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SYNOPSYS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION SAVITHA KUMARI. M Msc NURSING FIRST YEAR INDIAN ACADEMY COLLEGE OF NURSING YEAR 2012-2014 INDIAN ACADEMYCOLLEGE OF NURSING, HENNUR CROSS, BANGALORE-560043 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA SYNOPSYS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION MS. SAVITHA KUMARI. M 1. 2. 3. 4. NAME OF THE CANDIDATE AND 1ST YEAR M.SC. (NURSING) ADDRESS INDIAN ACADEMY COLLEGE NURSING HENNUR CROSS BANGALORE INDIAN ACADEMY COLLEGE NURSING HENNUR CROSS BANGALORE - 560043 COURSE OF THE STUDY AND 1ST YEAR M.Sc. (NURSING), MEDICAL SURGICAL NURSING SUBJECT NAME OF THE INSTITUTION DATE OF ADMISSION TO THE COURSE TITLE OF THE STUDY OF 11/06/2012 ‘EFFECTIVENESS 5. OF OF STRUCTURED TEACHING PROGRAMME REGARDING SELF-CARE MANAGEMENT IN TERMS OF KNOWLEDGE AND PRACTICE AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN SELECTED HOSPITAL, BANGALORE.’ 6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION “When you can’t breathe, nothing else matters” -American Lung Association.1 Never before in the history of the world was there so much wealth, and never before so much poverty; never before so much power, and never before so little peace; never before so much education and never before so little coming to the knowledge of truth. We live in a time when the value of human life is under attack. At the very least, the value of human life appears to have been significantly diminished. Today we measure our value and the value of others in terms of material possessions, wealth, power, position, title, education, houses, cars, pleasures and health.2 If life to maintain health it is important to maintain the different system in our body health and out of it the most important is the respiratory system and once it worsen it brings lots of complication to the health of the people and in that patient education programs to support patient participation in disease management have been proposed as an important strategy in limiting the growing burden of chronic disease. These programs have been studied more recently for COPD. Reported success varies between conditions, so it is important to assess the effectiveness of programs specifically in COPD.3 Chronic obstructive pulmonary disease (COPD), is the occurrence of chronic bronchitis or emphysema, a pair of commonly co-existing diseases of the lungs in which the airways narrow over time. This limits airflow to and from the lungs, causing shortness of breath (dyspnea). In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time. COPD is caused by noxious particles or gas, most commonly from tobacco smoking, which triggers an abnormal inflammatory response in the lung.4 The two main COPD disorders, that cause respiratory failure, are emphysema and chronic bronchitis. Emphysema is a disease where the walls between the lungs air sacs become weak and subsequently collapse. This results in the loss of the lungs elasticity. Chronic Bronchitis is a disease, where in the air passages swell and produce a lot of mucus leading to coughing, wheezing and infection. When a person has cough and mucus on a regular basis ( for at least 3 month a year) and in a row (for 2 years) , he/ she is considered to be suffering from chronic bronchitis. COPD occurs where a person breath in any of the following irritantsTobacco smoke, Chemicals, Air pollutants, Dusts. The lungs and air way of people are highly sensitive to the above irritants. When people inhale the above irritants their airways become inflamed and narrowed. Subsequently the elasticity of the lung is destroyed. This lead to difficulty in breathing in and out. The Symptoms are Shortness of breath, Chronic coughing, Wheezing, Reduced tolerance to exercise3 In COPD self care management is a best treatment structured for ill patients with chronic respiratory problems. It is also for patients who remain symptomatic, even if their pulmonary function has not decreased after other medical treatment. An example of somebody who could qualify for self care management are who come into this criteria of a program of exercise, disease management and counseling coordinated to benefit the individual.3 Self care has been shown to improve shortness of breath, exercise capacity and helps in the improvement of quality of life of the patients. It has also been shown to improve the sense of control a patient has over their disease as well as their emotions.4 Education and practice is the most important aspects of COPD managements. Patients with new onset of COPD require extensive education for their self care management and practice of it regularly to manage their disease safely and effectively reduce the complications. 