A STUDY TO ASSESS THE EFFECTIVNESS OF SIM ON KNOWLDGE REGARDING PERIOPERATIVE

NURSING MANAGEMENT OF PATIENTS UNDERGOING CABG IN CTVS UNIT AMONG THE

STAFF NURSES AT SELECTED HOSPITAL, BANGALORE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mr.AKHIL VINAYAK TD
1ST YEAR M.SC NURSING
MEDICAL SURGICAL NURSING
YEAR 2015 -2017

KOSHYS COLLEGE OF NURSING

HENNUR BAGALUR ROAD,
KADUSONNAPPANAHALLI, KANNUR POST,
BANGALORE- 562 149

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE , KARNATAKA

ANNEXURE I I
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1

Name of candidate and Address

( In block letters )

Mr.AKHIL VINAYAK TD
I YEAR MSc. NURSING
KOSHYS COLLEGE OF NURSING
HENNUR BAGALUR ROAD
BANGALORE - 562149

Name of the Institution

KOSHYS COLLEGE OF NURSING

HENNUR BAGALUR ROAD
BANGALORE - 562149

Course of Study and Subject

MSc NURSING,
(MEDICAL SURGICAL NURSING )

Date of Admission to the Course

5-10-2015

5 Title of the Topic

A STUDY TO ASSESS THE EFFECTIVENESS OF SIM ON KNOWLEDGE REGARDING
PERIOPERATIVE NURSING MANAGEMENT OF PATIENTS UNDERGOING CABG IN
CTVS UNIT AMONG THE STAFF NURSES AT SELECTED HOSPITAL, BANGALORE

BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION
A good

heart is better than all the heads in the world

Edward G Bulwer-Lytton

BACKGROUND OF THE STUDY

Heart is a muscular organ in humans, which pumps blood through the blood vessels of the circulatory
system .Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or
infirmity. Health and disease lie along a continuum. 1 Its the harmony among different body systems like nervous
system, renal system, respiratory system and cardiovascular system .The cardiovascular system begins its activity
when the fetus is barely 4 weeks old and is the last system to cease activity at the end of life. So heart, a vital organ
that pumps blood to whole body. This body system is so vital that it helps to define the presence of life.2
Cardiovascular disease (CVD) is the most common cause of death globally as of 2008, accounting for 30%
of death.. In India it has quadrupled in the last 40 years and WHO estimates that by 2020 close to 60 percent of
cardiac patients worldwide will be Indian. It covers a wide array of disorders, including diseases of the cardiac
muscle and of the vascular system supplying the heart, brain, and other vital organs. 3 Among cardio vascular
diseases Coronary artery disease is the most common type and accounts for the majority of deaths. Unstable angina
and myocardial infarction are the other serious manifestations of coronary artery diseases. The main treatment
modalities are drug therapy, nutritional therapy, coronary surgical revascularization, percutaneous coronary
interventions and coronary artery bypass graft surgery.4
Coronary artery bypass grafting (CABG) is defined as open-heart surgery in which a section of a blood
vessel is grafted from the aorta to the coronary artery to bypass the blocked section of the coronary artery and
improve the blood supply to the heart.Currently, the number of CABG is declining from a peak of 519,000
operations in 2000 to an estimated 300,000 cases in 2012
Coronary Artery Bypass Graft (CABG) surgery, recently called aortocoronary bypass (ACB) is a surgical
procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins
from elsewhere in the patients body are grafted to the coronary arteries to bypass atherosclerotic narrowings and
improve the blood supply to the coronary circulation supplying the myocardium. Commonly used conduits in
CABG are the internal mammary arteries, radial arteries and the greater saphenous vein5.
CABG produces the most dramatic and rewarding relief of severe disability in a high proportion of
patients. The development of CABG provides an example of the interdependence and interaction of many different
fields of technology and science leading to surgical advance. Coronary artery bypass grafting (CABG) is very
effective at prolonging life and relieving angina in selected patients. However, these patients are at high risk for

