Rajiv Gandhi University of Health Sciences, Karnataka s50

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the Candidate and LINOY KALAMPARAMBAN Address IST YEAR M.Sc NURSING

ROYAL COLLEGE OF NURSING,

7TH MAIN, 1ST BLOCK

UTTHARAHALLI MAIN ROAD,

UTTHARAHALLI

BANGALORE- 560061

2. Name of the Institution Royal College of Nursing,

Bangalore- 560061

3. Course of study and subject Ist year M.Sc Nursing

Medical Surgical Nursing

4. Date of admission to Course 30.06.2008

5. Title of the topic

“A Study To Assess The Knowledge Regarding Administration And Effects Of Inotropic

Drugs Among Fourth Year BSc Nursing Students In Royal College Of Nursing,

Bangalore-61, With A View To Develop Self Instructional Module.”

1 6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION “For the sick, the least is the best”. -Hippocrates.

Cardiac diseases are one of the major health problem which the world facing today, so it need emergency care. One among the four leading causes of death projected globally in 2030 to be heart disease, cardiovascular diseases Claimed 869/724 lives in 2004 (final mortality) (36.3 percent of all deaths or 1 of every 2.8 deaths)1. India, expected to account for 60 per cent of the world's heart disease cases by 2010.2Cardiovascular disease is the greatest source afflicting human population in the world over. Cardiovascular disease not only strikes down a significant fraction of population without warning, but also causes prolonged suffering and disability in an even large numbers.3

Inotropic drugs are used for treatment of heart diseases for a long period of time to treat emergency cardiac issues. Some inotropic drugs have been used for more than two hundred years, however the use of some of these drugs preparations has recently became controversial because they have never been shown to reduce mortality rates, but they do seem to offer some benefits in moderate to severe cardiac disease by reducing the period of hospitalization and symptoms . But today we have new generation inotropic drugs which are successful in therapeutic use. But these drugs are also associated with serious side effects.4

Despite improvements in surgical technique and myocardial protection, pharmacological support for low cardiac output is often required during and after weaning from cardiopulmonary bypass. Inotropics are drug of choice for this.5

An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction. Both positive and negative inotropes are used in the management of various cardiovascular conditions. The choice of agent largely depends on specific pharmacological effects of individual agents with respect to the condition. Some cardiac issues like Congestive cardiac failure, Right heart failure, Myocardial infarction etc, and cardiac surgeries like cardio pulmonary bypass, angioplasty, valvuloplasty etc. are some cardiac emergencies where inotropics are in use.6

2 Wrong administration of drug is common in clinical practice, important reason being (1) lack of knowledge about drugs (2) unethical drug promotions and (3) Irrational prescribing habits by clinicians. The knowledge about the use and risk factors of inotropic drugs will be useful in increasing fourth year BSc nursing students role and responsibility in caring those patients under support of inotropic drugs and in providing for more timely therapeutic intervention and optimizing the care in future.

6.1 NEED FOR STUDY

“Mind is the partial side of men; the heart is everything.”

- Rivarol

One of the consequences of medical progress in the last half of twentieth century is an increasing number of older adult living long with multiple health problems. The fact that propotion of the aged among the population is growing steadily will increase the number of elderly people at any one time suffering from cardiovascular disease, and caring for them will place a considerable burden on the health services. Inotropics are one of the main drug used in cardiac patient. Recent study reveals that, an age of >65 yr indicates an increased risk for inotropic support in the present study. Advanced age is always accompanied by a general decline in organ function, especially because of changes in the structure and function of the heart and vasculature that will ultimately affect cardiovascular performance, even in the absence of overt coexisting diseases. This may explain why post- ischemic systolic functional recovery was markedly worse in the older group of an ovine model.7

