Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Original Article Egyptian Journal of Health Care, 2015EJHC Vol.6 No.1

ZeinabHosny Ibrahim khalifa*, SanaaMohamed Ahmed A.Eldeen**, HebaAbd El Kader*, FawzyMegahed khalill*** *Medical Surgical Nursing Deprtement, Faculty of Nursing, Benha University ** Adult Nursing Deprtement, Faculty of Nursing, Alexandria University *** Internal Medicine Deprtement, Faculty of Medicine, Benha University

ABSTRACT The study aimed at assesses the effect of designed implemented nurses' educational program on minimizing incidence of complications for patients with upper gastrointestinal bleeding. To achieve this aim four research hypothesis were formulated; the nurses' post program mean knowledge scores will be higher than pre-program mean scores, the nurses' post program mean practice scores will be higher than pre-program mean scores, the frequency of patients' complications incidence post- program will be lesser than that of the preprogram and there will be a positive correlation between the nurses' knowledge and practice scores. A sample of (60) adult patients with upper gastrointestinal bleeding and (30) nurses were involved in this study. The study carried out at Benha University Hospitals at the Internal Medicine Department. Data related to this study were collected by three tools; astructuredinterviewing schedule to assess the nurses’ knowledge, an observation check list to assess the nurses' practice and patients' complications assessment sheet. Theresults implied that: there was plainly improvement in nurses' knowledge and practice score especially immediately post program implementation, as well as, there were significant differences between nurses' knowledge and practice in all study phases,also there was precisely decline in all complications' prevalence among each and every one in post program implementation group, as well there was a positive non-significant correlation between knowledge and practice score. Theconclusion revealed that the program had a positive effect on the nurses' knowledge and practice as regards to the management for patients with upper gastrointestinal bleeding, as well as, there was precisely decline in all complications' prevalence among the entire post program implementation group . The study recommended that a continuous in-service education program for all nurses working in Gastroenterology Unit based on the standards nursing performance is needed for caring with patients suffering from upper gastrointestinal bleeding. variceal causes. Manifestations of the INTRODUCTION disease depend on Where is the bleeding? Upper gastrointestinal bleeding What is causing it? How much blood (UGIB) refers to bleeding in the loses? If there is only losing a little bit of gastrointestinal tract above the ligament of blood the patient may have no symptoms. treitz (the duodenojejunal junctions).It is The patient also may have haematemesis, one of the most importance critical melaena, hematochezia, occult blood, problems, which has wide prevalence chronic blood loss & anemia. The worldwide, especially in our society (El diagnosis depends on the clinical wakil et al., 2011). The common causes for presentations, patient complains, diagnostic UGIB were classified into variceal and non studies, which include; lab results,

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Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed radiological and endoscopic finding gastrointestinal haemorrhage in Egypt (American College of Gastroenterology, (70.1%). Hematemesis due to ruptured 2012).Related to the management it will esophageal varices is a common cause of depend on the cause which may include; death in patients with portal hypertension drug therapy, endoscopic procedures, or (Reda et al., 2011; El-Gaidie, 2003). It surgical intervention (Leontiadis et al., was estimated that esophageal varices 2007). The complications of UGIB are develop in about 50-63% of patients with self-evident, but other complications can liver cirrhosis and portal hypertension who arise from treatments administered and represent about 14.7% from the Egyptian diagnostic studies, the worst of them are; population (El-Kady et al., 2004).With hypovolemic shock''it is life threatening more substantial morbidity and mortality complication that may lead to loss of than other causes of gastrointestinal patient's life''. Rebleeding ''that increases bleeding (Gameel et al., 2004; Swifee et risk for mortality. Prognosis is bad with the al., 2003).Peptic ulcer remains the following conditions; increasing age, co- commonest cause of non variceal upper morbidity, liver disease, shock at gastrointestinal bleeding particularly presentation, inpatient and continued duodenal ulcer, which accounts for two bleeding'' (British Society of thirds of all peptic ulcers and affects nearly Gastroenterology, 2008). 10% of population (Church and Palmer, 2003). Bleeding stops spontaneously in Nursing staff play a major role in more than 50% of patients, but mortality diagnosis, management and stabilizing of approached 70% in those with continued the patient's condition. The nursing role bleeding. Each bleed is associated with varies from assessment, assist with 30% mortality and the risk of rebleeding is diagnostic & therapeutic procedures, high until the varices are obliterated administer fluids & other treatments, (Osman et al., 2001). evaluation of the patient's condition and the Aim of the study conservative management (Lhynnelli, 2011).Prevention of the disease is focused The aim of this study is to assess the on treatment of the underlying cause. effect of designed implemented nurses' Discharge depends on patient general educational program on minimizing condition, diagnosis, risk for rebleeding, incidence of complications for patients the need for transfusion, need for surgery with upper gastrointestinal bleeding. and risk of death (Klebl et al., 2005). So this study was conducted to assess the Research hypothesis: effect of designed implemented nurses' -The post mean knowledge educational program on minimizing incidence of complicationsforpatients with andpractices score of the nurses who will upper gastrointestinal bleeding. be exposed to the designed educational program will be higher than the pre- Significance of the study program mean score. The frequency of complications' incidence post-program Upper gastrointestinal bleeding is a implementation will be lesser than that of common gastrointestinal emergency and the preprogram implementation. There carries a mortality rate of 5%-14% (Van will be a positive correlation between the Leerdam, 2008). Variceal bleeding was nurses’ knowledge and practice score. found to be the commonest cause of upper

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Subjects and Method: Inclusion criteria:- Design: - Nurses who are working actually as a bed side nurse. Quasi-Experimental design was utilized to fulfill the aim of this study. -Nurses who are assessing in caring of the patients with upper gastrointestinal Setting: bleeding, with different qualifications This study was carried out at Benha (diploma or diploma with specialty). University Hospital at The Internal -Age 21- 50 years old. Medicine Department. Exclusion criteria:- Subjects: - Nurses who are not helping in 1-Patients:- caring of the patients with upper Convenience sample of 60 adult gastrointestinal bleeding. patients with upper gastrointestinal - Nurses aged more than 50 bleeding at The Internal Medicine (according to hospital policy they don't Department at Benha University Hospital, share in patients' care). within the period of the study were divided randomly into two groups; control and Tools of the study:- experimental group each group was include The tools of this study were 30 patients, the patients had been selected included:- according to the following criteria:- 1- Gastroenterology nurses' Inclusion criteria:- knowledge regarding to the -Patients with confirmed diagnosis of uppergastrointestinal bleeding upper gastrointestinal bleeding. management structured interviewing schedule:- (Appendix -Adult patients (male and female). IA) -Age 18- 50 years old. Astructured interviewing schedule Exclusion criteria:- was designed by the researcher and adapted from previous research references after - Patients aged less than 18 or more reviewing related literature. The structured than 50. interviewing schedulewas aiming to assess -Patients who have serious the gastroenterology nurses' level of comorbiditis {cancer, liver failure, renal knowledge regarding to the upper failure, ischemic heart disease….ect}. gastrointestinal bleeding management. Also it helped the researcher in developing 2- Nurses:- the booklet. It was conducted in a simple A sampleof 30nurses who were Arabic form in order to prevent working actually as a bed side nurse at The misunderstanding. Internal Medicine Department at Benha The researcher interviewed the University Hospital within the period of the studied nurses and gave them chance for study. The nurses had been selected asking any questions and answer the according to the following criteria:-

