Proforma for Registration of Subjects for Dissertation s3

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Ms. SUBIJA.D First year M.Sc Nursing Obstetrics and Gynecological nursing Year 2008-2009.

PADMASHREE INSTITUTE OF NURSING NAGARBHAVI, BANGALORE – 560072.

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE MS. SUBIJA.D AND ADDRESS I Year M.Sc. Nursing, Padmashree Institute of Nursing, Nagarbhavi, Bangalore

2 NAME OF THE INSTITUTE Padmashree Institute of Nursing Bangalore

3 COURSE OF THE STUDY AND I Year M.Sc Nursing, SUBJECT Obstetrics and Gynecological Nursing

4 DATE OF ADMISSION 30th June 2008

5 TITLE OF THE STUDY Assessment of effectiveness of structured teaching programme on knowledge regarding management of hyperemesis gravidarum among primi gravida mothers.

2 6. BRIEF RESUME OF THE INTENDED WORK:

6.1 INTRODUCTION: - Hyperemesis gravidarum means excessive vomiting during pregnancy. In pregnant women, nausea and vomiting (morning sickness) are common affecting up to 80% of pregnancies and hyperemesis gravidarum occur in about 1% of pregnancies. Hyperemesis is seen more often in primigravida pregnancies and multiple pregnancies (twins, triplets etc).1

The etiology of hyperemisis is uncertain, with multifactorial causes such as endocrine, gasterointestinal and psychological factors proposed. Rising levels of oestrogen and Human Chorionic Gondotrophin hormones appear to be significant. Hyperemesis occurs more often when mothers have a multiple pregnancy or a hydatiform mole, both of which are associated with increased hormone levels. Infection with helicobacter pylori, the organism implicated in gastric ulcers may also contribute. Women with a previous history of hyperemisis are likely to experience in subsequent pregnancies. 2

Many risk factors are associated with severe nausea and vomiting in pregnancy including younger maternal age. Null parity, low socioeconomic status, unplanned pregnancy, passive smoking, previous pregnancy with nausea and vomiting in pregnancy, increased body mass index, eating disorders, ethnicity and fetal female gender (suggesting an immune mechanisms). 3

Hyperemesis gravidarum remains a puzzling condition for both physicians and patients because there is no known cause or cure. Yet, the exact causal

3 pathophysiological mechanism is unknown; the organicity of the pregnant state is either minimized or ignored. This paper examines how hyperemesis gravidarum is characterized in the literature and the empirical basis for psychogenesis analysis of the literature reveals a tension in the discourse such that both biologic and psychological approaches to hyperemesis gravidarum have existed in parallel tracks throughout the history. Still, results support that sociocultural factors rather than scientific evidence have shaped the overarching and predominant illness paradigm of psychogenesis.4

The main symptom of hyperemesis gravidarum is severe vomiting, which causes dehydration and weight loss. Women with this condition will start to show signs of starvation including weight loss. Physical examination and laboratory tests of blood and urine samples will be used to help to diagnose the condition. One of the most common tests used to help diagnosis and monitor hyperemesis gravidarum is a test for ketones in the urine. Excessive ketonuria indicate that the body is not using carbohydrates from food as full and is inadequately trying to break down fat as fuel. Ketonuria is a sign that the body is beginning to operate in starvation mode.

The management of hyperemesis gravidarum based on three main principles are to control vomiting, to correct the fluids, electrolytes and other metabolic disturbances promptly and effectively and to prevent or to detect the earliest, the ominous complications that may arise.5

Treatment and hospitalization are often required. Intravenous fluids with substances that help the body conduct nerve signals (electrolytes) may be given to correct the dehydration and excessive acid in the blood (acidosis). Antinausea or sedative medications may be given by injection to stop the vomiting. If food cannot be tolerated at all, intravenous nutritional supplements may be necessary.

4 Injections of vitamin B6, in particular, may help overcome nutritional deficiencies that often occur. The alternative treatments for these severe vomiting associated with hyperemesis gravidarum require medical attention. Milder episodes of nausea or vomiting may be reduced with deep breathing and relaxation exercises. The use of other balance remedies should be done with extreme caution during pregnancy, especially in the first trimester.6

Natural remedies to reduce nausea include a teaspoon of cider vinegar in a cup of warm water or tea made from anise, fennel seed, red raspberry, and a ginger. Wristbands can be positioned over acupressure points on both writs. Aromatherapy with lavender, large or chamomile can be soothing as can smelling ground ginger. Homeopathic remedies which age extremely diluted solutions, as treatments can be safe and effective for controlling symptoms in some women. Prognosis, in virtually all cases the pregnancy can continue to the successful delivery of a healthy baby. Prevention although there is no evidence that hyperemesis gravidarum can be prevented; vomiting during pregnancy sometimes may be lessened. Maintaining a healthy diet, getting adequate sleep and controlling stress may contribute to prevention of improvement as systems.

