prolongation of indwelling period of catheter clinical practice in catheter management vary widely and frequently are not evidence based effective nursing measure, which induce identifying patient who no longer need indwelling catheter and prolong positioning the drainage bag.

Urinary tract is most common site of nosocomial infection, accounting for more than 40% of the total number reported by acute care hospital and affecting an estimated 6,000,00 patients per year. Most of these infections 66%-86% follow instrumentation of the urinary tract mainly urinary catheterization. Although not all catheter associated Urinary tract infection can be prevented, this believes that large number could be avoided by the proper management of the indwelling catheters or individual who can be managed with intermittent catheterization may be different need.

6.1 NEED FOR STUDY

4 Urinary tract infection is the most common nosocomial infection and accounts for 15% of nosocomial bacteremias. If the use of indwelling catheter is unavoidable, the catheter drainage system should remain closed an unobstructed and kept securely fastened, with the catheter bag remaining below the level of bladder. Most importantly the catheter should remove as soon as possible. (3)

Asher E F, Oliver B G, Fry DE(1998) conducted a study regarding urinary tract infection in surgical patient. Urinary tract infection continues to be from a 2 year city country hospital experience, 212 nosocomial urinary tract infection were identified in 153 patient from 374 admissions. Foleys catheterization as an associated factor in 129 patients (84%) and found that urinary tract infection was caused by 40% different species of bacteria. Only 9 patients had bacteremia. Thus patients that have had antibiotic therapy demonstrate distribution of pathogens that are different from patients not receiving antibiotics and distributions different from community acquired urinary tract infection. (4)

Beetz (2003) conducted a study regarding mild dehydration a risk of urinary tract infection. Bacterial growth in the urinary tract is usually prevented by host factors including bacterial eradication by urinary and mucus flow, Urothelial bactericidal activity, urinary secretary IgA, and blood group antigens in secretions which interferes with bacterial adherence. Bacterial eradication from the urinary tract is partially dependent on urine flow and voiding frequency. There it seems logical to postulate a connection between fluid intake and risk of urinary tract infection.(5)

Calvin M Kunin (2001) conducted a study regarding nosocomial

Urinary tract infection & indwelling catheter. The Urinary catheter is a essential part of

5 modern medical care it is widely used to relieve anatomic or physiologic obstruction, to provide a dry environment for comatose or incontinent patient and to permit accurate measurement of urinary out put in severely ill patients. Unfortunately when used inappropriately or when left in place too long , it is hazard to very patients that it is designed to protect mechanism by which the indwelling catheter produce infection consist initially of ascending colonization of the urine within the catheter lumen and eventually along the space between urethra and catheter surface.(6)

Nicolle L.E (2005) conducted a study on Catheter related Urinary tract infection. Indwelling Urinary catheter are used frequently in older population for either short or long term catheter, the infection rate is about 5%per day. Escherichia Coli remains the most common infectious organism, but a wide variety of other organism may be isolated, including yeast species. With short term catheter, avoiding their use or limiting their use to as short as time as possible are the most effective prevention strategies. Maintaining a closed system and adhering to appropriate catheter care technique will also limit infection and complications.(7)

Bissett L (2005) conducted a study on reducing the risk of catheter related Urinary tract infection. It is estimated that 10%-12& & 4% of patients in the community have Urinary catheter at any one time. Recent researcher has estimated that patients who have a catheter for 20 days is almost certain to develop catheter related

Urinary tract infection. Urinary tract infection can extent patients hospital stay by six days.(8)

6.2 REVIEW OF LITERATURE

6 Review of literature is defined as a broad comprehensive indepth systematic and critical review of scholarly literature publications, unpublished scholarly print material, audiovisual material and personal communication.

The researcher presents their review under the following headings.

(1) Study related to Urinary tract infection in patient with Indwelling Catheter.

(2) Study related to organisms found causing urinary tract infection in patient with

Indwelling catheter.

(3) Study related to catheter associated Urinary tract infection in patient with various

disease condition.

(4) Study related to prevention of Urinary tract infection in patient with indwelling

catheter.

(1) Study related to Urinary tract infection in patient with Indwelling Catheter.