A study conducted in Adelphi University, School of Nursing, Garden City, New York, regarding Use of dimensional analysis to reduce cardiac medication errors, reveals that The purpose of this pilot study was to determine whether using dimensional analysis as the method of mathematical computation could reduce nursing medication calculation errors. The sample for this study consisted of second-year baccalaureate nursing students in a required clinical skills course. Students in the control group were taught cardiac medication calculations using the, traditional math method during one semester, whereas students in the experimental group were taught the same material using dimensional analysis during the next semester. Analysis of the collected data from a medication dosage calculation examination revealed the dimensional analysis group scored with greater accuracy than the traditional math group. It conclude that, emergency drugs like cardiac drugs (inotropics ,vasodilators, calcium channel blockers, etc) have immediate effect on patient. So wrong dose and drugs may lead to mortality. It indicates that, nurse should have deep knowledge about these drugs.8 3 Medication compliance posses a major threat to the health and wellbeing of the patient. It is estimated that non-adherence to prescribed medications causes nearly 1,25,000 death/year in USA, and 10% of hospital admission and 23% of nursing home admission are linked to medication error. Over half of that are filled associated with in correct administration of drugs.9

Inotropics are one of the main drugs which is used for cardiac issues. For decades inotropic drugs are used for treatment of heart disease, although knowledge of nurses, about these drugs are very low. After completion of BSc nursing course, students have to work in clinical side. Cardiac issues and cardiac drugs are common there. So knowledge about inotropic drug is very important, because it have lot of immediate effects and side effects. So close observation of patient is important while administrating it. Some adverse effects of these drugs are fatigue, nausea, vomiting, bradycardia, cardiac arrhythmias, abdominal pain, dysrhythmias, photophobia etc. Wrong administration of these drugs even may cause sudden cardiac arrest. So good knowledge about inotropic drugs are very essential for nursing students.

During the clinical placement in Hospital, the investigator found that most of the student nurses are listening the word inotrop at first time. This show the intellectual and psychomotor deficiency on inotropics among student nurses. Today’s nursing students are tomorrows staff nurses. So the investigator felt that the student nurse need to be assessed their knowledge regarding inotropics to improve the practice of future nurses on cardiac care and educating them as they are going to work as staff nurses in different set up after their course of training, to provide effective cardiac care.

6.2 REVIEW OF LITERATURE

Review of literature provides basis for future investigations, justifies the need for replication, throws light up on feasibility of the study, and indicates constrains of data collection and help to relate findings of one another.

A study conducted in Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago, regarding, Program to improve nurses' knowledge of pediatric cardiac emergency medications. The effects of an educational program designed to improve nurses' knowledge of the use of emergency medications in the pediatric cardiac intensive-care unit are reported. The clinical pharmacist and a clinical nurse educator developed a program to assess and extend nurses' knowledge of emergency medications with respect to calculations

4 of bolus and continuous infusions, pharmacology, and proper dosage and administration route. The program consisted of a pretest, a pharmacology lecture, calculation problems, a hands-on practicum, and a posttest. Drugs covered were atropine sulfate, sodium bicarbonate, calcium gluconate, calcium chloride, dopamine hydrochloride, dobutamine hydrochloride, epinephrine hydrochloride, isoproterenol hydrochloride, lidocaine hydrochloride, sodium nitroprusside, and norepinephrine bitartrate. A retest was given 13 months after the pretest. The program was completed by 21 nurses over seven months. There was a significant difference between the mean pretest score, 69.5%, and the mean posttest score, 87.3%, due to improvements in scores for the calculation questions. There was no significant difference in the mean time required to complete the pretest and the posttest. A significant correlation was observed between pretest score and months spent practicing in the PICU. Time to take the retest was significantly shorter than the posttest time, and scores continued to improve. An educational program developed cooperatively by pharmacy and nursing improved specific measures of PICU nurses' knowledge of cardiac emergency drugs.10

A study conducted in critical care nurses, regarding IV inotropic agents: dopamine, dobutamine, and amrinone clearly reveal that, three commonly used IV inotropic agents--dopamine, dobutamine, and amrinone--have been discussed in this article. Knowledge of their common mechanisms of action, individual actions, dosages, methods of preparation, precautions, and side effects can only help critical care nurses maintain or improve the quality of care given to patients receiving these medications.11

A study conducted in Cardiac Department, King's College Hospital, London, Great Britain, regarding, Common cardiac drugs and rehabilitation, reveals that Cardiac patients are often on drugs. They invariably benefit from a rehabilitation programme where they may be seen more frequently than in a routine follow-up clinic. Rehabilitation units must keep alert for drug-induced adverse effects or symptomatic deterioration, as well as the more usual psychological and physical benefits they induce. So the nurse should know about the effects and side effects of common cardiac drugs.12