Several strategies may help lessen the nausea and vomiting. Eating dry foods and limiting fluid intake may also be helpful. Small meals should be eating frequently throughout the day, with a protein snack at night. Eating soda crackers before rising from bed in a morning may help prevent early morning nausea. Iron supplements may cause nausea and can be eliminated until the nausea is controlled Sitting upright for 45 minutes after meals may also help.

Hyperemsis gravidarum is one of the high-risk problems during the antenatal period. Mainly it occurs in first and second trimester of pregnancy. If the antenatal

5 mother knows the complication and its management of hyperemsis gravidarum, it can prevent the maternal and fetal from complications.

6.2 NEED FOR THE STUDY

Excessive nausea and vomiting that start between 4 to 10 weeks gestation and resolve before 20 weeks, requiring intervention are known as hyperemesis gravidarum. It affects 0.3-3% of all pregnant women, this is associated with dehydration, electrolyte imbalance and weight loss of up to 10% of prepregnant weight and should not be confused with the common symptoms of nausea and vomiting of pregnancy that are self-limiting.

Hyperemesis gravidarum causes uncontrollable vomiting, severe dehydration and muscle wasting in pregnancy and usually requires weeks or months of intravenous fluid therapy.7 If hyperemesis gravidarum is left untreated the mother’s condition worsens. Wernicke’s encephalopathy is a complication associated with a lack of vitamin B1 (thiamine). Hepatic and renal involvement leads to coma and death. Termination of pregnancy may reverse the condition and has a place in preventing maternal mortality. Hyperemesis gravidarum persisting into the third trimester should be further investigated.

The biggest danger with hyperemesis gravidarum is that the women will become dehydration and no longer be able to provide the fetus with essential nutrients for growth. Prolonged hospitalization or home care with this disorder may result in social isolation. 8 Hyperemesis gravidarum is a high-risk problem because it increases chances for pregnancy loss, intra uterine growth retardation, maternal activity restriction, fatigue and depression.9

6 The impact of nausea and vomiting on the women and her daily life should not be underestimated. The midwife should enquire of all women attending early antenatal whether they are experiencing nausea and vomiting. Causes of vomiting not due to pregnancy, such as thyroid problem, urinary tract infection or gastroenteritis, need to be excluded. Diagnosis is made where there is a history of persistent, severe nausea and vomiting in early pregnancy. A mother suspected of suffering from hyperemesis presents, as being unable to retain food or fluids. She may have lost weight and be distressed and debilitative by her symptoms. The woman requires admission to hospital for assessment and management of symptoms.

Mothers need information to ensure they can make informed choices about care and consent to treatment. If mothers have knowledge regarding management of hyperemesis gravidarum they may be able to prevent from the above complications. Hence the investigator felt need to conduct the study and educate the primi gravida mother regarding management of hyperemesis gravidarum.

7 6.3 STATEMENT OF THE PROBLEM: - A study to assess the effectiveness of structured teaching programme on knowledge regarding management of hyperemesis gravidarum among primigravida mothers in selected hospitals, Bangalore.

6.4 OBJECTIVES: - 1) To assess the pretest knowledge regarding management of hyperemesis gravidarum among primi gravida mothers. 2) To assess the posttest knowledge regarding management of hyperemesis gravidarum among primigravida mothers. 3) To assess the effectiveness of structured teaching programme regarding management of hyperemesis gravidarum among primi gravida mothers. 4) To associate the posttest knowledge regarding management of hyperemesis gravidarum among primigravida mothers with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS: - 1) Effectiveness: - It refers to the increase in the level of knowledge of primi gravida mothers after receiving structured teaching progamme on management of hyperemesis gravidarum.

2) Structured teaching programme: - It refers to systematically developed instructional aids designed for primigravida mothers on aspects of management of hyperemesis gravidarum.

8 3) Knowledge: - It refers to the level of understanding and the ability to answer on the management of hyperemesis gravidarum by the primi gravida mothers as elicited through structured questionnaire.

4) Hyperemesis gravidarum: - This refers to severe type of vomiting of pregnancy which has got deleterious effect on the health of the mother and incapacitates her in day to day activities.

5) Primigravida mother: - It refers to the women who are pregnant for first time.