Egilmez T, Aridogan IA, Yachia D, (2006) conducted a comparative study to determine the efficacy of intra-urethral Metal stents in preventing

Urinary tract infection during management of bladder outlet obstruction. 76 patients cared of urethral stent, 60 patient with bladder outlet obstruction and 34 with permanent indwelling catheter. It was found that urinary tract infection was developed in 79.4% of patients had sterile urine, 40.9% in patient who had sterile urine & 44.6% of the catheterized patient who had infected urine. Only urinary tract infection was eradicated in patient having stent and concluded that urinary tract infection is common in patient with permanent indwelling urethral catheter and less frequent in patient with urethral stent.(9)

7 Jain P, Parada JP, David A, Smith LG. (2002) conducted a study upon over use of indwelling urinary catheter in hospitalized patient. They studied prevalence of unjustified use of indwelling catheter in a hospitalized medical patient and identified situations associated with its unjustified use. They took samples consisted of

202 patient admitted in Medical intensive care unit. The need of continued catheterization has observed by the observer and the proportion of unjustified indwelling urinary tract catheter, placement was determined by using study guidelines complications of catheterization were also recorded. It was resulted that indwelling urinary catheter was found to be unjustified in 21% of patient. Continued catheterization found unjustified in

47% of patient with indwelling urinary tract catheter. In the Medical intensive care unit

64% of total unjustified patient with indwelling urinary tract catheter resulted from it excessively prolonged use for monitoring urine out put.(10)

González Gonzalez JC, Martínez Carmona S, Valenzuela Plata

E, Pérez García C, Plans Domínguez M, Coll Batet M, et al (1995) performed one day study on presence of Urinary tract infection in patient after catheterization at a university journal hospital of Barcelona. It was found that 14.75% of patients were catheterized, among them 18% of surgical patients showed a higher incidence of urinary infection than other patient which was 14%. The indwelling catheter was used frequently for diuresis control in 74.5% of patients at the hospital. It was found 20% of patient had positive urine culture and only 14.5% had negative urine culture.(11)

8 (2) Study related to organisms found causing urinary tract infection in patient with

Indwelling catheter.

Kehinde EO, Rotimi VO, Al-Hunayan A, Abdul-Halim H,

Boland F, Al-Awadi KA (2004) performed a study to find out microorganism responsible for urinary tract infection and stent colonization’s in patient with indwelling J ureteral stent. It was found that 12 patients before stent insertion and 42 patients on the day of stent removal had positive urine cultures. Whereas 42% were cultural positive and

60% urine culture was sterile. The commonest isolated organisms were E coli,

Enterococcus, Streptococci, Pseudomonas and Candida. It was concluded that an indwelling J ureteral stents carries a significant risk of bacteriuria and stent colonization.

Tambyah PA, Halvorson KT, Maki DG (1999) conducted a study on pathogenesis of catheter associated Urinary tract infection. The sample consisted of 1,497 newly catheterized patients, paired quantitative urine cultures were obtained daily from the catheter specimen port and from the urine collection bag. The organism detected first in higher concentration in urine from the specimen port, and than from the urine collection bag. The result was found that 237 patients had 69.2% new onset of catheter associated urinary tract infection. Among this173 cases, where 66% were extraluminally acquired and 34% were intraluminally acquired and it was determined that catheter associated urinary tract infections caused by gram-positive cocci (enterococci and streptococci) and yeasts were far more likely to be extra luminal acquired than gram- negative bacilli.(13)

9 Christensen J J, Korner B, Kjaergaard H.(1989) they conducted a study to find out unnoticed urinary tract pathogen causing urinary tract infection. It took 4 month survey on 29 patients suspected of urinary tract infection, from whom an Aerococcus-like organism was isolated in significant numbers from urinary tract specimens, it was approximately 0.8% of all urinary tract specimens examined during the period yielded growth of Aerococcus-like organism. It was found that half of the patient have conditions predisposing to urinary tract infection, 9 of 11 patients without indwelling catheter Aerococcus-like organism in their urine.(14)

(3) Study related to catheter associated Urinary tract infection in patient with various disease conditions.

Werner GT, Gadomski M, Scheinert B.(1998) conducted a study to find out significance of Urinary tract infection in patient with cerebrovascular accident. Samples consisted of 361 patients with cerebral stroke. It was found that 33.2% of total of patient had striking incidence of urinary tract infection, patients with complication had an average stay of 61.2 days in hospital than those patients without urinary tract infection who had stay of 77 days hospital and they concluded that in patient with cerebrovascular accident great care must be taken to prevent complication and indwelling catheter should be used only over a short period of time.(15)

Kunin C M, Chin Q F, Chambers S (1987) conducted a comparative study in a nursing home among elderly patient treated with and without

10 indwelling catheter on the morbidity and mortality associated with indwelling catheter confounding due to the presence of associated diseases. They found that mortality among catheterized patient was 30.2% compared with 10.1% among the non catheterized groups

Cerebrovascular and hypertensive disease were significantly more common in catheterized patients In contrast, fractures and musculoskeletal disorders were significantly more common among non catheterized patients.(16)

Okishio N, Hanai S, Ishiguro K, Yanaoka M, Tamai H,

Naide Y.(1986) conducted a study on the patient having urinary tract infection associated with benign prostatic hypertrophy and related diseases and transurethral surgery. Samples consisted of 355 patients who were treated with transurethral resection of the prostate for partial urinary obstruction. Among them 188 had suffered from bacteriuria before surgery and the remaining 167 had been free of urinary infection before surgery. It was found that urinary infection was caused by urethral instrumentation including indwelling catheter for various periods of time.(17)

(4) Study related to prevention of Urinary tract infection in patient with indwelling catheter.