6.1 NEED FOR THE STUDY “Chose always the way that seems the best, however rough it may be, custom will render it easy and agreeable” Although COPD affects people of all ages and over all, the incidence of COPD in women than in men and higher industrialized sectors and nations. From 1980 to 2000, the death rate from COPD for women rose from 20.1 deaths per 100,000 women to 56.7 deaths per 100,000 women; while for men, the rate grew from 73.0 deaths per 100,000 men to 82.6 deaths per 100,000 men.5 In 2010, almost 24 million adults over the age of 40 in India had COPD. Data monitor expects this number to increase 34% to approximately 32 million by 2020. COPD is predominately a disease of men and only 40% of cases in India occur in women. Over the forecast period, the growth in the number of total prevalent cases of COPD will be primarily driven by demographic changes.6 The World Health Organization (WHO) estimates that COPD as a single cause of death shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular disease and acute respiratory infection). The WHO estimates that in 2000, 2.74 million people died of COPD worldwide. According to the WHO, passive smoking carries serious risks, especially for children and those chronically exposed. The WHO estimates that passive smoking is associated with a 10 to 43 percent increase in risk of COPD in adults.7 COPD is the fourth leading cause of death in the U.S. and is projected to be the third leading cause of death for both males and females by the year 2020. It is estimated that there may be currently be 16 million people in the United States currently diagnosed with COPD. 8 Men are 7 times more likely to be diagnosed with emphysema then women, though the prevalence in women is on a steady increase and this number is lowering with each year.9 More than 13 million Indians are victims of Chronic Obstructive Pulmonary Disease (COPD), where the patients’ airways are blocked.10 The prevalence rate of COPD in Indian males is 5% and in women is 2.7%, male to female ratio being 1.6:1.10 Home care management of COPD includes education of patients about, Following pharmacotherapy including using inhaler (metered dose Inhaler) and medications, smoking cessation, exercise (Respiratory muscle exercise, upper extremity and lower extremity exercise, relaxation techniques), breathing training and bronchial hygiene techniques ,medication, nutrition and diet, self care activities, follow up.11 COPD is a systemic disease with major impact worldwide. In the treatment of COPD a holistic approach should be taken. Home care management programs may improve quality of life by reducing shortness of breath, increasing exercise tolerance, promoting a sense of well - being and to a lesser extend decreasing the number of hospitalizations12. In this year COPD day has took place on November 17 around the theme “2011- the year at the lung measure your lung health-ask your doctor about a simple breathing test called spirometry.” In 1990, a study by the World Bank and WHO ranked 12th as a burden of disease, by 2012, it is estimated that COPD will be ranked 5th. 13 According to the WHO, passive smoking carries serious risks, especially for children and those chronically exposed. The WHO estimates that passive smoking is associated with a 10 to 43 percentage increase in risk of COPD in adults. The WHO estimated that in 2000, 2.74 million people died of COPD worldwide. The WHO states that 5.4 million people die each year from causes directly due to COPD, in this 2.4 million people die each year directly attribute to air pollution, with 1.5 million of these attributable to indoor air pollution.14 A survey performed in 2008 at various centers of the country reveals that there were over 40 million COPD patients in India. The research study report of the Indian chest Society (ICS) and chest research foundations (CRF) study reveals that COPD is one of the main causes of death in INDIA- more than 5.50 lakhs people every year. The rate of hospital admission of cases with COPD showed a rate of 47.8 / 10, 00,000 persons at the community level and 57.28 percentage of between the age group of 18 - 64 and 54. 6 percentages above 65 years. The other major findings of the study are, 57. 4 percentage of the disease are chronic cases, Only 16 percentage are mild form, The remaining 26.6 percentage are in moderate category, The male – female ratio is 2.6:1, There is an association exist between tobacco smoking and the occurrence of COPD, it is the second largest cause of COPD in INDIA.15 The smoker non smoker ratio is 1.25:10.2 in INDIA 29.4 percentage males and 2.5 percentages of females are current smokers. In India 75 percentage of the homes uses a biomass like wood, crop residue and dung cakes or kerosene exposing 700 million people to high risk of indoor air pollution, affecting women and young children. Indoor air pollution and not smoking is the most important cause of COPD in India, says a prevalence study conducted by Pune based “Chest Research Foundation” (CRF) in collaboration with the KEM hospital, Pune, and the Imperial College, London. The CRF study found that the prevalence of the respiratory disease was 6.9 percentages in Indian population, among COPD suffers 7 percentages only were smoker and 93 percentage non smokers16. Smoking is the major cause of COPD. Approximately 80-90% of COPD cases are caused due to smoking. According to American Cancer Society, men who smoke have 12 times more probability of dying from COPD. Women who smoke have 13 times more probability of dying form COPD. 15 to 20 percentages of long-term smokers have the tendency to develop COPD because long term tobacco use cause swelling in the lungs and destroys the air passages and the air sacs in the lungs. Second hand exposure smoke (smoke in the air from other people smoking cigarette) also cause COPD.17 In Asia COPD prevalence in 12 Asia Pacific Countries and regions a Projection based on the COPD prevalence estimation model and the results shows the total number at moderate to server COPD cases in the 12 countries of this regions, as projected by the model, is 56.6 million with an overall prevalence rate of 6.3%. The COPD prevalence rate for the individual countries range from 3.5 percentage (Hong Kong and Singapore) to 6.7 percentage (Vietnam). 