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed assessment sheet andit included the Standardized observational checklist following parts:- was developed by the researcher based on review of literature, adopted from (Nasr El i. Socio-demographic characteristics Dain, 2007&Taha, 2004) and it included of the nurses included in thestudy the following main parts:- such as age, qualifications, marital status and years of experience … i. Assessment phase for patients with etc. gastrointestinal bleeding was include:history taking, check ii. Group of questions to assess the hemodynamic status and assess gastroenterology nurses' level of gastrointestinal bleeding (location, knowledge regarding to the upper characters, duration and severity) , gastrointestinal bleeding identify result of management. diagnosticstudies,assessment of patients' needs, diagnosis of patients' Knowledge scoring system: (Appendix response, then planning for patients' IA) care ,followed by implementation of All knowledge variables were care and lastly evaluation of the weighted according to the items included in success of the implemented care. the answer of each question. The data ii. Ongoing care it included:maintain collected from the knowledge test was effective ventilation , monitor computed and the test received a grade out cardiovascular status, maintain fluid of 70 points, the scores were allocated as and electrolyte balance, relieve the following: (1) for right answer (0) for patient’s pain, stability of wrong answer and the answer that didn't be neurological status, oxygen therapy, known by the nurse. cardio pulmonary resuscitation, post- The score of knowledge test resuscitation care, administration of expressed as percent from a maximum of I.V. infusion and medications, blood 70 points as the following:- transfusion, relief discomfort problems and care of the  Good: 70- 45 points, which represent devices……ect. (100:65 percent). iii. Care for patient undergoing  Moderate: from 44- 35 points,which endoscopy it included: standardized represent (from less than 65:50 steps including preparation of the percent). equipment.  Poor: 34- 0 points, which represent iv. Discharge: patient and family (less than 50 percent). teaching about the disease, the . The scoring technique adopted from important of the follow up and (Gomah, 2013). community resources that may be needed. 2- Gastroenterology nurses' care practice observational checklist Nurses' care practice observational regarding to the management of checklist scoring system:- patient with gastrointestinal Scoring of observational checklists bleeding:- ( Appendix IB) was assigned to score according to the

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding number of its sub-items. For each sub-item  Medical history & physical the nurse assigned (2) if she had done it examination (Part II):- completely, if she had done it incompletely Diagnosis, medical history, history of (1) was given, but if she had not done a previous bleeding,current diseases,history (zero) was given. The scoring system of the of drugs,generalcomplains,eye check list was computed and the sheet examination,skin examination,chest received a grade out of total 386 points. examination,abdominal examination,limbs examination,disorders of NB:-according to the management consciousness,vital signs,urinary output, regimen at Benha University laboratory findings and radiology findings. Gastroenterology Unit, the insertion of balloon tamponade technique didn't used  Complications (Part III):- during the period of study ,so the score of this procedure had been modified from (18) Assessment sheet for patients' to (6)& the final score had been modified complications, that arise actually from from (386) to (374) . upper gastrointestinal bleeding or result from diagnostic procedure and, or caused The score of nurses’ practice by treatment administration. expressed as percent from a maximum of 374 points as the following:- Patients' complications scoring  Good: 374- 243 points, which system:- represent (100:65 percent). The frequency of complications'  Moderate: 242- 187 points,which incidence among patients with upper represent (from less than 65:50 gastrointestinal bleeding was calculated for percent). the preprogram implementation group of 30 studied patients preprogram  Poor: 186- 0 points, which implementation and it was recalculated for represent (less than 50 percent). the experimental group of 30 studied . The scoring technique adopted patients post- program implementation by from (Gomah, 2013). the researcher. The patient received grade (1) if the complication was present and

grade (0) if it wasn't present. 3- Upper gastrointestinal bleeding The score of complications' incidence patients' complications assessment expressed as a numeral from a maximum sheet:- (appendix IC) of 13 points as the following:- It was designed by the researcher and  Good: 0 points. adopted from previous research references after reviewing related literature and it was  Poor: 1- 13 points. include the following parts:- Guidelines construction:-  Patients' sociodemographic characteristics (Part I):- . This was based on the results obtained from preprogram assessment Patient’s name,age, gender and using the interviewing questionnaire , occupation. observation check list as well as ,

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

literature review ,aiming to satisfy the gastrointestinal stability, effective studied nurses' deficit knowledge and communication, improve activity practice about caring for patients with status& effective ambulation and upper gastrointestinal bleeding . home care". . The guidelines was include different  The last one cover (indication of sessions developed by the researcher every procedure, nursing roles in for the purpose of improving nurses’ each procedure, aseptic technique, knowledge and practice related to care preparation of patient, preparation for patients with upper gastrointestinal of the needed equipment, technique bleeding. The guidelines contain three or steps of procedures, the rational session :- in each steps of procedure, caution and complications of procedures,  The first one contain (purpose of nursing roles in complications' educational program, revise the management and written basic anatomical parts of information related to every gastrointestinal tract, physiology of procedure). the gastrointestinal tract, definition, incidence, types, Method pathophysiology,causes & risk factors, manifestations,  The research approval was obtained complications, prognosis and from the ethical committee. diagnostic methods of upper gastrointestinal bleeding).  The objectives and the aim of the research were clarified by the  The second enclose (initial researcher to all subjects. management techniques, common used drug therapy and the needed  Assure maintaining anonymity and consultation and triage, different confidentiality of the subject’s data. endoscopic therapy techniques  Allow the nurses and the patients to "mechanical therapy, thermal choose to participate or not in the therapy, chemical therapy", surgical study, they have to withdrawal at any treatments for variceal and non time from the study. variceal bleeding, preventive strategies for upper gastrointestinal  The research tool was not embarrass bleeding and different nursing roles; of modesty and was not cause any Assessment phase includes; obtain harm or pain for the participants. history, examinations and  The researcher got written consent investigations. Intervention phase from all nurses and patients to includes; respiratory, hemodynamic, participate in the study & neurological, pain, blood confidentialities wereassured. transfusion, oral nourishment, care of the devices, verbal  A convenient sample according to the communication, activity status & previous criteria was selected. ambulatory and home care. Evaluation phase includes; air way  The managements of gastrointestinal & respiratory stability, bleeding weredone according to hemodynamic stability, hospital routine.