.6.6 ASSUMPTIONS: -

1) The primigravida mothers may have inadequate knowledge on management of hyperemesis gravidarum. 2) Administering the structured teaching programme may improve the knowledge regarding management of hyperemesis gravidarum among primi gravida mothers.

6.7 RESEARCH HYPOTHESIS: -

H1 – There is significant difference between mean pretest and posttest knowledge regarding the management of hyperemesis gravidarum in primi gravida mothers.

H2 – There is significant association between the posttest knowledge regarding management of hyperemesis gravidarum among primi gravida with their selected demographic variables.

9 6.8 REVIEW OF LITERATURE Review of literature is an important source for development of research project. It helps to gain insight into the research problem and provide information of what has been done previously. It helps the researchers to be familiar with the existing studies, provide basis for future investigation and helps to develop the methodology, tools for data collection and research design.10 A comparative study was conducted to assess the three out patient regimens in the management of nausea and vomiting in pregnancy. This study compares pyridoxine-metoclopramide combination therapy to prochlorperazine and promethazine monotherapies in the outpatient treatment of nausea and vomiting in pregnancy. In total, 174 first trimesters, singleton pregnancies were evaluated for nausea and vomiting. The study conclude that their were no differences in the number of emesis responses to treatment differed among the objective responses to treatment differed among the three groups when comparing combination therapy to the monotherapies. 11

A descriptive study was conducted to identify factors commonly reported by women that alleviate their symptoms of Nausea and vomiting in pregnancy. It state that nausea and vomiting in pregnancy is a multi faceted condition. Lifestyle changes including validation, supportive counseling and dietary adjustments are important components that can be used to council women with nausea and vomiting in pregnancy, concomitantly with safe and affective treatment.12

An experimental study was conducted about hyperemesis Beliefs Scale (HBS), a new instrument for assessing patient perception factors of hyperemesis gravidarum (HG) that influence reported patient satisfaction with medical care. The findings revealed that exploratory factor analyses of patient and physician versions of the hyperemesis beliefs scale demonstrated broad support for the

10 hypothesized factor structure. First, the patient items exhibited two causal factors (general and personal), whereas the physician items showed only a single causal factor. Second, in the patient version, items assessing the impact of hyperemesis gravidarum on the babies' health loaded separately from the rest of the items in the HBS, whereas the analyses of the corresponding physician items indicated that the baby items loaded well on the degree of seriousness factor.13

A descriptive study was conducted to determine what advice and support to be given for women experiencing nausea and vomiting in pregnancy, with a particular interest in and how herbal and alternative therapies are prescribed. The finding revealed that advice most commonly given to women experiencing and vomiting was to eat frequent small meals and snacks (91%). avoid of fatty/spicy foods (53%); eating before rising in the morning, e.g. consumption of dry biscuits/toast (51%); and keep hydrates (49%). Most midwives (39*46, 85%) included some for of vitamin or herbal supplement in their advice for nausea and vomiting in pregnancy; however, many were unaware of potential harmful side effects or what would constitute appropriate doses.14

A comparative study was conducted to evaluate the obstetric and medical complications with hypermesis gravidarum, comparing those who are supported with total parental nutrition (TPN group) and who did not receive total parental nutrition (Non-TPN group). The study concludes that the parental nutrition group had a marked and significant increase in serious complication directly related to parental nutrition use. These data suggest that great care should be taken to assess the need for parental therapy in patients with hypermesis gravidarum.15

A descriptive study was conducted to assess the effects of different methods of treating nausea and vomiting in early pregnancy. The findings revealed that the twenty-eight trials met the inclusion criteria. Nausea treatments were different

11 antihistamine medications, Vitamin B6 (Pyridoxine). The combination tablet dehendox occurrence and ginger based on R trials; there was an overall reduction in nausea for antiemetic medication. The study concludes that anti-emetic mediation appears to reduce the frequencies of nausea in early pregnancy.16

A descriptive study was conducted about the high prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals. At the results, approximately 29% of cases reported their mothers had severe nausea and vomiting or hyperemesis gravidarum while pregnant with them of the 721sisters with a pregnancy history 137 (19%) had hyperemesis gravidarum. The finding revealed that the most severe cases, those requiring total potential nutrition or naso gastric feeding tube, the proportions of effected sisters was even higher, 491 198 (25%) nine percent of cases reported having at least two confected relatives including sister, mothers, grand mothers, daughters, aunt and causing.17

