<p>RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA</p><p>PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION</p><p>MS. DEFINY JAMES M. Sc NURSING I YEAR MEDICAL SURGICAL NURSING YEAR 2009-2011</p><p>PADMASHREE INSTITUTE OF NURSING BANGALORE RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA</p><p>PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION</p><p>1 NAME OF THE Ms. DEFINY JAMES CANDIDATE AND I Year M. Sc Nursing, ADDRESS Padmashree Institute of Nursing Bangalore.</p><p>2 NAME OF THE Padmashree Institute of Nursing, INSTITUTION Bangalore.</p><p>3 COURSE OF THE STUDY I Year M. Sc Nursing AND SUBJECT Medical Surgical Nursing.</p><p>4 DATE OF ADMISSION 19th June 2009 TO COURSE </p><p>5 TITLE OF THE STUDY Assessment of Effectiveness of Structured Teaching Programme on Knowledge Regarding Complications of Hypertension among Hypertensive patients attending OPD.</p><p>2 6. BRIEF RESUME OF THE INTENDED WORK</p><p>6.1 INTRODUCTION</p><p>Hypertension is a condition of having high blood pressure. It is a persistent elevation of the systolic blood pressure at a level of 140 mmHg or higher and the diastolic blood pressure at a level of 90 mmHg or higher.1 </p><p>Hypertension is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India. Hypertension is the most common cardiovascular disease, emerging as a major public health problems in developing as well as developed countries. The World Health Organization (WHO) reports that the number of people with hypertension worldwide is estimated at 600 million, of whom 3 million will die annually as a result of hypertension. In 1998, the WHO report states that considering the prevalence of any disease, hypertension ranks fourth in the world. Pooling of epidemiological studies shows that the hypertension in India is 25% in urban and 10% in rural population. Hypertension is very common and affects around 50 million Americans of which about 30% are not yet diagnosed. Hypertension have already become the first cause of death in such countries as Argentina, Chile, Mauritius, Sri Lanka, Singapore, Trinidad and Tobago and Uruguay. 2</p><p>High blood pressure (HBP) itself usually has no symptoms. Rarely, headaches may occur. People can have HBP for years without knowing it. During this time, HBP can damage the heart, blood vessels, kidneys, and other parts of the body. Some people only learn that they have HBP after the damage has caused problems, such as coronary heart disease, stroke, or kidney failure. Knowing blood pressure numbers is important, even when an individual is feeling fine. If blood pressure is normal, he/she can work with their health team</p><p>3 to keep it that way. If his/her numbers are too high, he/she can take steps to lower them and control blood pressure.This helps reduce risk for complications.3</p><p>Most people are not aware that they have high blood pressure because of a lack of symptoms. Symptoms of hypertension may be mild and vague. The most common symptoms are headache, morning headache, tinnitus - ringing or buzzing in ears, dizziness, confusion, papilloedema. Most symptoms occur from complications of hypertension like fatigue, shortness of breath, convulsion, changes in vision, nausea, vomiting, anxiety, increased sweating, nose bleeds and palpitations.4 </p><p>A whole range of signs including headaches, convulsions, walking difficulties, giddiness, depression and blurry vision can be caused by hypertension. Pain while passing urine or increased frequency of urination may mean kidney damage because of heightened blood pressure. Electrolyte loss and dehydration may cause the skin to appear dull and lifeless. Hypertension - induced cardiac damage can result in difficulties with even minimal physical exertion. The patient may feel unusually tired after even a short walk, for instance. Breathlessness and / or excessive perspiration may also be a sign of cardiac damage.This is quite serious and anyone in this condition needs urgent medical attention. The eyes can also be affected by hypertension. It can result in lesions in the eyes which can possibly lead to loss of vision.5</p><p>Hypertension is a silent killer. Indians are racially predisposed to cardiovascular disease, and the increasing burden of hypertension has only added to the problem. Lifestyle modifications that effectively lower blood pressure are increased physical activity, weight loss, limited alcohol consumption, reduced sodium intake and the Dietary Approaches to Stop Hypertension (DASH) diet. In the management of hypertension , clinical</p><p>4 trials have shown that weight loss, especially when combined with dietary sodium restriction, lowers hypertension