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Validity Limitation of the study  Validity of content was done by a jury ● Lack of nurses' cooperation in of five experts professors from The different phases of the study. Internal Medicine and Medical ● It was difficult to collect all the Surgical Nursing department, that is nurses together at the same time to attend to check the relevancy, coverage and the guideline sessions. This problem was clarity of the questions. Accordingly overcome by repetition the guideline. modifications were done and the final form was developed. Statistical design Reliability . Statistical presentation and analysis of  Reliability of the tool was test- retest the present study was conducted as; and was modified and developed. Categorical variables were presented as absolute values and percentages Pilot study were compared by use of the Chi-  A pilot study was carried out on five square χ2 test. Continuous variables patients and five nurses in order to were expressed as mean ± SD. The evaluate the developed tools for the correlation coefficient among variables visibility, clarity and applicability of was assessed by Pearson’s and the designed form in providing the Spearman’s coefficient. Analysis was required data and the necessary performed with SPSS statistical modification was done. The pilot software version 20 (SPSS). P value study was excluded from the results more than 0.05 indicates non- of the study. significant result, when P value less than 0.05 indicates a significant result

Results The results present that the majority of the nurses were in between [30-39] years old, had diploma degree, married and had from [10-20]years of experience .The majority of the patients in both groups were in between [40-50] years old ,males , had work in the preprogram implementation group, whilst they hadn't work in the post program implementation group .As to the patients' medical history there were significant differences between all patients in both groups. The greater part of patients in both groups had liver cirrhosis& esophageal varices. Each and every one of patients experienced hematemsis. Moreover some patients in both groups suffered from melena, hematochezia, previous leeding attacks, DM, HTN and drugs misuse or abuse.

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

Figure (1) distribution of the studied subjects (nurses) according to their demographic variables (N = 30)

Figure (2) distribution of the studied subjects (patients) according to their demographic variables (N = 60)

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Table (1)mean and stander deviation of the studied subjects (nurses) according to their total knowledge and total practice score (N = 30)

Immediately Two month Knowledge score One month Practice Preprogram post post post program score program program

Total knowledge Mean ±Std. 36.3667 ± 63.6667 ± 60.3667 ± 56.0333 ± score Deviation 14.51630 9.20769 10.13864 8.76310

Total practice 136.0667 ± 307.9000 ± 292.1000 ± 270.4667 ± score Mean ±Std. 43.9607 41.83411 42.09132 40.276 Deviation

Table (1):presents that in relation to total knowledge scoreMean ± SD, it was (36.3667 ± 14.51630) preprogram, improved to (63.6667 ± 9.20769)immediatelypost program, then shrunken to (60.3667 ± 10.13864) one month post program and dropped down to (56.0333 ± 8.76310) two months post program. As to total practice scoreMean ± SD, it was (136.0667 ± 43.96075) preprogram, promoted to (307.9000 ± 41.83411) immediatelypost program, afterward contracted to (292.1000 ± 42.09132) one month post program andlimited to (270.4667 ± 40.27640) two months post program.

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

Table (2) distribution of the studied subjects (patients) according to their present complications related to upper gastrointestinal bleeding (N = 60)

Preprogram Post program implementation implementation Chi-square Complications related to upper group group gastrointestinal bleeding P- N % N % X2 value

No 9 30.0 26 86.7 Homodynamic instability 1.667 .197 Yes 21 70.0 4 13.3

Recurrent GI No 16 53.3 23 76.7 5.400 .020* hemorrhage Yes 14 46.7 7 23.3

No 6 20.0 13 43.3 Fluid disturbance 8.067 .005* Yes 24 80.0 17 56.7

No 10 33.3 17 56.7 Electrolytes disturbance .600 .439 Yes 20 66.7 13 43.3

No 6 20.0 13 43.3 Anemia 8.067 .005* Yes 24 80.0 17 56.7

No 3 10.0 9 30.0 Coagulopathy 21.600 .000* Yes 27 90.0 21 70.0

Blood transfusion No 23 76.7 27 90.0 26.667 .000* reaction Yes 7 23.3 3 10.0

No 26 86.7 28 93.3 Shock 38.400 .000* Yes 4 13.3 2 6.7

No 10 33.3 23 76.7 Infection .600 .439 Yes 20 66.7 7 23.3

No 23 76.7 27 90.0 Pneumonia 26.667 .000* Yes 7 23.3 3 10.0

No 25 83.3 28 93.3 Disturbed conscious level 35.567 .000* Yes 5 16.7 2 6.7

No 28 93.3 29 96.7 Renal failure 48.600 .000* Yes 2 6.7 1 3.3

No 29 96.7 30 100 Cardiac arrest 56.067 .000* Yes 1 3.3 0 0

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Table (2):illustrates that with reference to the incidence of homodynamic instability near three quarter (70%) in the preprogram implementation group & only (13.3%) in the post program implementation group had this complain. On the subject of the presence recurrent GI hemorrhage near one half of the patients (46.7%) in the preprogram implementation group & in close proximity to one quarter of the patients (23.3%) in the post program implementation group had this complain.As regards the incidence of fluid disturbance massiveness (80%) of the patients in the preprogram implementation group & extra one half (56.7%) in the post program implementation group had this complain. In relation to the event of electrolytes disturbance over two thirds of the patients (66.7%) in the preprogram implementation group & about half (43.3%) in the post program implementation group had this complain. As regards the incidence of anemia bulk of the patients (80%) in the preprogram implementation group & more than half (56.7%) in the post program implementation group had this complain. Concerning with the incidence of coagulopathy the majority of the patients (90%) in the preprogram implementation group & about three quarters (70%) in the post program implementation group had this complain.

In relation to the event of blood transfusion reaction not far away to one quarter (23.3%) of the patients in the preprogram implementation group & only (10%) in the post program implementation group had this complain. Pertaining to the incidence of shock only (13.3%) in the preprogram implementation group & merely (6.7%) in the post program implementation group had this complain. As regards the incidence of infection over two thirds of the patients (66.7%) of the patients in the preprogram implementation group & in close proximity to one quarter of the patients (23.3%) in the post program implementation group had this complain. About the episode of pneumonia nearby one quarter (23.3%) of the patients in the preprogram implementation group & no more than (10%) in the post program implementation group had this complain.In relation to the incident of disturbed conscious level only (16.7%) of the patients in the preprogram implementation group & barely (6.7%) in the post program implementation group had this complain. About the event of renal failure just (6.7%) of the patients in the preprogram implementation group & no more than (3.3%) in the post program implementation group had this complain. In relation to the experience of cardiac arrest just (3.3%) of the patients in the preprogram implementation group & no one (0%) in the post program implementation group had this complain. All the results were very highly statistical significant where p-value < 0.05, except (homodynamic instability,electrolytes disturbance &infection) where p-value > 0.05.

Table (3) correlation between the nurses' knowledge score and their practice score

Knowledge score Correlation r P-value Practice score .237 .104

Table (3):points up that there was positive correlation between knowledge score and practice score. The correlation wasn't statistically significant where p-value  0.05.