Sindhaghatta K. Venkatram, Horiana Grosu, Frantz Torchon,

Anita Soni, (2007) conducted a study on reducing catheter related urinary tract infection in patient who had indwelling urinary catheter inserted during hospitalization. In an effort to decrease the incidence of catheter related urinary tract infection, several interventions were made included using anti-infective urinary catheter, new closed drainage system and

11 daily evaluation of catheter removal. It was concluded that 88% reduction in incidence rate of catheter related urinary tract infections was based on intervention done.(18)

Regal R E, Pham C Q, Bostwick T R.(2006) conducted a study on urinary tract infection extended care facilities and preventive management strategies. to provide health care professionals with an overview of interventions that may be done to reduce the incidence of urinary tract infections in elderly patients, especially those residing in extended care facilities. It was found that urinary tract infection can be controlled by establishing good infection-control practices by health care givers and minimizing the use of indwelling catheters, adequate staffing and training. (19)

Manas A, Glaría L, Pena C, Sotoca A, Lanzos E, Fernandez C,

(2006) conducted a study on prevention of urinary tract infections in palliative radiation for vertebral metastasis and spinal compression. Sample consisted of 71 patients. It was found that urinary tract infection prevalence over the hospitalization period compared to usual care given to patient suggesting that bladder instillations of hyaluronic acid effectively prevent in patient with indwelling catheter receiving radiotherapy for nerve compression. (20)

12 PROBLEM STATEMENT

A study to assess the effectiveness of structured teaching program for the prevention of Urinary tract infection in patients with indwelling catheter admitted in selected hospitals in kolar.

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge among patients for the prevention of urinary tract

infection.

2. To evaluate the knowledge of the patient after structure teaching program on

prevention of Urinary tract infection.

3. To determine correlation between pre test knowledge and post test knowledge.

4. To associate the knowledge of the patient with demographical variables.

6.4 OPERATIONAL DEFINITIONS

Effectiveness:-

It refers to outcome of structured teaching program assessed by difference in pre and post test score of the knowledge of the prevention of urinary tract infection

Structured teaching program:-

Here in this study, it refers to the well planned instructional material designed to provide information regarding prevention of urinary tract infection in patient with indwelling catheters.

Prevention: -It refers to the measures adopted by clients to reduce the occurrence of urinary tract infection.

13 Urinary tract infection: - Urinary tract infection is defined as the multiplication of more than100, 000 organisms per ml in a midstream of urine.

Indwelling catheter: -

Indwelling catheter is a self retaining catheter which is introduced in urinary bladder and secured inside for the purpose of draining urine.

6.5 HYPOTHESIS

1. The post test knowledge score regarding prevention of urinary tract infection will be significantly higher than the pretest knowledge score of patients with indwelling catheter.

2. There will be significant association between pre test & post test knowledge of the experimental group and selected variables such age, sex, educational status, type of family, religion, life style, previous exposure of information regarding urinary tract infection.

6.6 ASSUMPTION

1. Adequate knowledge on Urinary tract infection will help in adopting positive

attitude toward care.

2. Health education promotes early health seeking behaviour.

3. Awareness regarding prevention of catheter related Urinary tract infection will

improve self care knowledge among patients.

4. The structured teaching program will increase the knowledge of the patient

regarding prevention of Urinary tract infection.

14 6.7 VARIABLES UNDER STUDY

6.7.1 Dependent variables:- Knowledge regarding prevention of urinary tract infection.

6.7.2 Independent variables:- Structured teaching program on prevention of urinary tract infection.

6.7.3 Attributed variables:- It includes Age, Sex, Educational status, Type of family,

Religion, Life style, Previous exposure of information regarding urinary tract infection.

7. MATERIALS & METHODS

7.1 Source of data: -

Patients with indwelling catheter admitted in S.N.R and RL Jallappa hospital Kolar.

7.2 Method of data collection: -

Structured teaching interview & questionnaire.

7.2.1 Research design: -

Pre- experimental design.

7.2.2 Setting: -

The study will be conducted in medical and surgical wards of S.N.R and RL Jallappa hospitals Kolar.

7.2.3 Population: -

The population for the study comprises of all patient (male & female) in the medical and surgical ward with indwelling catheter.