in hypertensives and also in normotensive patients. Increasing aerobic physical activity such as brisk walking, jogging, swimming, or bicycling has been shown to lower blood pressure. Trial have reported that reduction in alcohol intake can lower blood pressure in normotensive and hypertensive men who are heavy drinkers. Dietary salt has a linear association with blood pressure. Reduced sodium intake to approximately 100 ml/day can prevent hypertension. </p><p>In industrialized countries, vegans diet have been noted to have lower blood pressure with a lower age- related rise in blood pressure. The DASH diet advocates increased usage of fruits, vegetables and low- fat dairy products and includes whole grains, nuts, poultry and fish reduces blood pressure. High potassium intake is associated with reduced blood pressure. Omega- 3 poly unsaturated fatty acid (commonly called fish oil) supplements at high doses can lower blood pressure in hypertensives. Fiber intake showed that an average increase of 14g/day of supplement fiber reduced the average systolic and diastolic blood pressure. Calcium supplementation of 400- 2000 mg/ day is associated with small reductions in systolic and diastolic blood pressures. Behavioural techniques, meditation and yoga is widely believed to reduce blood pressures.6</p><p>Complications of hypertension mainly are left ventricular hypertrophy, heart failure, aneurysms, kidney failure, stroke, memory loss, vision changes or blindness. </p><p>6.2 NEED FOR THE STUDY</p><p>Hypertension is a major contributing factor for cardiovascular disease. Essential hypertension accounts for 90 to 95% of all types of hypertension. There are many risk factors for essential hypertension such as advance in age, sex(male), race (black), family history of</p><p>5 hypertension, obesity, atherosclerosis , high salt diet, alcohol and emotional stress. In this modern world, stress is increasing in personal life. 26.4% of adult in the world and 24.6% in India is suffering from hypertension.7 </p><p>Hypertension is a worldwide epidemic with an estimated 690 million people having high blood pressure. The prevalence of high blood pressure among citizens of the United States, and Canada is 20.4% and 22% respectively. In the United States, 50 million people either have elevated blood pressure or are taking antihypertensive medications. Only half of them have their blood pressure under control. Many people with hypertension do not know they have it because it causes no symptoms. The prevalence of hypertension increase with age and is higher in African Americans than in whites.8</p><p>High blood pressure makes heart work harder and, over time, can damage blood vessels throughout body. If the blood vessels in kidneys are damaged, they may stop removing wastes and extra fluid from body. The extra fluid in blood vessels may then raise blood pressure even more. It’s a dangerous cycle. High blood pressure is one of the leading causes of kidney failure, also commonly called end- stage renal disease (ESRD). People with kidney failure must either receive a kidney transplant or go on dialysis. Every year, high blood pressure causes more than 15, 000 new cases of kidney failure in the United States.9 </p><p>Hypertension or high blood pressure can lead to several complications, the most common of which is the narrowing & hardening of the arteries, a condition known as Arteriosclerosis. This happens when fatty deposits build up on the inner lining of the arteries, causing it to</p><p>6 harden & thicken. When hypertension worsens, the fatty build up may rupture forming blood clots. High blood pressure also causes aortic aneurysm wherein aorta or the main artery expands because of the accumulation of fatty deposits .This is dangerous because the aorta may burst. Aneurysms may occur below the kidneys, in the chest or abdomen. One of the most serious cardiovascular complications of hypertension that could result in heart failure is left ventricular hypertrophy, wherein, the muscles of the heart’s left chamber thicken as the heart works harder to pump blood.