A study conducted in Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, Turkey regarding, the use of levosimendan in comparison and in combination with dobutamine in the treatment of decompensated heart failure shows that, Levosimendan is a new calcium sensitizer with inotropic and vasodilatory actions .Its alternative mechanisms of action to those of other traditional inotropes provide a new approach in the management of decompensated heart failure. In contrast to dobutamine, levosimendan does not increase myocardial oxygen demand and, therefore, it is thought to have a lower potential to induce increases in

5 myocardial ischemia and cardiac arrhythmias. The commonly used inotropic agent dobutamine increases myocardial contractility at the expense of increased myocardial oxygen consumption and, therefore, it can result in poor outcomes. Although dobutamine may also have favorable hemodynamic and symptomatic effects, levosimendan has been shown to be superior to dobutamine in increasing cardiac output and decreasing pulmonary capillary wedge pressure in patients with decompensated heart failure.13

A study conducted in University of Greenwich, Avery Hill Road, Eltham, London, United Kingdom regarding, Student nurses need more than math’s to improve their cardiac drug calculating skills, shows that, Nurses need to be able to calculate accurate drug calculations in order to safely administer drugs to their patients. Studies have shown however that nurses do not always have the necessary skills to calculate accurate drug dosages and are potentially administering incorrect dosages of drugs to their patients. Nursing Standard Program to improve nurses' knowledge of cardiac emergency medications clearly indicate the need of drug calculating skills. A study was undertaken to investigate the effectiveness of implementing several strategies which focused on developing the mathematical and conceptual skills of student nurses to improve their drug calculation skills. The study found that implementing a range of strategies which addressed these two developmental areas significantly improved the drug calculation skills of nurses. The study also indicates that a range of strategies has the potential ensuring that the skills taught are retained by the student nurses. Although the strategies significantly improved the drug calculation skills of student nurses, the fact that only 2 students were able to achieve 100% in their drug calculation test indicates a need for further research into this area.14

A study conducted in Florence Nightingale School of Nursing and Midwifery, King's College London, regarding, Clinical skills: assessing and treating shock: a nursing perspective. This article outlines the pathophysiology associated with hypovolaemic, cardiogenic and distributive shock, and discusses how each of these might present clinically in the patient. Nursing assessment of a patient in shock is explored, and the use of tools such as the pulse oximeter is examined. The evidence base for a variety of interprofessional interventions is analysed, including fluid therapies such as blood transfusion, the use of crystalloids and colloids, and drug therapies such as the use of inotropic and vasoactive agents. The nursing role in managing the patient in shock and cardiac arrest considered as very importent, so nurse should have great knowledge on emergency cardiac drugs.15

A study conducted in Covenant Home Health & Hospice, Milwaukee, WI, USA, regarding Positive inotropic drug infusions for patients with heart failure: current controversies and best practice, reveals that, Patients who experience severe symptoms of heart failure and repeated hospitalizations for exacerbations may benefit from positive inotropic drug infusion therapy such as dobutamine or milrinone. This article provides an 6 overview of inotropic drug delivery in the home including current controversies and best practices to ensure safe home care policies and practice. It gives the importence to need of nuserses knowledge about inotropics for giving better care and education to patient.16

A study conducted in San Diego Cardiac Center, Sharp Memorial Hospital, California , regarding Inotropic, vascular and neuroendocrine effects of dopexamine hydrochloride and comparison with dobutamine shows that Dopexamine hydrochloride is a novel beta 2- and dopaminergic-receptor agonist proposed for intravenous therapy in patients with congestive heart failure. To gain a clearer knowledge of its efficacy relative to other agents, intravenous infusions of dopexamine hydrochloride (4 micrograms/kg/min) and dobutamine (10 micrograms/kg/min) were administered to 10 patients with congestive heart failure (ejection fraction less than 0.4). Both agents increased stroke volume and cardiac indexes to a similar degree, and both decreased systemic vascular resistance, with a trend toward a greater decrease with dopexamine hydrochloride. Dobutamine and dopexamine hydrochloride, therefore, improve cardiac function by way of both vasodilator and inotropic mechanisms. At the doses administered, dopexamine hydrochloride relies on a greater systemic vasodilator effect than dobutamine to achieve and increase in left ventricular performance.17