7.2.4 Sample size: -

Sample size comprises of 50 patients with indwelling catheters.

15 7.2.5 Sampling technique: -

Non probability convenient sampling technique will be used for the study based on inclusive criteria and exclusive criteria.

7.2.6 Sampling criteria: -

Inclusive criteria:-

1) Patients who are: -

- Admitted in medical and surgical wards with indwelling catheter.

- Available at the time of data collection.

- Willing to participate in this study.

Exclusive criteria:-

1) Patients who are:-

- Not having indwelling catheter.

- Not willing to participate in the study.

- Admitted with critical conditions.

7.27. Tools of research: - The tools of the study includes.

1) Structured interview will be used to collect the data.

2) The questionnaire will be administered to assess patient’s knowledge prior

to Structured teaching program.

16 7.2.8 Method of data collection:-For the present study the structured teaching interview

& questionnaire will be prepared to assess the knowledge of the patients with indwelling catheter for the prevention of urinary tract infection.

7.2.9. Data analysis and interpretation: - On the day of assessment pre-test and after 7 days post test to be conducted, then data to be analyzed using descriptive and inferential statistics.

Interpretation will be done using various tables and diagrams.

7.3. Does the study requires any investigation to be conducted on other or animals?

The study involves noninvasive intervention, i.e. structured teaching program will be implemented to the patients having indwelling catheter by conducting pre & post test.

7.4. Has ethical clearance has been obtained from concerned authorities?

Prior to the study permission will be taken from concern authorities to conduct the study and also from research committee of Pavan College of Nursing, Kolar. The purpose of the study will be explained to the respondents.

17 8. LIST OF REFERENCES

1. Sharon Mantik.Lewis, Idolia Cox Collier, Text book of Medical Surgical Nursing, 3rd

Edn, Mosby Publications, (1987) P 1169-1184.

2. Malcingi U, Moro ML, Carpie D, Ramella A, Italian Journal of Urology and

Nephrology (1996), March; 48(1) P 43-46.

3.Charles C J, Carpenter, Robert C Griggs, Joseph Loscalzo, Cecil Essentials of

Medicine, 6th Edn, (2004), Elsevier Company, New Delhi, P 905-906.

4. Asher E F, Oliver B G, Fry D E, American Surgeon, (1998) July, P 466-469.

5. Beetz European Journal of Clinical Nutrition, (2003), Dec, 57, supp (2) P 552- 558.

6. Calvin M, Kunin, Nosocomial Urinary tract infection and indwelling catheter (2001),

120, P10-12 from www.google.com.

7. Nicolle L E, Drugs & Aging, Department of Internal medicine, (2005), P 622-639.

8. Bissett L, Nursing Times, (2005), March 22-28, 101(12), P 64-65, 67.

9. Egilmez. T, Aridogan I A, Journal of Endo Urology (2006), April 20(4) P 272-277.

10. Jain P, Parada J P, Annals of Internal Medicine (2002), july16, 137(2), P125-127.

11. Gonzalez J C, Martinez Carmona S et al, Archivous Espanoles de Urologia, (1995),

July-Aug, 48 (6), P 563-568.

12. Kehinde EO, Rotimi VO, Al-Hunayan A, Abdul-Halim H, Boland F, Al-Awadi KA,

Journal of Endo Urology, (2004), Nov18(9), P 891-896.

13.Tambyah PA, Halvorson KT, Maki DG, Mayo Clinic Proceedings, (1999), Feb

74(2),P 131-136.

18 14. Christensen JJ, Korner B, Kjaergaard H, APMIS ( acta pathologica, microbiologica,

et immunologica Scandinavica), (1989), June 97(6), P539-546.

15. Werner GT, Gadomski M, Scheinert B, De Rehabilitation, (1998), May 37(2), P 64-

16. Kunin CM, Chin QF, Chambers S, Journal of American Geriatrics Society, (1987),

Nov35(11), P 1001-1006.

17. Okishio N, Hanai S, Ishiguro K, Yanaoka M, Tamai H, Naide Y, Acta Urologica

Japonical, (1986), Nov 32(11), P 1610-1616.

18. Sindhaghatta K. Venkatram, Horiana Grosu, Frantz Torchon, Anita Soni, Critical

Care Infection Control and Antibiotics, (2007), from www.google.com.

19. Regal RE, Pham CQ, Bostwick TR, Journal of American Society of Consultant

Pharmacists (2006), May 21(5), P 400-409.

20. Manas A, Glaría L, Pena C, Sotoca A, Lanzos E, Fernandez C, International Journal

of radiation Oncology, Biology, Physics, (2006) March 1, 64(13), P 935-940.

19 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12. 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL

12.2 SIGNATURE