</p><p>Hypertensive retinopathy and severe hypertensive retinopathy are two complications of hypertension that effect the eye, particularly the retina. High blood pressure may damage the retina’s blood vessels and this may lead to headaches, problems with eyesight and even blindness. Complications may also affect cognitive abilities and memory. Uncontrolled hypertension has been associated with senile dementia. Stroke is another complications of high blood pressure that occurs when the flow of blood to a part of the brain is cut off, causing the cells in that area to die. This may result in permanent damage of the brain. High blood pressure increases the risk of having a stroke by 6 times.10</p><p>Depending on the other risk factors, even the high end of normal may be too high for some people. A study done by researchers at the University of Michigan suggested that even slightly elevated blood pressures can be dangerous for some people, especially those who are obese ( those with 20 percent to 30 percent above the recommended body weight). High blood pressure increases chances ( or risk ) for getting heart disease and / or kidney disease, and for having a stroke. It is estimated that one in every four American adults has high blood pressure. But only about half of those who have it know they have it. Once high blood pressure develops, it usually lasts a lifetime. It can prevent and control blood pressure by taking action.</p><p>7</p><p>The National Council on Aging (NCOA) conducted a national survey of more than 1,500 Americans over the age of 50 to gauge the awareness of high blood pressure, including its risks and causes. This group is considered to be at great risk for complications from uncontrolled high blood pressure. The survey findings shows that 1) 46% of survey respondents did not know their systolic ( top) and diastolic ( bottom) blood pressure numbers. 2) More than two out of three respondents ( 69%) have not discussed the physical consequences of high blood pressure with a healthcare provider(doctor or nurse) in the past 12 months. 3) Only 27% knew the importance of the systolic number as an indicator of high blood pressure. 4) 46% of those surveyed incorrectly believed that the main cause of high blood pressure is stress. 4) While many people know that stroke and heart disease are consequences of untreated high blood pressure, half the respondents did not know that kidney failure can result from hypertension. About half of the people diagnosed with high blood pressure have borderline to mildly high blood pressure.11 </p><p>With so many possible complications of hypertension, it is critical for a person with this disease to take active steps in controlling it. Most of the studies emphasize the need of formal education regarding diet and lifestyle changes, including regular exercise, stress management and self- monitoring with a home blood pressure device, can be used to control and bring down the blood pressure with no side effects. However, if person have elevated blood pressure, he will have to take medication to bring it down and then implement lifestyle changes to make sure that the blood pressure stays low. There are many ways to effectively lower blood pressure starting with making changes to one’s lifestyle. </p><p>8 6.3 STATEMENT OF THE PROBLEM </p><p>A study to assess the effectiveness of Structured Teaching Programme on knowledge regarding complications of hypertension among hypertensive patients attending Out Patient Department (OPD) in selected hospitals, Bangalore.</p><p>6.4 OBJECTIVES OF THE STUDY</p><p>1. To assess the existing knowledge regarding complications of hypertension among hypertensive patients 2. To assess the post test knowledge regarding complications of hypertension among hypertensive patients. 3. To compare pre test and post test knowledge regarding complications of hypertension among hypertensive patients. 4. To associate the pre test knowledge regarding complications of hypertension among hypertensive patients with their selected demographic variables.</p><p>6.5 OPERATIONAL DEFINITIONS</p><p>1. Effectiveness</p><p>It refers to the improvement in knowledge regarding complications of hypertension among hypertensive patients after receiving structured teaching programme.</p><p>2. Structured Teaching Programme</p><p>It refers to the systematically developed instructional aids designed for hypertensive patients on the aspects of complications of hypertension. 3. Knowledge Awareness and understanding regarding complications of hypertension among hypertensive patients. </p><p>9 4. Complications Of Hypertension</p><p>It includes stroke, coronary artery disease, renal dysfunction, hypertensive retinopathy, and blindness. </p><p>5. Hypertensive Patients</p><p>It refers to a person who is medically diagnosed to have blood pressure of above 140/90 mmHg. </p><p>6.6 ASSUMPTIONS</p><p>1. Patients with hypertension may have inadequate knowledge regarding complications of hypertension 2. Administration of structured teaching programme may improve the knowledge regarding complications of hypertension among hypertensive patients.</p><p>6.7 RESEARCH HYPOTHESIS</p><p>H1: There will be a significant difference between the mean pre test & post test knowledge regarding complications of hypertension among hypertensive patients .