A Study conducted in St. Vincent's University Hospital, Heart Failure Unit, 1st Floor, St. Michaels Hospital, Dunlaoghaire, Co. Dublin, Ireland, regarding, Is heart failure nursing practice at the level of a clinical nurse specialist or advanced nurse practitioner? The Irish experience. Since 2000 there has been a significant increase of Heart Failure Nursing positions in the Irish health service. The background to these positions has been based on the model established at St. Vincent's University Hospital, Dublin since 1998. Recognition of nursing practice in Ireland has also transformed with the introduction of Clinical Nurse Specialist and Advance Nurse Practitioner positions. To date Clinical Nurse Specialists coordinate and manage heart failure programmes, however it remains to be seen whether current practices are within the scope of practice of these nurses. Advanced Nurse Practitioner is a new position in Irish Nursing from examining guidelines and education this may be the way forward for Heart Failure Nursing in Ireland.18

A study conducted in Serviço de Cardiologia, Hospital de Santa Marta regarding The influence of therapy (sympathomimetic amines versus vasodilators) in the indexes of ejection fraction derived from an analysis of Doppler aortic flow, revealed that, PURPOSE: To assess the influence of inotropic IV therapy-- dobutamine and/or dopamine--versus vasodilator therapy--nitroprusside, captopril or hydralazine--in aortic flow ejection phase indexes obtained by pulsed Doppler echocardiography. The study contain 17 patients, admitted to the ICU (11 males, 62 +/- 14 years, 9 with ischemic cardiomyopathy and 8 with dilated cardiomyopathy, all in sinus 7 rhythm), with congestive heart failure, and submitted to tailored therapy, 53 serial pulsed Doppler and hemodynamic evaluations were made as the therapy changed the hemodynamic and clinical status. Considering serial consecutive evaluations, a hemodynamic improvement was obtained only with inotropics in 13 (group A), and with vasodilators in only 15 (group B).The study reveals that, Vasodilator therapy, although inducing hemodynamic changes similar to inotropics, does not alter the ejection phase indexes.19

A study conducted regarding levosimendan: beyond its simple inotropic effect in heart failure resulted that, Classic inotropic agents provide short-term haemodynamic improvement in patients with heart failure, but their use has been associated with poor prognosis. A new category of inotropic agents, the Ca (2+) sensitizers, may provide an alternative longer lasting solutioun. In conclusion, levosimendan is a promising agent for the treatment of decompensated heart failure. As further to its positive inotropic effect, it affects multiple pathways with key roles in the pathophysiology of heart failure. 20

A study conducted in Department of Pharmacy Practice and Administration, University of the Sciences in Philadelphia, about Levosimendan: a novel inotropic agent for treatment of acute, decompensated heart failure. Theire objective was to review the literature on a novel calcium sensitizer, levosimendan. Levosimendan 6- 24 mug/kg intravenous bolus followed by a 24-hour continuous infusion of 0.05-0.2 microg/kg/min improved cardiac output and reduced pulmonary capillary wedge pressure in a dose-dependent manner. Clinical trials evaluating retrospective mortality data and combined endpoints (mortality, rehospitalization) have demonstrated better outcomes with levosimendan compared with dobutamine. The incidence of hypotension with levosimendan is not significantly different than with dobutamine, but there is a dose-related increase in heart rate. The study reveals that Levosimendan is useful in moderate to severe low-output heart failure in patients who have failed to respond to diuretics and vasodilators. Based on current studies, levosimendan appears to be a safe alternative to dobutamine for treatment of acute, decompensated heart failure.21

A study conducted about the Inodilator therapy for heart failure early, late, or not at all. The result revealed that Inodilation, i.e., the combination of positive inotropic and vasodilating therapy, conceptually should be an ideal form of heart failure treatment. Moreover, dopaminergic compounds that, besides dopamine-1 and dopamine-2 activation, act through beta-receptor stimulation do not consistently improve the patient's clinical condition. In contrast, clinical efficacy may be present when partial phosphodiesterase (PDE) inhibitors that also act features, and the term "inodilators" has been used to characterize them. Inodilators can be further classified on the basis of their mechanism of action, i.e., phosphodiesterase inhibitors, and sympathomimetic and dopaminergic