disease progression and recurrence of cardiac events such angina, myocardial infarction, repeat revascularization
and death6.
Nurses play a critical role in the improvement of quality of life. Nurses are the linchpin of the hospital care
delivery. These frontline caregivers represent a critical and costly resource. Maximizing the efficiency and
effectiveness of nurses is essential to the integrity of hospital function and the promotion of safe patient care
The patient undergoing CABG surgery deserves to have confidence that the professional nurse is
knowledgeable, caring, efficient, and effective in providing necessary perioperative care. Proper preparation of the
patient and significant others, expertise during the intraoperative phase, and a thorough knowledge base combined
with skill and compassion of the nursing staff during the postoperative phase increase the likelihood of a positive
outcome for the patient7.
6.2 NEED FOR THE STUDY
CABG surgery is indicated for patients with coronary artery disease to relive symptoms, improve quality
of life and prolong life. The patient undergoing CABG surgery deserves to have confidence that the professional
nurse is knowledgeable caring, efficient and effective in providing perioperative care. proper preparation of the
patient and significant others expertise during the intra operative phase, and through knowledge base combined
with skill and compassion of the nursing staff during the post operative phase increase the like hood of a positive
outcome for the patient. Pulmonary dysfunction and hypoxemia may occur in 30% to60%of patients after CABG
Heart diseases have become a major killer of mankind, accounts for over one million deaths each year. Coronary
artery disease is the most common type of cardio vascular disease. This develops because of hardening of the
arteries [arteriosclerosis] that supplies blood to the heart muscle. In the diagnosis of coronary artery diseases,
helpful tests include stress test, echocardiography, coronary angioplasty and coronary artery bypass graft surgery
which help to re-establish sufficient blood flow to deliver oxygen and nutrients to the heart muscles.8
Overall mortality related to coronary artery bypass graft surgery is 3-4%. Shortly after coronary artery
bypass graft surgery heart attacks occurs in 5-10% of patient and is main cause of death. About 5% of patients
require exploration because of bleeding. This surgery increases the risk of chest infections and lung complications.
Stroke occurs in 1-2%, primarily in elderly patients.9
Coronary Artery Bypass Graft(CABG) surgery has become a conventional method of treatment. It has been
used to improve patient outcomes related to cardiac symptoms, prolonged life and health related quality of life.
Although these surgical outcomes are beneficial, research has suggested that the experience and recovery process
after CABG surgery may be more complex than anticipated and presents challenges that continue well after
discharge10.
During this century, the number of CABG surgeries done per day is increasing in a tremendous manner 11.
According to American Heart Association statistics, in 1995, 5,73,000 bypass surgeries were done in United States.
In 2006, the number reduced to 4,48,000, of these 3,23,000 were men and 1,25,000 were women 12. Each year nearly

3,00,000 bypass surgeries are performed in US which means 61 in every 1,00,000 people have a coronary bypass
operation. In Britain, only 6 in every 1,00,000 have the same operation. In Japan, 1 in 1,00,000 patients will have a
coronary bypass operation13.
In India, the CABG surgery industry is booming. Medicare data (1992-2003) shows that the number of
CABG procedures in India has increased from 1,58,000 in 1992 to a peak of 1,90,000 in 1996 and then fell to
1,52,000 in 2003. The number of CABG hospitals increased steadily, from 891 in 1992 to 1069 in 200314.
As more and more persons undergo Coronary artery bypass graft (CABG) surgery, the professional nurse
acquires many additional responsibilities. Today, for instance, nurses read cardiac monitors, ascertain venous
pressures and listen to the patients breath sounds with a stethoscope as regularly as they take his vital signs. In
addition, to assess the persons condition in order to plan his care, the nurse must become familiar with a variety of
new equipments too15.
The care of the CABG patient is intense, complex and rewarding 16 Proper peri-operative nursing
management can prevent many of the complications following surgery and thus can improve the quality of life of the
patients. In the pre-operative care, emphasis is given to the need for good coronary arteriograms and left ventricular
cineangiograms, providing psychological support to client and family and the proper timing of operation after these
investigations17. The major areas of post operative care includes maintenance of patent airway, infection prevention,
wound care, hemodynamic monitoring, post operative exercises, diet, prevention of post operative complications,
medications, management of stress and anxiety and follow up care18..
CABG wound site infections remain a challenge for health care institutions that provide this surgical
service. The multi-centre US National Health care Safety Network (NHSN) reported in 2008 their 2 year data
(2006-07) for CABG SSI rates of 3.29% (2,259/68,647). UKs Health Protection Agency (HPA) reported a similar
rate, 3.2% in 2008 from about 4,200 CABG procedures19.
Study was conducted during a scientific meeting of the Council on Cardiovascular Nursing and Allied
Professionals within the European Society of Cardiology to study the practice, responsibility and confidence of
cardiac nurses in the sexual counseling of cardiac patients. 87% of the cardiovascular nurses who completed the
survey felt responsible to discuss sexual concerns with their clients, especially when patients initiated a discussion.
However in practice, most respondents rarely addressed sexual issues. The study concludes that although cardiac
nurses feel responsible and not anxious discussing patients' sexual concerns, these issues are not often discussed in
daily practice. Nurses might need more knowledge and specific practical training in providing information on sexual
concerns and sexual counselling to cardiac patients20.
A study was conducted in PD Hinduja National Hospital and Medical Research Centre, Mumbai among
615 patients to report post operative wound infection in CABG surgery patients. Study results revealed that 116
(18.86%) developed SSI. It is concluded that the post CABG surgery SSI rate is high and sternum and leg are the
common infection sites. This suggests limited knowledge of nurses regarding pre and post operative management of
CABG patients21