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

Table (4) correlation between the nurses' knowledge & practice score and the incidence of patients' complications knowledge score practice score Correlation r P-value r P-value

Homodynamic instability -.076 .345 -.585 .000*

Recurrent GI hemorrhage -.190 .158 -.073 .350

Fluid disturbance -.318 .043* -.039 .420

Electrolytes disturbance -.053 .390 -.123 .259

Anemia -.318 .043* -.039 .420

Coagulopathy -.206 .138 -.084 .330

Blood transfusion reaction -.059 .378 -.497 .003*

Shock -.091 .317 -.199 .146

Infection Patients' Complications -.246 .095 -.479 .004*

Pneumonia -.214 .128 -.082 .333

Disturbed conscious level -.109 .284 -.207 .136

Renal failure -.116 .271 -.263 .080

Cardiac arrest -.107 .286 -.312 .047*

Table (4): shows that; there was a negative correlation between knowledge score&practice scoreand all complications. The correlation wasn't statistically significant where p-value  0.05, except; knowledge score&(fluid disturbance and anemia) and practice score& (homodynamic instability, blood transfusion reaction, infection and cardiac arrest) where p- value < 0.05. connection with the previous an evaluating Discussion tools were developed to assess the nurses' The aim of this study is to evaluate knowledge and practices level related to the effect of designed implemented nurses' caring of patients with upper educational program on minimizing gastrointestinal bleeding. Additionally, incidence of complications for patients another tool was developed in the purpose with upper gastrointestinal bleeding.In of assessing the patients' condition and the

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding complications' incidence rate. As to the markedly improvement in nurse's findings an educational program had been knowledge score especially immediately prepared for up to date nurses’ knowledge post program implementation. Also,this and actual practices required for the care of finding quite the reverse with (sheta, 2006) patients suffering from upper who revealed that the nurse’s knowledge gastrointestinal bleeding to follow up the between pre and post program showed no rapid progress in this field. significant difference. 1. Demographic characteristics of the 3. Nurses' care practice regarding to the studied nurses:- management of patients with upper gastrointestinal bleeding pre/post The study revealed that; the majority program implementation:- of the nurses were in between [30-39] years old, had diploma degree, married and The study revealed that as to practice had from [10-20]years of experience score(assessment phase) there was clearly enhancement in nurses' practice score in These findings in similarity with assessment phase especially immediately (Ghonaiem, 2007; Said, 2006) who post program implementation. As well as, affirmed that the majority of nurse's age there were significant differences between was between [25-35] years, had secondary nurses' practice score (assessment phase) diploma, married and had from [5 - 15] preprogram, immediately post program, years of experience. These findings in one month and two months post program. contrast with (Hamed, 2009;Mahrous, The assessment phase included;collect 2003)who affirmed that less than half of demographic data, history taking, the nurses within age [20 – 29] years, had a respiratory assessment, hemodynamic diploma degree and more than half of the assessment, gastrointestinal assessment, nurses were single with years of experience diagnostic studies, communication more than 4 years. assessment and activity status assessment. 2. Nurses' knowledge regarding to the These findings in likeness with upper gastrointestinal bleeding (Gomah, 2013)who presented that nurses management pre/post program performance were un-satisfactory in implementation:- preprogram implementation ,but after the The study disclosed that the program implementation the nurses knowledge score was markedly improved performance was improved with statistical especially immediately post program significant difference among studied nurses implementation, also there were significant practices at preprogram, immediately post- differences between nurses' knowledge program and 3 months post-program. Also score preprogram, immediately post the findings in correspondence with (sheta, program, one month and two months post 2006)who showed that there was a slight program implementation. improvement in nurses practice between pre and post program implementation These findings in likeness with regarding nurse’s role during assessment (Gomah, 2013) revealed that the nurse’s phase for patients in cardiac unit. knowledge showed statistically significant Additionally, (Refai, 2006) discovered that differences between pre, immediate and the nurses had insufficient practice level post program implementation.Too preprogram, but there was progress in (Ghonaiem, 2011) affixed that there was

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed nurses practice level post program blood transfusion, pain assessment, care for implementation and there was a highly patient with nausea, vomiting, abdominal statistical significant difference between distention , fever, adequate hygiene, care of pre and post program implementation. the tubes, health education and discharge Also, gradual decrement in nurses' practice instructions.Additionally the findings in score by time had been found.These similarity with (sheta, 2006) who showed findings in similarity with (said, 2006)who that there was a slight improvement in stated that the majority of nurse’s skills nurses practice between pre and post were unsatisfied in both hospitals in most program implementation regarding nurses’ aspects of care; take history for patient and role during ongoing care ( maintain asses laboratory values. effective ventilation, management with oxygen therapy, cardio-pulmonary With regard to practice score resuscitation, monitor cardiovascular status (intervention phase) there was plainly , maintain fluid and electrolyte balance , enrichment in nurses' practice score in relieve patient’s pain , stability of intervention phase particularly immediately neurologic status and reading central post program implementation. Additionally venous pressure). Too (Shalby, 2005) there were significant differences between revealed that the nurses had substandard nurses' practice score (interventionphase) practice level related to (maintain air way preprogram, immediately post program, ,check vital signs , fluid balance ,urinary one month and two months post program. tract infection, intake and output, adequate The interventionphase consisted nutrition, bowel elimination ,oral hygiene, of;respiratory status, hemodynamic status, neurological system assessment, blood transfusion , inserting nasogastric communication ,family support and tube, gastric lavage, endoscopic therapy & documentation). (Saleh, 2004; Mahrous , insertion of balloon tamponade, relieve 2003) revealed that the nurses had patient’s pain , oral nourishment , unsatisfactory practice level preprogram, neurological status , cardio pulmonary there was a highly statistical significant resuscitation and post- resuscitation care, difference between pre and post program care of the devices , impaired verbal implementation regarding (cardio- communication, activity status and pulmonary resuscitation) and patient ambulatory & home care. teaching before discharge but after the These findings in resemblance with program nurse’s practice was improved. (Ghonaiem, 2011)who affirmed that Pertaining to practice score nurses' performance were unacceptable in (evaluation phase) there was apparently preprogram implementation ,but after the improvement in nurses' practice score in program implementation the nurses' evaluation phase mainly immediately post performance was enhanced with statistical program implementation, furthermore there significant difference among studied nurses were significant differences between practices at preprogram, immediately post- nurses' practice score (evaluationphase) program and 3 months post-program. preprogram, immediately post program, Furthermore (said, 2006) who stated that one month and two months post program. the majority of nurses’ skills were unsatisfied in both hospitals in most These findings in similarity with aspects of care; administration of (Nasr El Dain, 2007) who stated the intravenous infusion and medications, standard of nursing care for patients with