8 drugs. Differently from the parenteral drugs (e.g., dobutamine), the oral agents present many important shortcomings including central nervous system effects, increased myocardial oxygen consumption, tachyarrhythmias, and, above all, development of tolerance during chronic administration. Dopamine is still one of the most useful drugs for the through calcium sensitization, such as pimobendan, are administered to patients with mild to moderate or moderately severe heart failure. Whether they improve the condition of such patients without affecting relaxation and whether they do not lead to adverse events and an increase in mortality rate have as yet to be evaluated. Furthermore, the potential beneficial effect of additional neurohumoral modulation by dopaminergic inodilator compounds and of heart rate-reducing properties of inodilators.22

A study conducted in Italy regarding, the Clinical pharmacology of inodilators. The result revealed that recent advances in our knowledge of heart failure have shown that both a central and a peripheral factor are involved in this syndrome. Therefore, the ideal drug should combine the properties of a positive inotropic agent with those of a peripheral vasodilator; many drugs recently introduced into clinical practice have been shown to present both of these treatment of acute heart failure; the two oral drugs that more closely resemble its actions are levodopa and ibopamine. The administration of levodopa to patients with heart failure can induce a significant hemodynamic improvement that is maintained during chronic therapy. 23

A study conducted regarding predictive factors of inotropic support in myocardial revascularization surgery in Servicio de Anestesia, Hospital Universitario La Paz Madrid .Two hundred forty-two patients who underwent myocardial revascularization were studied retrospectively. The parameters collected were age, sex, left ventricular telediastolic pressure at baseline and after contrast, ejection fraction, collateral circulation, number of distal anastomoses, time of clamping, time of extracorporeal circulation, need for inotropic support to end extracorporeal circulation and during the first 6 hours after surgery. Inotropics were used in 27.6% of the sample. The need for inotropic support was related to female sex, low injection fraction and prolonged extracorporeal circulation .The study concluded that the independent variables associated with the need for inotropic support during the perioperative period in myocardial revascularization are female sex, low injection fraction and prolonged extracorporeal circulation. This study reveals the importance of inotropic drugs and factors associated with it’s therapeutic use.24

6.3 OBJECTIVES OF THE STUDY

1. To assess the knowledge of fourth year BSc nursing students regarding inotropic drugs and its administration. 9 2. To assess the knowledge of fourth year BSc nursing students regarding effects of inotropic drugs. 3. To find out the association between the knowledge regarding the inotropic drugs, its administration and selected demographic variables.

4. To find out the association between the knowledge regarding the effects of inotropic drugs and selected demographic variables.

5. To prepare a self instructional module on admission and the effects of inotropic drugs based up on the knowledge of the student nurses.

6.4 OPERATIONAL DEFINITIONS

ASSESSMENT: Assessment refers to the critical analysis and valuation or judgement of the status or quality of a particular condition or situation.

KNOWLEDGE: It is the student nurse’s intellectual ability regarding the administration of inotropic drugs, its effect and assesses their intellectual ability by administering questionnaire.

NURSING STUDENTS: It refers to the students those who are studying in fourth year basic BSc nursing course and who have successfully completed third year examination and are studying in a college of nursing which is recognized by RGUHS, KNC and INC.

INOTROPIC DRGUS: It is the drugs which affecting the contraction of heart muscle.25

.EFFECTS: Increase in contraction of heart muscles in response to inotropic drugs.

ADMINISTRATION: The act or process of administering

6.5 HYPOTHESIS OF THE STUDY

H1 : Their will be statistically significant association between student knowledge regarding inotropic drugs and its administration and percentage of mark obtained in last year.

H2 : Their will be statistically significant association between student knowledge regarding administration of inotropic drugs, its effect and course attended regarding cardiac drugs.

6.6 ASSUMPTIONS

10 1. Fourth year BSc nursing student posses some knowledge about administration of inotropic drugs and its effects

2. Fourth year BSc nursing student’s knowledge regarding administration of inotropic drugs and its effect can be measured by using a knowledge questionnaire.