Cardiac surgery is not the cure for coronary artery disease. It gives the opportunity to make needed lifestyle
adjustments and achieve the highest degree of health possible. Nurses are a part of the team that makes this return to
health a possibility for the patient. A compassionate, knowledgeable and skilled nurse caring for the patient after
CABG surgery is an asset in the achievement of positive outcomes for the patient and his/her significant others22.
Since many of the studies and researchers own experience reveal an inadequate knowledge among staff
nurses regarding peri operative management of CABG patients, the researcher wants to improve their knowledge by
using a self instructional module.
6.3 REVIEW OF LITERATURE
The literature review will be presented under the following headings

Literature related to general information on coronary artery bypass graft surgery

And Complications in CABG patients

Perioperative management of CABG patient.

Knowledge of staff nurses regarding management of CABG patient

SIM as an effective teaching aid.

Literature related to general information on coronary artery bypass graft surgery and complications in
CABG patients
A retrospective study was conducted on management of spontaneous coronary artery dissection, concerns
12 cases of Spontaneous coronary artery dissection in female patients under the age of 60.Ten patients undergone
percutaneous coronary intervention and the other 2 had conservative medical therapy. Study reveals that
Conservative medical therapy is a reasonable approach in the case of distal dissection or conserved coronary flow
and Percutaneous coronary intervention is feasible in the acute phase to restore coronary perfusion. 23
An evaluative study was conducted in selected hospitals, Italy among 74,577 patients of different age
groups and gender to examine the rates of complications following coronary artery bypass surgery. A significant
effect modification by gender was found in 39 hospitals; the adjusted odds ratios showed significant increased risk
for females. In three of these hospitals a significant increased risk was found for older age. Two hospitals showed a
significant excess risk for patients 75 years. The result shows that women and elderly are more prone for post
operative complications after a CABG24.
A descriptive study was conducted in Brazil among 574 patients referred to CABG surgery to analyze the
incidence and temporal distribution of cardiac complications during waiting for elective coronary artery bypass
grafting and to identify predictive factors of such complications. Median time to surgery was 126 days (51022).
Results revealed that sudden or cardiac death occurred in 2.5% and myocardial infarction or unstable angina
occurred in 22.9%. Most complications (72.1%) were observed within 120 days. The main factors predictive of

sudden or cardiac death were severe left ventricular dysfunction and heart failure. The researcher concluded that
during long delay for coronary artery bypass surgery, cardiac events are frequent and tend to occur early25.
Perioperative management of CABG patient
An experimental study was conducted in Italy among 201 patients to assess the effectiveness of an
educational intervention led by nurses for patients admitted for coronary artery operations. Attendance at the
meeting significantly increased the patients' understanding of atherosclerosis, coronary vessel function, causes of
cardiac necrosis or ischemia, need to increase fruit and vegetable consumption and need to increase physical
activity. This findings show the impact of health education given by nurses in improving patients knowledge of
their illness and awareness of the benefits of correct lifestyles to prevent worsening of the disease26.
A randomized controlled trial was conducted among 100 patients in Canada to assess the outcome of cardiac
medical therapy for patients after coronary artery bypass grafting. The drugs used were aspirin, antilipid agents, betablockers, calcium channel blockers (CCBs), nitrates, and angiotensin-converting enzyme (ACE) inhibitors. Both
aspirin and antilipid agents were found to reduce the progression of atherosclerosis and the occurrence of graft
occlusion. Cardiovascular events were decreased with antilipid agents. In small trials, beta-blockers and CCBs failed
to decrease the incidence of cardiovascular events. No trials examined nitrates, and one small one documented a
reduction in cardiovascular events among patients treated with ACE inhibitors. Researcher concluded that few trials
have examined the efficacy of cardiac medical therapy in post-CABG patients.
An experimental study was conducted in Canada among patients following CABG surgery but before
discharge from hospital to assess the effectiveness of educational interventions involving the provision of self-care
information. Results indicated larger effect sizes for CABG patient education in which the content was
individualized, and given in a combination of media on an individual basis, and in more than one session. This
suggests the need for post operative health education for CABG patient28
Knowledge of staff nurses regarding management of CABG patient
An experimental study was conducted in Bosnia and Herzegovina, Norway among 1276 patients to assess
the outcome of a training given to surgeons and critical care nurses on coronary artery bypass surgery. Operations
were performed before training in 540 and after in 736 patients. Overall mortality for coronary bypass grafting
surgery was 1.6%, and the major complication rate was 4.5%. Patients operated after training developed fewer
complications and had a shorter length of stay. Unfavorable outcome was more common in patients who were
operated before. The result shows the need for more training of cardiac surgeons and critical care nurses in the
management of CABG patient.