</p><p>H2: There will be a significant association between level of pre test knowledge regarding complications of hypertension among hypertensive patients with their selected demographic variables.</p><p>10 6.8 REVIEW OF LITERATURE</p><p>A prospective study was conducted over a period of 7 months in a multispeciality hospital, Coimbatore, Tamilnadu, India to develop and implement Patient Information Leaflets (PILs) and to assess the effectiveness of Patient Information Leaflets. After implementation among the 180 hypertensive patients, 30 patients were excluded from the study due to lack of response. This study concluded that disease specific knowledge through PILs are necessary to heighten patient’s self confidence in management of hypertension and to improve self management.12 </p><p>A cross - sectional study was conducted in rural areas of Jawan Block District Aligarh, Uttar Pradesh, India covering a total population of 3760 drawn from 11 villages. The total number of confirmed hypertensives was 59 with prevalence rate of 15.7 per 1000 of the general rural population. The study concluded that hypertension gradually increased with increase in age and male were more prone to develop hypertension as compared to females and obesity, social class and occupation had a direct impact on hypertension.13</p><p>A study was conducted to calculate the magnitude of complication and to identify the most common complication of hypertension at Medical & Dental College, in Karachi. For this purpose data collected randomly from 50 hypertensive patients from different localities of Karachi. The study concluded that Angina is the most common complication of hypertension, that is, 11 (36%) while the subsequent complications were eye problems, myocardial infraction and renal failure.14</p><p>11 A study was conducted to determine the investigation of prevalence of cardiac complications in patients suffering from metabolic syndrome and hypertension. The study showed that left ventricular wall thickness( LVWT) was found to be significantly related to pulse pressure (P less than 0.003) and significantly inversely related to Fasting Plasma Glucose/Fasting Plasma Insulin (FPG/FPI) ratio, while duration of hypertension was also a significant factor for the development of Congestive Heart Disease (CHD).15 </p><p>A study was conducted about hypertension in Blacks. This review discusses the magnitude of the problem, its epidemiology, and the evaluation and management of hypertension as recommended by the reports of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Although substantial evidence indicates a significant increase in awareness of hypertension over the past three decades, control rates are remarkably low, particularly among Blacks. This review serves to emphasize and reiterate the burden of hypertension among Blacks and acts as a reminder of the need for additional research to determine if culturally component interventions are appropriate to prevent, treat, and control this disease within this population.16</p><p>A cross- sectional study was conducted to study the prevalence of hypertension and its risk factors as well as its extent of diagnosis and management among adults residing in an urban slum area of Tirupati, Andra Pradesh. The study concluded that despite treatment, most of the hypertensives had not achieved control of blood pressure. Health education of the public is needed to control the various risk factors of hypertension.17 </p><p>A prospective comparative analysis study of common symptoms of presentation and prevalence of target organ damage</p><p>12 among 200 adult patients with hypertension who are diagnosed at the age of 60 years or above and 200 adult patients with hypertension aged below 40 years were included in the study. The study concluded that in both, the young and elderly hypertensives, headache was the chief complaint. The prevalence of target organ damage was significantly higher in the elderly hypertensives compared to the young hypertensives.18</p><p>A study was conducted at hypertensive clinic TN Medical College and BYL Nair Hospital, Mumbai to study the clinical profile of hypertension in the elderly, development of end organ complications and the effect of hypertension with other risk factors in producing these complications among 136 hypertensive patients attending the Hypertension clinic. The study concluded that elderly hypertensive patients tend to have isolated systolic hypertension (ISH). Uncontrolled hypertension, ISH, left ventricular hypertrophy (LVH) and other associated risk factors are responsible