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding upper gastrointestinal bleeding,which found that only thirty eight percent consisted of ''assessment, intervention routinely used barrier techniques (gloves, evaluation phases and their sub items''. masks and aprons). In addition these results Besides, (Taha, 2004) determined that the in match with (Taha, 2004) who located nurses had insufficient practice level the infection control measures for patients preprogram, there was progress in nurses undergoing upper gastrointestinal practice level post program implementation endoscopy, which composed of the and there was a highly statistical significant beforehand pointed out activities and their difference between pre and post program sub items. implementation. Gradual decrement in The nurses' knowledge & practice nurses' practice score by time had been level reached to the highest mean found. immediately post program implementation. With reference to practice score The acceptable level could be attributable (standardized endoscopic care) there was to recent gain of information; this actually upgrading in nurses' practice score improvement could also convey the in standardized endoscopic care chiefly effectiveness of the educational program in immediately post program implementation. relation to its objectivity and content.The Moreover there were significant score decline may be due to time factor, differences between nurses' practice but still even at the end of study period score(standardized endoscopic care) greater than preprogram implementation preprogram, immediately post program, and significantly different with baseline one month and two months post measures. This inadequacy of knowledge program.The standardized endoscopic care could be attributed to limited qualification composed of; universal precaution and lack of post basic clinical education measures, precautions related to biopsy and insufficient readings after graduation samples handling, precaution related to and it was also noticed that there wasn't cleaning spills of blood & other body any in-services educational program fluids, universal precaution related to performed in the hospital, lack of linens, gowns, gloves and masks disposal, preparation regarding the theoretical pre cleaning of endoscope, leak testing, knowledge enabling them to answer any cleaning of the endoscope, rinsing using question, inability to relate knowledge to fresh clear water, disinfect/ sterilize the practice during care for patient and lack of endoscope, rinsing, drying and alcohol self-confidence. flush , endoscope accessories (reusable Un-satisfactory practice level could accessories including water bottle) and be due to overflow of patients. Shortage of storage . nurses that deal with patient, which The result also in union with probably related to their performing non- (Egyptian ministry of health, 2008) who nursing tasks such as transporting patients, affirmed that all the previous steps are a ordering, coordinating or performing necessary nurse's practice in standardized ancillary services. In addition to decrease endoscopic care. This result is supported the nurses number especially in afternoon by (Mohamed, 2007; Mostafa, 2005) who and night shifts (three nurses in each shift). stated that nurses had a low level of Also imbalance nurse patient’s ratio, which practice. They need guidelines to apply possibly connected to lack of correct work disinfection and sterilization practice. They distribution. Moreover history taking is

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed responsibility of the physicians. Lack of that the clinical teaching has the systemic assessment of patient, also the responsibility of using feedback and assessment sheet written in English and enhancement of both the nurse and the most of them does not perfect in English teacher role by repetition of behavior to language. improve the quality of care given. Increase patients' acuity which 1) Correlation between the nurses' possibly affects nurses' psychological knowledge score and their status, also may reflect on their practice score:- performance. Shortage in preparation The study signified that there was a related to theoretical knowledge & positive non-significant correlation practical competence. Inadequate facilities between knowledge score and practice required for in-services education training. score among nurses who are working with Lack of financial resources needed for patients suffering from upper incentive reward. Poor communication gastrointestinal bleeding, which mean that among patients and nurses.Excessively the improvement in knowledge score was insufficient physical & human resources in accompanied with upgrading in practice the hospital affect the care that introduced score. to the patents .Equipment & supplies were one of the contributing factors related to As well (Gomah, 2013; Refai, 2006; malpractice, for example lack of antiseptic Youniss, 2002) they stated that there was a solutions, cotton, inadequate disposable positive significant correlation between and sterile gloves lead to bad aseptic studied nurses’ knowledge and practice technique, poor care and increase pre, immediate and 3 months post program transferring of infections. As well as the implementation.This finding is supported participation of some un experienced and by (Peter et al., 2013) who stated that acute un trained persons as a care givers, such as; care hospitals face daily challenges to their the workers and the patients' relatives efforts to achieve nurse workforce stability, whom represent a contributing factors in safety and quality of care. A body of miss practicing. knowledge shows a favorably rated nurse practice environment as an important Additionally lack of supervision in condition for better nurse and patient afternoon and night shift may affect the outcome variables. What's more quality of nursing care which arise from (Spenceley et al., 2008) stated that scope deficit in guide and furthermore possibly and context of nursing practice have can lead to negligence from nurses. influenced knowledge development in the Moreover the care provider unaware of the area of information-seeking to support diagnosis advances in disease pathogens practice. and the new trends of disease. On the other hand the improvement in the nursing actual 2) Demographic characteristics of practice post program implementation the studied patients:- could be attributed to the fact that the The study exposed that; the majority change in performance usually needs of the patients in both groups were in enough time , follow up , preparation for in-services training program to improve the between [40-50] years old, males, had practice and motivation for nurses to work in the preprogram implementation group, whilst they hadn't work in the post participate in the training program. Besides program implementation group. Chronic

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding liver disease affects people in their most This finding is supported by(El productive years. Since cirrhosis is Wakil et al., 2011) who studiedcauses and asymptomatic condition in which the liver outcome of upper gastrointestinal bleeding slowly deteriorates and malfunctions, in Emergency Endoscopy Unit of Ain several decades passed before the Shams University Hospital,who stated that complications become visible, so this facts variceal causes of bleeding were the most can explained the age distribution among common representing70.1% ,followed by the studied subjects. The disease affects non-variceal causes (26.1%) and obscure men slightly more often than women.It causes (3.8%). More to the point (Mumtaz may be due to prevalence of known risk et al., 2011) stated that esophageal varices factors ''HCV along with Schistosomal is the commonest cause of upper parasite infection is the major risk factor gastrointestinal hemorrhagewhen non- for chronic liver disease in most Egyptian esophageal variceal bleed is the second patients'' in rural life ''areas with the leading cause of upper gastrointestinal highest prevalence'' men more often hemorrhage .What's more (Hosny, 2010) exposed than women to this factor as to the who stated that the majority of the studied natural of their work. Fine number of the subjects were suffered from liver cirrhosis, studied subjects hadn't work; this may be esophageal varices, the majority of the due to the burden of the disease. patients hadn't {DM or HTN} and drugs misuse or abuse. This finding is supported by (Hosny, 2010; Farag, 2006) who stated that the Other than this finding is in contrast most frequency of the patients' age were with (Endonurse, 2006) who stated [50-60] years, males, married, illiterate and that the American Society for not work. Plus (Bajaj et al., 2010; Gastrointestinal Endoscopy (ASGE) Ibrahim, 2005; Habib et al., 2000) their affirmed that UGIB result from: peptic studies revealed that males are more ulcer disease (35 percent to 50 percent) and affected than females. Nevertheless this varices (5 percent to 10 percent). This finding in contrast with (Mehdi et al., finding is supported by (John, 2013) who 2007) who found that females are more stated that patients with acute upper affected than males. gastrointestinal bleeding commonly present with hematemsis, melena and/or 3) Patients' illness related data and hematochezia which usually occur with clinical data:- massive UGIB. Besides (Farag, 2006) The study represented that stated that the majority of the patients concerning the medical history there were hadn't the previous diseases ''DM, HTN''. significant differences between all patients 4) Patients' complications related in both groups. The greater part of patients to upper gastrointestinal in both groups had liver cirrhosis & bleeding:- esophageal varices. Each and every one of patients experienced hematemsis. In relation to complications related Moreover some patients in both groups to the upper gastrointestinal bleeding suffered from melena, hematochezia, there was precisely decline in all previous bleeding attacks, DM, HTN and complications'prevalence among each and drugs misuse or abuse. every one in post program implementation group especially homodynamic instability,