SIM as an effective teaching aid

A quasi-experimental study was conducted in UK, to assess the effectiveness of self instructional module(SIM) on
Cardio Pulmonary Resuscitation (CPR). The subjects were randomly allocated to one experimental and two control
groups. The subjects' CPR ability was assessed concurrently using a resuscitation manikin and an observational checklist.
Subjects undertaking self-instruction produced significantly (P < 0.05) higher ability scores than those who did not
participate in retraining. The study suggested that SIM is an effective teaching method 30.

6.4 STATEMENT OF PROBLEM

A STUDY TO ASSESS THE EFFECTIVNESS OF SIM ON KNOWLDGE REGARDING PERIOPERATIVE NURSING MANAGEMENT OF PATIENTS UNDERGOING
CABG IN CTVS UNIT AMONG THE STAFF NURSES AT SELECTED HOSPITAL, BANGALORE

6.5 OBJECTIVES
1) To assess the pre test knowledge score regarding perioprative management of patients undergoing CABG
among staff nurses working in cots unit.
2) To find out effectiveness of SIM in terms of gain in post test knowledge score regarding peroprative
patients undergoing CABG .
3) To associate pre test knowledge score regarding perioprative management of patients undergoing CABG
with there selected demographic variable
6.6 OPERATIONAL DEFINITION

Assess:. , assess means valuing the quality of knowledge of staff nurses on pre and post operative
management of client underwent CABG.

Effectiveness: In the present study, effectiveness refers to the extent to which the self instruction module has
achieved the desired objective, that means improvement of knowledge scores among staff nurses on pre and
post operative management of clients underwent CABG.

Self instructional module(SIM):., SIM is a planned module which is a printed material in English language,
containing pre and post operative management of clients underwent CABG and is prepared based on pretest
knowledge score of staff nurses working in CTVS Unit at selected hospital.

Perioperative management: perioprative management refers to process of caring a patient undergoing

CABG from the period of time when the decision for surgical intervention is made to when the patient is
transferred to the operating room, patient under going CABG and patient underwent CABG from the period
of that begins with the admission to intensive trauma care unit and ends with the discharge of patient. The
areas include physical assessment, psychological preparation, physiological preparation, informed consent
and measures to prevent post operative complications maintenance of patient airway, infection prevention,

wound care, hemodynamic monitoring,

post-operative exercises, diet, prevention of post-operative

complications, medications, management of stress and anxiety and follow-up care.

Patient: A person receiving or registered to receive medical treatment.

In the present study, client is a patient admitted in CTVS unit of selected hospital before, intra and after a
CABG surgery.

CABG:CABG refers to a surgical intervention done for a cardiac patient by opening the coronary arteries by
using cardio-pulmonary bypass machine.

CTVS UNIT: CTVS Unit is a unit within the selected hospital which provides for the monitoring and
intensive care by a specialist team of staff to clients who have suffered an attack those who are in the
immediate Perioperative period following CABG.

6.7 VARIABLES

Independent variable: - SIM on perioperative management of clients underwent CABG.

Dependent variable :- Staff nurses knowledge on perioperative management of clients underwent CABG.

6.8 ASSUMPTIONS
The study assumes that:

Staff nurses may have some knowledge regarding peri-operative management of clients underwent CABG.

SIM may enhance the knowledge of staff nurse regarding perioprative management.