for cardiovascular and cerebrovascular morbidity.19</p><p>Population based study of hypertension among the elderly in northern India was conducted in the urban and rural areas of Chandigarh during 1998-1999 among 362 elderly subjects above 65 years of age. The study concluded that health education campaigns should be started to increase awareness regarding risk factors and bring about changes in lifestyle for the control of hypertension and reduction of its complications.20</p><p>An observational retrospective study was conducted in all diabetic hypertensive patients visiting Al- Watani government medical center to determine target blood pressure attainment and to evaluate blood pressure control relative to type of therapy among diabetic</p><p>13 hypertensive patients from August 01, 2006 until August 01, 2007. The study showed that of the 311 patients, 79 had their blood pressure controlled. The study concluded that despite the common use of angiotensin converting enzyme-1/angiotensin receptor blockers (ACE- 1/ARB) as recommended per Joint National Committe (JNC) 7 th report, the majority of the patients had controlled hypertension. Diuretics is an important drug class in attaining target blood pressure.21</p><p>A randomized controlled trial was conducted to determine self- measurement of blood pressure at home reduces the need for antihypertensive drugs. In this study they investigated whether antihypertensive treatment based on self measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. The study concluded that self measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage.22</p><p>7. MATERIALS & METHODS;</p><p>7.1 SOURCE OF DATA;</p><p>The data will be collected from patients with hypertension in selected hospital, Bangalore.</p><p>7.2 METHODS OF DATA COLLECTION</p><p> i. Research Design Quasi Experimental- one group pre test post test design.23 ii. Variables Dependent Variable-</p><p>14 Knowledge on complications of hypertension Independent Variable- Structured teaching programme regarding complications of hypertension Demographic variables Age, sex, family income, occupation, educational status, family history of hypertension, duration of illness, previous knowledge about complications of hypertension iii. Setting The study will be conducted at outpatient department in selected hospital, Bangalore.</p><p> iv. Population All hypertensive patients attending outpatient department at selected hospital, Bangalore. v. Sample Patient with hypertension who fulfill the inclusive criteria are considered as sample and the sample size is 60. vi. Criteria For Sample Selection Inclusion Criteria: The study includes; 1. Patients diagnosed with hypertension within 1 year 2. All male & female patients who are having hypertension 3. Hypertensive patients within the age group of 30-40 years 4. Patients who can understand English or Kannada.</p><p>Exclusion Criteria: The study excludes;</p><p>15 1. Patients who are not willing to participate. 2. Patients who are unable to participate due to deliberate illness; such as unconsciousness, paralysis, and stroke vii. Sampling Technique Non probability convenience sampling technique. viii. Tool for data collection The tool consists of the following sections; Section A: Demographic data which includes baseline information such as age, sex, family income, occupation, educational status, family history of hypertension, duration of illness, previous knowledge about complications of hypertension Section B: Structured questionnaire to assess the knowledge regarding complications of hypertension. ix. Method of data collection After obtaining the required permission from the concerned authorities and informed consent from the samples, the investigator will collect data pertaining to demographic variables. The data regarding knowledge on complications of hypertension among hypertensive patient by using structured interview schedule will be collected by following 3 phases. Phase one: Pretest will be conducted to assess knowledge on complication of hypertension among hypertensive patient Phase two: A structured teaching programme will be conducted on complications of hypertension among hypertensive patients. Phase three: After a week, post test will be conducted using the same questionnaire. Duration of data collection is 4 – 6 weeks.