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed followed by incidence of infection. This significant differences between all patients may be explained as a reflection to the in both groups. Besides (Aiken et al., 2012) previously mentioned results, as noticed stated that better hospital nurse staffing, hemodynamic status in the assessment and more educated nurses and improved nurse intervention phase had the best score rather work environments have been shown to be than the other practices. Moreover the associated with lower hospital mortality. incidence of infection which may be a Too(Linda et al., 2012) stated that in all result of following the aseptic techniques in countries nurse staffing and the quality of different stages of care, beginning with the the hospital work environment were assessment phase as "physical examination significantly associated with patient and diagnostic studies" ending with '' satisfaction, quality and safety of care and applying aseptic techniques in all invasive nurse workforce outcomes. More procedures , care of the devices and specifically hospitals with good work endoscopic procedures'' .Which confirm environments and nurse staffing had the improvement in nurses' knowledge and improved outcomes for patients and nurses practice score. Furthermore there were alike. Deficits in hospital care quality were significant differences between all patients common in all countries. Improvement of in both groups related to the presence of hospital work environments might be a the majority complications. relatively low cost strategy to improve safety and quality in hospital care and to This analysis is in agreement increase patient satisfaction. with(John et al., 2013) confirmed that allof the pervious complications arise from 5) Correlation between the nurses' upper gastrointestinal bleeding. In addition knowledge, practice score and (Hosny, 2010) referred to the presence of the incidence of patients' the following complication {ascites, complications:- hepatomegaly, splenomegaly, anemia and The study represented that there was chest infection} among the studied a negative correlation between knowledge subjects. What's more (Smith et al., 2004) score&practice score andall mentioned that the nurse plays a critical complications.This implies that the role in the blood transfusion. She is enhancement in the knowledge & practice responsible for administration in a manner score was associated with decline in the that will ensure safety and efficacy. The entire complications' prevalence. The nurse must understand the correct correlation wasn't statistically significant in technique for administration and be aware all parameters except; knowledge of complications before administrating any score&[fluid disturbance and anemia] and blood product. (Arora et al., 2002) stated practice score& [homodynamic instability, that rebleeding is more likely to occur if blood transfusion reaction, infection and the patient has hematemsis, liver disease, cardiac arrest]. coagulopathy, hypotension and, oranemia. (Martínez et al., 2001) stated that iron- This finding is sustained by (Gomah, deficiency anemia is common in the elderly 2013) who stated that there was a negative and chronic upper gastrointestinal bleeding high significant correlation coefficient is its most frequent cause. between studied nurses practice regarding the incidence of urinary tract infections on This finding is supported by (Gomah, three times of catheterization first day after 2013) referred to the presence of catheter insertion, fourth day and before

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding catheter removal. As well(Mc Gahan et since emotions also can affect on work al., 2012) stated that nurse staffing levels outcomes.Together with the beforehand among many other factors in the hospital mentioned reasons, insufficient facilities setting contribute to adverse patient required for in-services training programs. outcomes. Concerns about patient safety Alongside the precisely turn down in all and quality of care have resulted in complications'prevalence can be inferred to numerous studies being conducted to effectiveness of the educational program examine the relationship between nurse and its positive effect on the staffing levels and the incidence of adverse patients.Additionally the findings of this patient events in both general wards and study showed the importance of nurse intensive care units. Most studies staffing and its relationship to the patient demonstrated a trend between increased outcome of hospital mortality. The nurse staffing levels and decreased adverse significant correlation between the patient outcomes in the intensive care variables perhaps due to the possibility that unit.Additionally (Penoyer, 2010) stated the nurse staffing had a main role in their that studies over the past several decades incidence, neverthelessnon-significant have shown an association between nurse correlation between the variables may be staffing and patient outcomes. Most of caused by other contributing factors those studies were generated from general because the nurse staffing is one of several acute care units. Critically ill patients variables influencing patient outcome. demand increased nurse staffing resources Moreover the researcher can assume that and nurses who have specialized during any interacting process there are knowledge and skills. Appropriate nurse many factors and it is too difficult to put all staffing in critical care units may improve the factors under control, or neglect the the quality of care of critically ill patients. effect of some of them.As a final point, the Likewise (Vanet al., 2009) stated that present study showed that there were nurse staffing is one of several variables significant improvements in the studied influencing patient safety.Correspondingly nurses’ knowledge and practice after (Coster and Norman, 2009) stated that the program implementation. This study pin burden of chronic disease on healthcare pointed that the nursing care process in services worldwide is growing and the anywhere depends on human, facilities and increased development of educational information, if there is a lack in any steps interventions, which have definite benefits in nursing care process the nursing care for patients. that introduce to the patients will not complete. Additionally there was The incidence of complications is a accurately turn down in all common process due to prevalence and complications'prevalence among each and severity of the disease. Increase the burden every one in post program implementation of chronic disease, markedly deficient in group .Furthermore, there were significant physical & human resources in the differences between all patients in both hospital, reflect on health care team groups related to the presence of most performance and affect the care that complications. Subsequently the findings introduced to the patients. Raise nurses' of this study revealed that application of suffering from stress and health problems designed nurses' educational program was owing to the characteristics of their work effective on minimizing incidence of and their contact with patients and death,