A descriptive study was conducted to determine evaluate maternal and neonatal outcomes among women with hyperemesis during pregnancy. Hyperemetic pregnancies were defined as those requiring one or more antepartum admissions for hyperemesis before 24 weeks of gestation. Severity of hyperemesis was evaluated according to the number of antenatal hospital admissions (1 or 2 versus 3 or more) and according to weight gain during pregnancy (< 7 kg [15.4 lb] versus 7 kg). The finding revealed that maternal outcomes evaluated included weight gain during pregnancy, gestational diabetes, gestational hypertension, labor induction, and cesarean delivery. Neonatal outcomes included 5-minute Apgar score of less than 7, low birth weight, small for gestational age, preterm delivery, and perinatal death.18

12 A cohert study was conducted to assess whether maternal pregnancies body mass index was associated with the use of antimetric drugs in early pregnancy and or with the occurrence of hypermesis gravidarum. The findings revealed that underweight pregnant women were more likely to use antimetric drugs to become hospitalized hypermesis gravidarum compared to over weight women. Obese women were less likely to use antimetric drugs less likely to require hospitalization because of hypermesis gravidarum.19

An experimental study was conducted to determine if ginger syrup mixed in water is an effective remedy of the relied of nausea and vomiting in the first trimester of pregnancy. The finding revealed that after days 10 of the 13(77%) subjects receiving ginger had at least a 4-point improvement on the nausea scale only 2 of the 10 (20%) remaining subjects in the placebo group had the same improve conversely, no women in the ginger group but 7(70%) of the women in the placebo group, had a 2 point or less improvement on the nausea scale. Right of the 12(67%) women in the ginger group who were vomiting daily at the beginning of the treatment were vomiting daily at the beginning of the treatment stopped vomiting by day 6. only 2 of the 10(20% women in the placebo group who were vomiting stopped by day. The findings concluded that the ingestion of 19 of ginger in syrup in a divided dose daily may be useful in some patients experiencing nausea and vomiting in the first trimester of pregnancies.20

13 7. MATERIALS AND METHODS OF STUDY:

7.1 SOURCES OF DATA: - The data will be collected from the primigravida mothers attending antenatal OPD and admitted in the antenatal ward in selected hospitals, Bangalore.

7.2 METHOD OF DATA COLLECTION: -

I. Research design: Quasi-experimental - one group pretest post test design.

II. Research variables: a) Independent variable: - Structured teaching programmme on knowledge regarding management of hyperemensis gravidarum. b) Dependent variable: -level of knowledge of primigravida regarding management of hyperemesis gravidarums.

III. Settings: The study will be conducted in antenatal OPD and antenatal ward in the selected hospitals in Bangalore.

IV. Population:

14 All the primi gravida mothers who are attending OPD and admitted in antenatal ward in the selected hospitals in Bangalore.

V Sample: The sample consists primi gravida mothers who fulfill the inclusive criteria and the sample size is 60.

VI. Criteria for sample selection: - Inclusive criteria:-The study includes 1. The primigravida mothers who are in first and second trimester. 2. The primigravida mothers who are attending OPD and who are admitted in antenatal ward. 3. The primigravida mothers who can understand Kannada or English.

Exclusive criteria: -The study excludes 1. Primigravida mother who are not willing to participate in the study. 2. Primigravida mothers with complications like hypertension, diabetic mellitus, preeclamsia and cardiac disease.

VII. Sampling technique: - Non-probability convenience sampling technique.

VIII. Tool for data collection: - A structured questionnaire will be prepared as a tool. The questionnaire will consist of the following section. Section A: - Demographic proforma of primi gravida mothers include age, occupation, education, religion, family income.

15 Section B: - Structured questionnaire on management of hyperemesis gravidarum will be used to assess the knowledge level of primi gravida mothers.

IX Method of data collection : - After obtaining permission from the concerned authority and informed concerned from the samples, the investigator will collect the data. The data will be collected in the following phases.

Phases I: Structured questionnaire will be administered to assess the pretest knowledge of primi gravida mothers regarding the management of hyperemsis gravidarum.

Phases II: On the same day structured teaching programme will be conducted to primi gravida mothers regarding management of hyperemesis gravidarum by the help of instructional aids for 45 mt-1 hr duration.

Phases III: Same questionnaire will be administered after 7 days of structured teaching programme. Data will be collected for duration of 4 to 6 weeks.

X Plan of data analysis: - The data collected will be analyzed by using descriptive and inferential statistics.