6.7 DELIMITATIONS OF THE STUDY

1. The study is limited to only fourth year BSc nursing students.

2. The study is limited to fourth year BSc nursing students, who are successfully completed the third year in Royal college of nursing Bangalore.

6.8 PILOT STUDY

The study will be conducted with 5 samples. The purpose to conduct the pilot is to find out the feasibility for conducting the study and design on plan of statistical analysis.

6.9 VARIABLES

Variables are an attribute of a person or object that varies, that is takes on different values.

 Dependent variables: Knowledge level of fourth year BSc nursing student regarding administration and effects of inotropic drugs.

 Independent variables: Age, Sex, classes attended regarding inotropic drugs.

7.0 MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from fourth year BSc nursing students, who are successfully completed third year in royal college of nursing Bangalore

7.1.1 RESEARCH DESIGN

Non-experimental design

The research approach adopted for this study is Descriptive in nature 11 7.1.2 RESEARCH APPROACH

Descriptive approach.

7.1.3 SETTING OF THE STUDY

The study will be conducted in Royal College of nursing Bangalore.

7.1.4 POPULATION

All the fourth year BSc nursing student who have successfully completed the third year in Royal College of nursing Bangalore.

7.2 METHODS OF DATA COLLECTION (INCLUDING

SAMPLING PROCEDURE)

The data collection procedure will be carried out for a period of one month. This study will be conducted after obtaining permission from the concern authorities. The investigator will collect the data from the Bsc nursing student by using structured questionnaire to assess the knowledge regarding effects and side effects of inotropic drugs.

The structured questionnaire schedule consists of following sections.

Section A: Questions related to demographic data

Section B: Questions related to assess the level of the knowledge regarding effects and side effects of inotropic drugs

7.2.1 SAMPLING TECHNIQUE

Sampling technique adopted for selection of sample is non probability Random sampling.

7.2.2 SAMPLE SIZE

The samples consist of 50 BSc nursing students who are studying in Royal college of nursing Bangalore.

SAMPLING CRITERIA 12 7.2.3 INCLUSIVE CRITERIA

1. Students who are studying fourth year BSc nursing course.

2. Students who are studying in Royal College of nursing Bangalore.

3. Students who are willing to participate in the study

7.2.4 EXCLUSIVE CRITERIA

1. Students who are studying 1st year to 3rd year BSc and GNM students.

2. Students who are not available at the time of study.

3. Students who are not willing to participate in the study.

7.2.5 TOOL FOR DATA COLLECTIO

A structured questionnaire is used to collect the data from the nursing students.

7.2.6 DATA ANALYSIS METHOD

The data collected will be analyzed by using descriptive and inferential statistics.

. Descriptive statistics: Frequency and percentage for analysis of demographic data and mean, mean percentage and standard deviation will be used for assessing the level of knowledge

 Inferential statistics: Chi-square test will used to find the association between knowledge and selected demographic variables

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INVESTIGATION TO THE PATIENTS OR OTHER HUMAN

BEING OR ANIMAL?

Since the study is descriptive study, interventions are not required.

7.4 ETHICAL CLEARANCE

13 The main study will be conducted after the approved of research committee of the college. Permission will be obtained from the head of the institution. The purpose and detail if the study will be explained to the study subjects and assurance will be given regarding the confidentiality of the data collected

8. LIST OF REFERENCE (VANCOUVER STYLE FOLLOWED)

14 1. Statistics by country for Heart diseases. WHO Report. Heart disease in Sourthen Asia 2008.

2. India To Carry Majority Of World's Heart Disease Burden by 2010, WHO.24 Apr 2008 - 21:00 PDT

3. Eugene Braunwald. ‘The Heart’.5th edition 2002 VOL I: 542.

4. Lewis, Heitkemper, Dirksen. Medical Surgical Nursing Assessment and Management of Clinical Problems.6th ed.St.Louis (US). Mosby 2004: 845-847.

5. Richard D, Howland, Mary Julia Mycek, Richard A, Harvey, Pamela C. Pharmacology. 3 rd ed. USA. Lippincott Williams & Wilkins 2003: 189-191

6. Kenneth H, Dangman, Dennis Senji Miura. Electrophysiology and Pharmacology of the Heart. 2nd ed. Newyork, US. Informa Health Care 2005: 463-466

7. Norman Sharpe . Heart Failure Management.1st ed. Newyork, US. Informa Health Care 2006:96-99.

8. Greenfield S and Whelan B. Use of dimensional analysis to reduce medication errors. J Nurs Educ 2006 Feb; 45(2):91-4. Available from URL:http://www.pubmed.com.