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed complicationsforpatients with upper 288(16):1987-93. Center for Health gastrointestinal bleeding. Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Conclusion 420 Guardian Dr, Philadelphia, PA 19104-6096, USA. The study concluded that the program [email protected]. had a positive effect on the nurses’ knowledge & practice, what's more the American College of Gastroenterology patients .Which observed as the nurses' (2012): Guideline for understanding post program mean knowledge &practice gastrointestinal bleeding, available at scores was higher than pre-program mean www. UpToDate.com. scores especially immediately post program implementation, additionally there Arora, N.K., Ganguly, S., Mathur, P., was precisely decline in all Ahuja, A., Patwari, A. (2002): complications'prevalence among each and Uppergastrointestinalbleeding: etiology every one in post program implementation and management. Indian J Pediatr. 2002 group . Feb; 69(2):155-68. Department of Recommendations Pediatrics, All India Institute of Medical Sciences, New Delhi. . Prevention and early detection of liver [email protected]. cirrhosis and their sequels should be considered to help lessen the burden Bajaj, J., Schubert, C., Sanyal, A.J., of the disease, prevent complications (2010): Severity of chronic cognitive and improve quality of life. impairment in cirrhosis increases with . A continuous in-service education number of episodes of overt hepatic program for all nurses working in encephalopathy, 45th Annual Meeting Gastroenterology Unit based on the of the European Association for the standards nursing performance Study of the Liver EASL, Vienna, needed for caring with patients Austria, 14-18. suffering from upper gastrointestinal bleeding. British Society of Gastroenterology(2008): UK comparative audit of upper . Initiation of studies to identify and gastrointestinal bleeding and the use of develop different nursing strategies blood, London: Available from suitable for available resources in the http://www.bsg.org.uk/pdf_word_docs/ Egyptian hospitals, which improve blood_audit_report_07.pdf: [Accessed. the provided care and circumstances 19 August 2008. for patients with chronic illness like upper gastrointestinal bleeding. Church, N.I. and Palmer, K.R. (2003): References Ulcers and nonvariceal bleeding, Endoscopy 35, 1:22-6. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H. (2002): Coster, S. and Norman, I. (2009):Cochrane Hospital nurse staffing and patient reviews of educational and self- mortality, nurse burnout, and job management interventions to guide dissatisfaction. JAMA. 2002 Oct 23-30; nursing practice,International Journal of

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Nursing Studies, Volume 46, Issue 4, Manial University Hospital, April 2009, 508-528. unpublished Master Thesis Cairo University. Egyptian Ministry of Health (2008): National Program for Infection Control, Gameel, K., Waked, I., Saleh, S.M., et al. Policies and Procedures Manual, (2004):Endoscopic variceal band second edition, First part, and Stander ligation versus sclerotherapy in the precaution for infection control prevention of first variceal bleeding: A endoscopic unit, 43-57. prospective randomized controlled trial, Afro-Arab Liver J. 3, 1:33-45. El-Gaidie, A. (2003):Comparative study of the results of both sclerotherapy and Ghonaiem, S. E. (2007): Infection control surgery for bleeding esophageal varices measures applied in the I.C.U at Benha and cases with past history of bleeding University Hospital, a Thesis submitted varices, Med. J. Teach. Hosp. Inst. for partial fulfillment of Master Degree 59:85-90. in Medical-Surgical Nursing, Faculty of Nursing, Benha University. El-Kady, N., El-Boraey, Y.A., Hamza, I., et al. (2004):Clinical endoscopic and Ghonaiem, S. E. (2011): Impact of doppler assessment of patients on long- designed infection control training term injection sclerotherapy for program of knowledge and practice at oesophageal varices, Med. J. Cairo I.C.U at Benha University Hospital a Univ. 68, 1:63-9. Thesis Submitted for Partial Fulfillment of Doctorate Degree, Faculty of ElwakilReda, Reda, A. Mohga, Nursing, Benha University. Abdelhakam, M. Sara, Ghoraba, M. Dalla , Ibrahim, A. Wesam (2011): Gomah, S. (2013):Effect of Implement Causes and outcome of upper Nurses Guidelines Among Patients gastrointestinal bleeding in emergency Users Long -Term Urinary Catheter On endoscopy unit of Ain Shams Minimizing Incidence of Urinary tract University Hospital Departments of Infections, Thesis Submitted for partial Tropical Medicine1 and Internal fulfillment of the requirements of the Medicine2, Faculty of Medicine, Ain Doctorate Degree in Nursing Science Shams University, Cairo 11566, Egypt (Medical Surgical Nursing ) ,Faculty of Journal of the Egyptian Society of Nursing ,Benha University. Parasitology, Vol. 41, No. 2, August 2011 J. Egypt. Soc. Parasitol, 41 (2): Habib, M., Abdel Aziz, A., Gameel E. And 455 – 467. cline, E. (2000): The epidemiology of schistosomiasis in Egypt Qulyubia Endonurse(2006):GI Bleeding,available at Governorate, copy right by American http://www.endonurse.com. society of tropical medicine and hygiene, available at http://www FaragMastouraKhames (2006): The google.com, accessed in 18,5,2009, 8 relationship between functional status, Am. self-esteem and hope level among patients undergoing paracentesis at AL

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

Hamed, S. M. (2009): Nurses performance Lhynnelli (2011): Upper gastrointestinal during cardio pulmonary resuscitation bleeding, You are here: Home / Critical in I.C.U and cardiac units in University Care and Emergency Nursing / Upper Hospital, A Thesis Submitted for Gastrointestinal Bleeding , September Partial Fulfillment of Master Degree in 24, 2011, available at www.goggel Medical-Surgical Nursing, Faculty of .com. Nursing, Benha University. Linda, H. Aiken, Walter Sermeus, Koen Hosny, Z. (2010): Associates of functional Van den Heede, Douglas, M. status among hospitalized patients with Sloane,ReinhardBusse, et al. (2012): liver cirrhosis, Thesis Submitted for Patient safety, satisfaction, and quality Partial Fulfillment of The Requirements of hospital care: cross sectional surveys of the Master Degree in Nursing of nurses and patients in 12 countries in Science (Medical Surgical Nursing), Europe and the United States BMJ Faculty of Nursing, Benha University. 2012;344doi: http://dx.doi.org/10.1136/bmj.e1717(Pu Ibrahim, S.M. (2005): Impact of Pat Hatnet blished 20 March 2012)Cite this as: breathing rehabilitation program on BMJ 2012; 344:e1717. selected physical responses among patient with ascites in Al Manial Cairo Mahrous, F.M. (2003): Standards of University Hospital, unpublished nursing care for cardiac arrhythmic Master Thesis Cairo University. patients, Master thesis, Faculty of Nursing,Ain Shams University, 34. John, R. Saltzman (2013): Approach to acute upper gastrointestinal bleeding in Martínez Rey, C., González Quintela, A., adults, UpToDate, .com. DomínguezSantalla, M.J., FernándezCastroagudín, J., Lorenzo John, R. Saltzman, Mark Feldman, Anne, Zúñiga, V. (2001): [Upper digestive C. Travis(2013): Acute upper tract findings in elderly patients with gastrointestinal bleeding in adult Topic iron-deficiency anemia, A comparison 2548 Version 24.0 ,Wolters Kluwer between users and non-users of non- Health UpToDate© 2013. steroidal anti-inflammatory drugs], an Med Interna, 2001 Jul;18(7):357-60, Klebl, F.H., Bregenzer, N., Schofer, L., Servicios de MedicinaInterna, Hospital Tamme, W., Langgartner, J., ClínicoUniversitario, Santiago de Scholmerich, J., et al.(2005): Compostela. Comparison of inpatient and outpatient upper gastrointestinal haemorrhage, Int Mc Gahan, M., Kucharski, G., Coyer, F. J Colorectal Dis 2005; 20(4):368-75. (2012):Nurse staffing levels and the incidence of mortality and morbidity in Leontiadis, G.I., Sharma, V.K., Howden, the adult intensive care unit: a literature C.W. (2007): Proton pump inhibitor review,Winner ACCCN Best Nursing therapy for peptic ulcer bleeding: Review Paper 2012 sponsored by Cochrane collaboration meta-analysis Elsevier,Aust Crit Care, 2012 of randomized controlled trials, Mayo May;25(2):64-77, available at Clin Proc. Mar 2007;82(3):286-96. [email protected].