Descriptive statistics: -Frequency, mean, percentage distribution and standard deviation will be used to analyze knowledge regarding management of hyperemesis gravidarum.21

16 Inferential statistics: - Paired‘t’ test will be used to compare pretest and posttest knowledge and chi-square test will be used to analyze the association between posttest knowledge and with their selected demographic variables.22

XI Projected Outcomes: - After administering the structured teaching programme, there will be increase in the level of knowledge among primi gravida mothers regarding the management of hyperemesis gravidarum. This will enhance the primi gravida mothers to improve the management of hypermesis gravidarum and prevent the further complications.

7.3 Does the study require any investigations or intervention to the patient or other human being a animals? Yes, structured teaching programme will be administer as intervention for the antenatal mother.

7.4 Has ethical clearance been obtained from your institutions? Yes, permission will be obtained from the concerned authorities in the selected hospitals. Informed consent will be obtained from the samples. Confidentiality and privacy of data will be maintained.

17 8. LIST OF REFERENCES

1. The gale group. Gale encyclopedia medicine. Third edition, available from: URL: http\\www.answerbag.com.

2. Diane.M.Fraser, Margaret.A.Cooper. Myles textbook for midwifes. Fourteenth edition: Churchill livingstone; 2003: P. 214-18

3. Susan.A.Orghan. Maternity, newborn and women’s health nursing: First edition .New York; Lippincott Williams and Wilkins; 2007 P 522-23

4. Shari Munch. The biological-psychological controversy surrounding hyperemesis gravidarum. Social science& medicine, 2002/October/ 7; (7): 1267- 78.

5. D.C.Dutta. Textbook of obstetrics. Sixth edition.2004; Calcutta: new central book agency (P) LTD; 2004. P. 100-04.

6. Sally B Olds, Marcia.L.London, Patricia A Ladewig. Maternal newborn nursing. Second edition. California; 1984 P. 328.

7. R.Taylor, P.Moran. Successful management of hyperemesis gravidarum. Department medicine, oxford university press; 2002/February /1, volume 95 (2):103-07.

8. Adele Pilliter. Maternal and child health. Third edition. New York: Lippincott Williams and Wilkins; 2004 P. 295.

9. C.S.Dawn.Text book of obstetrics, neonatology and reproductive and cnild health education. Sixteenth edition.Kalkata: Dawn books; 2004.P.136 . 10. Basavantha B.T. Nursing research: New Delhi: Jaypee Brothers.medical publishers (P) LTD; 1998

11. Fadi .A.Bsat, Despina .E. Hoffman, David .E.Seubert. Journal of perinatology: 2003; volume 23; P 531-35.

12. K.Chandra, L. Magee, A.Kinarson,G. Koren. Journal of psychosomatic obstetrics and gynecology. 2003/June; Volume23 (2): 71-75.

13. Share Munch,Mark F.Schmitz. Journal of psychosomatic obstetrics and gynecology.2007; volume 28 ;( 4) 219-29 .

18 14. Gemma Wills, Della Forster. Midwifery. Nausea and vomiting in pregnancy.2007/ September/11; available from: URL: http\\www.interscience.wiley.com.

15. JJ Folk, HF Leslie- brown, JT Nasovitch, R.k. Silverman. Division of maternal fetal medicine.1998/ December; available from URL: http\\www.interscience.wiley.com.

16. Jewell.D, Young.G. Interventions for nausea and vomiting in early pregnancy. 2007/September.volume 36.(9).P.698-701.Available from : URL: http\\[email protected].

17. Marlena S.Fejzoa, Sue Ann Inglesb, Melissa Wilsona, Wei Wanga. High prevalence of severe vomiting of pregnancy and hyperemesis gravidarum.2008/August/26.Elsevier Ireland Ltd. Available from URL: http\\ www.cure-morning-sickness.com.

18. Linda Dodds, Deshayne B.Fell, K.S.Joseph, Victoria M.Allen. The American college of obstetrics and gynecology. 2006; volume107: 285-92

19. Lill I.S.Trogstad, Camilla Stoltenberg, Per Magnus. Medical Birth Registry. 2005/August/1.Available from URL: http\\ www. Inter science.wiley.com.

20. Keating A, chez RA. Ginger soup as a anti emetic in early pregnancy. 2003. Available from URL: http\\ www. Inter science.wiley.com.

21. Polit .E, Beck. T. Nursing research: Describing data through statistics. New yolk; Lippincott Williams and Wilkins; 2008. P-556-83.

22. Barbara Hazard Munro. Statistical methods for health care research: inferential statistics. Philadelphia; Lippincott; 3rd edition.1997. P.73.

19 09. Signature of the candidate :

10. Remarks of guide :

11.1 Name and designation of the guide:

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of the department :

11.6 Signature :

12.1 Remarks of the principal :

12.2 Signature :