</p><p>16 x. Plan for data analysis The data will be analyzed by using descriptive and inferential statistics. Descriptive statistics: Frequency, percentage distribution, mean and standard deviation will be used to analyze the knowledge regarding complications of hypertension among hypertensive patients. Inferential statistics: Paired ‘t’ test will be used to compare the pre and post test knowledge regarding complications of hypertention among hypertensive patients. Chi-square test will be used to analyse association between post knowledge regarding complications of hypertension among hypertensive patients with their selected demographic variables.24</p><p> xi. Projected outcome Structured Teaching programme will improve the knowledge of patients with hypertension regarding complications of hypertension.</p><p>7.3 Does the study require any investigation or intervention to be conducted on patients or other human or animals? Yes. Structured teaching programme will be administered for patients with hypertension.</p><p>7.4 Has ethical clearance been obtained from your institution? Yes, Permission will be obtained from the concerned authorities of the hospitals; Informed consent will be taken from the samples, confidentiality and privacy of data will be maintained 8. LIST OF REFERENCES </p><p>1. Joyce M Black, Jane Hokanson Hawks. Medical Surgical Nursing .7 th Edition. New Delhi: Elsevier Publisher; 2004.</p><p>17 2. Dr. Fernado S Antezana. Epidemiological aspects of Hypertension in the world. http.//www.gfmer.ch/TMCAM/Hypertension 3. What are the signs & symptoms of High Blood Pressure? available from http://www.nhlbi.nih.gov/health/di/diseases/Hbp/HBp-signs&symptoms.htm/ 4. Symptoms of hypertension :Introduction http://www.wrongdiagnosis.com/h/hypertension/symptoms. 5. Hypertension signs & symptoms - warning you can’t afford to ignore http://www.nhlbi.nih.gov/healthquadrant.com 6. Bhatt T K Luqma, Arafath, Randeep Guleria. Non- pharmacological management of Hypertension available from http://www.indianjmedsci.org/article.asp 7 . Shylamma Job, R Thamilmani. Hypertension and Abdominal Breathing Exercise. The Nurse- International 2009 ;1:( 1)18-21 8. Lewis, Heitkemper, Dirksen ‘O’ Brien, Giddens. Medical Surgical Nursing. 6thEdition.India: Elsevier publisher; 2004. 9. Complications of hypertension. http://www.wrongdiagnosis.com/ 10. Milos Pesic. Learning about Hypertension Complications. Ezine Articles. May 2007. http://ezinearticle.com/ 11.Hypertension (High blood pressure):Introduction:http://www.holisticonline.co 12. Arul Kumaran K.S.G., Julie K. Yohannan, Jiji John. Development and Implementation of Patient Information Leaflet on Hypertension and to Assess its Effectiveness. http.//sphinxsai.com/Pharm Tech July sep/2009 13. Jamal Ahmad,Ashok Kumar Agarwal, Mohammad Yannus, Aziz Khan. Hypertension in Rural Population of Jawan Block, Distt, Aligarh(up) India.The journal of the Royal society for the promotion of health 1994; 114:(1) 17-19 14. Faiza Masounal, Saimia Nagivi, Nandia Naz. Awarness regarding complications of hypertension. March 2002.http://www.packmed.com/2246. 15. Sofia M Voyak, Aris D Efstralopoulous, Athnasios A, Baltas, Hypertensive complications associated with metabolic syndrome: http://www.nature.com/ajh/journal/v18/n4s/ajh200577 </p><p>18 16. Modele O. Ashaye, Wayne H. Glies, Hypertension in Blacks.: A Literature Review.http://www.ncbi. n/m 17. SS Reddy, G R Prabhu. Prevalence and Risk Factors of Hypertension in Adults in an Urban Slum, Tirupati, A.P. Indian Journal of Community Medicine . 2007; 30:(30) http://www.ijcm.org. 18. Chowta K N, Sundeep S, Chowta MN. Comparative study of clinical profile of Elderly & Young Hypertensives. Indian Journal for the practicing doctor 2009; 5: (6) http://www.indimedica.com/journals.php? 19. Vrinda Kulkarni, N Bhagwat, Avi Hakim, Sandhya Kamath. Hypertension in the Elderly. http://www.japi.org. 20. H. M. Swami, V.Bhatia, M Gupta. Population based study of hypertension among the elderly in Northen India. 3 October 2001 http://www.journals.elsevierhealth.com/vol.116. Issue I , January 2002.p45-49. 21. 21. Sweileh WM . Target blood pressure attainment in diabetic hypertensive Patients: need for more diuretics.www.ncbi.n/m. gov/ pubmed/ 19640349. 22 Verbeck WJ, Kroon AA, Lenders JW, Kessels AG. Self- measurement of Blood Pressure at Home Reduces the Need for Antihypertensive drugs: a randomized controlled trail. http://www.ncbin/m.nih.gov/pubmed. 23. Polit F, Beck T. Nursing Research-Generating and assessing evidence for nursing practice. 8th edition. Philadelphia: Wolters Kluwer, 2008 24. Veer Bala Rastogi. Fundamentals of biostatitics. Data analysis. NewDelhi. Anes books, India;2008</p><p>9. Signature of the Candidate: </p><p>10. Remarks of the guide: </p><p>19 11.1 Name and Designation of the Guide: </p><p>11.2 Signature: </p><p>11.3 Co-guide:</p><p>11.4 Signature: </p><p>11.5 Head of the Department: </p><p>11.6 Signature:</p><p>12.1 Remarks of the Principal:</p><p>12.2 Signature:</p><p>20</p>