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Mehdi Mohamadnejad, Kamran Nursing ) Faculty of Nursing, Alimoghaddam, Mohyeddin- Alexandria University. BonabMandana, Mohamad Bagheri, Bashtar Maryam, HosseinGhanaati, Osman, M., El Okby, S., El-Wakeel, R., et HosseinBaharvand, al. (2001): Role of endoscopic ArdeshirGhavamzadeh, Malekzadeh ultrasonography in evaluation of Reza (2007): Phase 1 trial of esophageal varices before and after autologous bone marrow mesenchymal sclerotherapy, Egypt. J. Gastroenterol, stem cell transplantation in patients 6, 1:99-114. with decompensated liver cirrhosis, Archives of Iranian Medicine, volume Penoyer, D.A.(2010):Nurse staffing and 10, number 4, October, available at patient outcomes in critical care: a http://www. scincedirect.com, accessed concise review, Center for Nursing in 14, 9, 2009, 3pm. Research, Orlando Health, Orlando, FL, USA, Crit Care Med. 2010 Mohamed, S. O. (2007): Assessment of Jul;38(7):1521-8; quiz 1529. doi: infection control measure practiced by 10.1097/CCM.0b013e3181e47888, nurses in the labor of delivery unit a [email protected]. Thesis Submitted for Partial Fulfillment of Master degree, Faculty of Nursing, Peter VanBogaert Benha University. ,Christoph Kowalski,Susan Mace Weeks ,Danny Van heusden and Mostafa, W. (2005): Assessment of Sean, P. Clarke(2013):The relationship intensive care unit nurses knowledge between nurse practice environment, and practice of infection control nurse work characteristics, burnout and precaution a Thesis Submitted for job outcome and quality of nursing Partial Fulfillment of Master Degree, care: A cross-sectional Faculty of Nursing, Monofia survey,International Journal of Nursing University. Studies, Volume 50, Issue 12 , Pages 1667-1677, December 2013. Mumtaz Khalid &KamaniLubna& Hamid Saeed &Abid Shahab & Shah, A. RedaElwakil, Reda A. Mohga, Abdelhakam Hasnain& Jafri Wasim (2011): Impact M. Sara, Ghoraba M. Dalia andWesam of a bleeding care pathway in the A. Ibrahim (2011); Causes and outcome management of acute upper of upper gastrointestinal bleeding in gastrointestinal bleeding, Indian J Emergency Endoscopy Unit of Ain Gastroenterol (March–April 2011) Shams University Hospital by 30(2):72–77 DOI 10.1007/s12664-011- Departments of Tropical Medicine1 and 0089-5. Internal Medicine2, Faculty of Medicine, Ain Shams University, Cairo Nasr El Dain, W. (2007): The standard of 11566, Egypt Journal of the Egyptian nursing care for patients with upper Society of Parasitology, Vol. 41, No. 2, gastrointestinal bleeding ,Thesis August2011 J. Egypt, Soc, Parasitol, 41 Submitted for partial fulfillment of the (2), 2011: 455 – 467. requirements of the Doctorate Degree in Nursing Science (Medical Surgical

Zeinab Hosny, SanaaMohamed, HebaAbd El Kader, FawzyMegahed

Refai, A. S. (2006): emergency nursing nutrition at home, Public health care for critically ill patients, impact of nursing, 19(2) 122-128. a designed protocol on nurses' knowledge and practices at Intensive Spenceley, S.M. ,O'Leary, K.A. , Care Units at University Hospital and Chizawsky, L.L. ,Ross, A.J. , Teaching Hospital at Benha City, a Estabrooks, C.A. (2008):Sources of Thesis Submitted for Partial Fulfillment information used by nurses to inform of Master Degree in Medical Surgical practice: An integrative review , Nursing, Faculty of Nursing Benha International Journal of Nursing Studies University. ,Volume 45, Issue 6, June 2008, 954- 970. Said, S. (2006): comparative study between the nursing performances for general Swifee, Y.M., El-Atar, M.M., Ayad, E.E., et post-operative patients at University al. (2003):Prognostic indicators in Hospital and Teaching Hospital at cirrhotic patients with bleeding Benha City, Thesis Submitted for oesophageal varices, Assiut Med. J., 27, Partial Fulfillment of Master Degree in 1:53-62. Medical Surgical Nursing, Faculty of Nursing Benha University 2006. Taha, A. (2004):The infection control measures for patients undergoing upper Saleh, A. A. (2004): Discharge plan model gastrointestinal endoscopy, Thesis for coronary artery disease patients, Submitted for partial fulfillment of the Master thesis, Faculty of Nursing,Ain requirements of the Doctorate Degree Shams University;75. in Nursing Science (Medical Surgical Nursing) Faculty of Nursing Alexandria Shalby, A.Y. (2005):Nursing intervention University 2004. for unconscious patient and suggested protocol for nursing care, a thesis Taha, N.M. (2004):Comatosed patients: submitted for partial fulfillment of Impact of a training program provided Master Degree in Fundamental of for nurses working in critical care units, Nursing, Faculty of Nursing, Benha Zagazig university Hospital on Nurses' University. knowledge and performance levels as well as on patient outcome, a thesis Sheta, H.(2006): Effect of an educational submitted for partial fulfillment of program on the performance of nurses Doctorate Degree in Medical/Surgical working with cardiac patients, thesis Nursing, Faculty of Nursing, Zagazig submitted for partial fulfillment of the University, (1-187). requirements of the Doctorate Degree in Nursing Science (in Fundamental of Van den Heede, K. , Lesaffre, E. , Diya, L. , Nursing) Faculty of Nursing Benha Vleugels, A. , Clarke, S.P. , Aiken, L.H., university. Sermeus, W. (2009):The relationship between inpatient cardiac surgery Smith, C. E., Moushey, L., Ross, J.A., mortality and nurse numbers and &Gieffer, G., (2004): Responsibilities educational level: Analysis of and reactions of family caregivers of administrative data,International patients dependent on total parental

Effect of Designed Implemented Nurses' Educational Program on Minimizing Incidence of Complications for Patients with Upper Gastrointestinal Bleeding

Journal of Nursing Studiesvolume46, issue(6), June 2009, 796-803.

Van Leerdam, M.E. (2008): Epidemiology of acute upper gastrointestinal bleeding, Best Pract. Res. Clin. Gastroenterol, 22:209-24.

Youniss, A. (2002): Infection control training programmers: An approach for nursing staff development a thesis submitted for partial fulfillment of Doctorate degree at Faculty of Nursing, Ain Shams University, Cairo, Egypt.