6.9 DELIMITATION
The study is delimited to the staff nurses willing in CTVS unit working in a selected hospital, Bangalore.
The study is delimited to limit 50 nos

6.10 HYPOTHESES
H1: There will be a significant difference between pre test and post-test knowledge scores regarding
perioprative management among staff nurse.
H2: There will be a significant relationship between pre-test knowledge scores with their selected demographic
variables
MATERIALS AND METHODS
7.1.1 SOURCE OF DATA:
Data will be collected from the staff nurses working in CTVS unit at selected hospital, Bangalore.

7.1.2 RESEARCH DESIGN:

The research design selected for this study is quasi experimental one group pre and post test design.
O1 --- X --- O2

O1= Pre test knowledge of staff nurses

E = O2 - O1

X = Intervention with SIM

O2= Post test knowledge of staff nurses
E = Effectiveness of SIM

7.1.3 SETTING :
The study will be conducted in CTVS unit at selected hospital, Bangalore.

7.1.4 POPULATION:
The population of this study will be staff nurses working in CTVS unit at selected hospital, Bangalore.
7.2 METHOD OF DATA COLLECTION
7.2.1 SAMPLING PROCEDURE:
Purposive sampling technique will be adopted for this study.
7.2.2 SAMPLE SIZE:
The sample size will be approximately 50 staff nurses working in CTVS unit at selected hospital, Bangalore.
7.2.3 INCLUSION CRITERIA:
Staff nurses who are:

able to speak and understand English/Kannada

willing to participate in the study

available at the time of data collection

Working in CTVS unit

7.2.4 EXCLUSION CRITERIA

Staff nurses who are not:

available during the period of data collection

willing to participate in the study

working in CTVS Unit

7.2.5 DEVELOPMENT OF TOOL

Instruments Used
1. Closed ended questionnaire related to the perioperative nursing management of clients undergoing CABG.
2. Self instructional module on perioperative nursing management of patients undergoing CABG.

Description Of The Tools

Closed ended questionnaire will be prepared to assess the knowledge of staff nurses regarding peri operative
management of patients undergoing CABG.
The closed ended questionnaire will have two parts
Part A- Demographic characteristics
Part B- Items on peri operative nursing management of clients undergoing CABG.
Self instructional module will be prepared based on objectives, literature review, pre-test knowledge score and
experts opinion.
7.2.6 DATA COLLECTION METHOD
Prior to the data collection permission will be obtained from the concerned authority for conducting the
study. The data will be collected from approximately 50 staff nurses working in CTVS Unit, after obtaining their
consent. Pretest will be conducted using structured knowledge questionnaire and a SIM will be prepared based on
the need as found by pretest knowledge score. The post test will be conducted by using the same questionnaire on
seventh day.
7.2.7 DATA ANALYSIS PLAN
The data will be planned and analyzed using differential and inferential statistics.

The differential statistics will be used are mean, median, standard deviation, and mean percentage etc

Inferential statistics will be used are paired t test and chi- square test.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON PATIENTS OR

OTHER HUMANS OR ANIMALS?
Yes, a self instructional module on perioperative Nursingmanagement of patients undergoing CABG will be
required to assess the knowledge of staff nurses.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTE IN CASE OF 7.3?
Yes, ethical clearance will be obtained from the concerned authority.

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Cardiovas Nsg (abstract) 2006 [cited Apr 2006]; 21(2): 109-117. Available from Lippincotts nursing
center.com, www.nursingcenter.com/library/journalarticle.asp
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[cited 2002 Apr]; 18(4): 397-402. Available from www.ncbi.nlm.nih.gov/pubmed/11992133
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[cited 2002 Apr]; 18(4): 397-402. Available from www.ncbi.nlm.nih.gov/pubmed/11992133
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http://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery
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indmed.nic.in/imcwebij.html.
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coronary artery bypass graft surgery: incidence, temporal distribution and predictive factors. Eur J
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Signature of the Candidate

8

Remarks of the Guide

9

The Study helps the staff nurses to improve

knowledge on Nursing care of CABG patients.

Name and designation

10
10.1

Name of the Guide

Prof. Neethi Selvam

Head of Department
Medical Surgical Nursing

10.2

Signature

10.3

Name of the Co- Guide

10.4

Signature

10.5

Head of the Department

Prof. Neethi Selvam

Head of Department
Medical Surgical Nursing

11.1
11

Remarks of the
Principal

11.2

Signature

Good Study.