9. Evans L, Spelman M. The problem of non compliance with drug therapy. Drugs 25 1983: 63

10. Kraus DM, Stifter J. Program to improve nurses' knowledge of emergency medications. AMJ Hos Pharm 1991 Jan; 48(1):97-101. Available from URL:http://www.pubmed.com.

11. Budny J, Anderson-Drevs K. IV inotropic agents: dopamine, dobutamine, and amrinone CritCareNurse. 1990Feb; 10(2):5462.Availablefrom URL:http://www.pubmed.com.

12. Jackson G, Metcalf J. Common cardiac drugs and rehabilitation. nt Disabil Stud. 1988; 10(3):138-9. Available from URL:http://www.pubmed.com

13. Cavusoglu Y. The use of levosimendan in comparison and in combination with dobutamine in the treatment of decompensated heart failure. Expert Opin Pharmacother 2007Apr; 8(5):665-77. Available from URL:http://www.pubmed.com.

15 14. Wright K. Student nurses need more than maths to improve their drug calculating skills. Nurse Educ Today 2007 May; 27(4):278-85. Epub 2006 Jul 31.

15. Bench S. Clinical skills: assessing and treating shock: a nursing perspective.Br J Nurs 2004 Jun 24-Jul 7; 13(12):715-21. Available from URL:http://www.pubmed.com.

16. Gorski LA. Positive inotropic drug infusions for patients with heart failure: current controversies and best practice. Home Health Nurse 2002 Apr; 20(4):244-53; quiz 2534. Available from URL:http://www.pubmed.com.

17. Jaski BE, Peters C. Inotropic, vascular and neuroendocrine effects of dopexamine hydrochloride and comparison with dobutamine. Am J Cardiol 1988 Aug 11; 62(5):63C-67C. Available from URL:http://www.pubmed.com.

18. Ryder M. Is heart failure nursing practice at the level of a clinical nurse specialist or advanced nurse practitioner? The Irish experience. Eur J Cardiovasc Nurs 2005 Jun; 4(2):101-5.Available from URL:http://www.pubmed.com.

19. Martins S, do Rosário L. The influence of therapy (sympathomimetic amines versus vasodilators) in the indexes of ejection fraction derived from an analysis of Doppler aortic flow. Rev Port Cardiol 1998 Jun; 17(6):515- Available from URL:http://www.pubmed.com.

20. Antoniades C, Tousoulis D. Levosimendan: beyond its simple inotropic effect in heart failure. Pharmacol Ther 2007 May; 114(2):184-97. Epub 2007 Feb 16.Available from URL:http://www.pubmed.com

21. Earl GL, Fitzpatrick JT. Levosimendan: a novel inotropic agent for treatment of acute, decompensated heart failure. Ann Pharmacother 2005 Nov; 39(11):1888-96. Available from URL:http://www.pubmed.com

22. Remme WJ. Inodilator therapy for heart failure. Early, late, or not at all? Circulation 1993 May; 87(5 Suppl):IV97-107. Available from URL:http://www.pubmed.com.

23. Dei Cas L, Metra M, Visioli O. Clinical pharmacology of inodilators. J Cardiovasc Pharmacol. 1989 14 Suppl 8:S60-71. Available from URL:http://www.pubmed.com.

24. Maseda E, Suárez L, Peinado R. Predictive factors of inotropic support in myocardial revascularization surgery. Rev Esp Anestesiol Reanim 1996 Apr;43(4):123-5. Available from URL:http://www.pubmed.com. 16 25. Oxford Dictionary of Nursing. 4thed. Newyork: Oxford 2004:245.

17 9 9. Signature of the Candidate.

10. Remarks of the Guide.

11. Name & Designation of

11.1 Guide

11.2 Signature.

11.3 Co-Guide.

11.4 Signature.

11.5 Head of Department.

11.6 Signature.

12 12.1 Remarks of the Chairman & Principal.

12.2 Signature.