18 COPD is the leading cause of hospitalization in the US. Statistics reveal that it occurs in 4.1 percentages above the age of 30 years with male to female ratio 1.56:1. Occurrence in Bidi smokers is 8.2 percentage and Cigarette smokers 5.9 percentage. Risk factors are higher among men, elderly, poor, and urban residents. 19 Non communicable/ chronic respiratory ailments like COPD and Asthma account for nearly 1.5 percentage of total disease burden in the country. There are currently 15 million cases of COPD and 25 million cases of asthma which are expected to grow by 50 percentages by 2015. According to WHO estimates, chronic COPD will elevate to 3rd amongst top 10 killers in 1990. Close to 90 percentage of COPD cases can be attributed to tobacco smoke. 20 Investigator himself during his service period as a staff nurse in medical ward, dealed with management of many patients with COP exacerbation. Most of the patients is readmitted to hospital because of the exposure to unaware risk factors. So it is important to make the people aware about the cause, risk factor prevention and management of the COPD. Then only we can effectively control this disease. 6.2 REVIEW OF LITERATURE According to Polit and Hungler (1999) Review of Literature is a critical summary of research on a topic of interest generally prepared to put a research problem in context to identify gaps and weakness in prior studies so as to justify a new investigation.21 The review of literature is traditionally considered as a systematic critical review of the most important published scholarly literature on a particular topic. For the present study the review of literature is organized under the following headings. 1. Reviews related to prevalence and incidence of COPD 2. General reviews related to COPD 3. Reviews related to home care management. Reviews related to prevalence and incidence of COPD Information on the prevalence of COPD was obtained from vital statistics, health interview surveys, hospital charge records, national publications, and the World Health Organization (WHO). These data indicate that COPD is a common disease with implications for global health. In the United States, morbidity caused by COPD is 4%, making COPD the fourth leading cause of death, exceeded only by heart attacks, cancer, and stroke. Internationally, there is substantial variation in death rates possibly reflecting smoking behavior, type and processing of tobacco, pollution, climate, respiratory management, and genetic factors. The Global Obstructive Lung Disease Initiative, initiated by the National Heart, Lung, and Blood Institute and the WHO, aims to raise awareness of the increasing burden of COPD, decrease morbidity and mortality, promote further study of the condition, and implement programs to prevent COPD.22 Silvi J (2009) conducted a study on incidence of COPD those who are all are at a risk of different complications. Primary prevention is the home care management is investigated. Investigators although recommended that chronic bronchitis prevalence was higher than the other two others factors. During follow up many cases were identified and adverse effect was found.23 Loveman E (2011) conducted a study on factors influencing the outcomes of patients with COPD. Currently 20 million adults have had diagnosed of COPD, with estimates that an additional 9% of the total US population will be diagnosed with COPD. Currently the annual cost of health care is too high for the people to afford. So the COPD clients are taught about the home care management. 24 R. J. Hopkins, & R. P. Young, chronic obstructive pulmonary disease (COPD) is a common co morbid disease in lung cancer, estimated to affect 40–70% of lung cancer patients, depending on diagnostic criteria. As smoking exposure is found in 85–90% of those diagnosed with either COPD or lung cancer, coexisting disease could merely reflect a shared smoking exposure. Potential confounding by age, sex and pack-yr smoking history, and/or by the possible effects of lung cancer on spirometry, may result in overdiagnosis of COPD prevalence. In the present study, the prevalence of COPD (prebronchodilator Global Initiative for Chronic Obstructive Lung Disease 2+ criteria) in patients diagnosed with lung cancer was 50% compared with 8% in a randomly recruited community control group, matched for age, sex and pack-yr smoking exposure. In a subgroup analysis of those with lung cancer and lung function measured prior to the diagnosis of lung cancer (n = 127), we found a no significant increase in COPD prevalence following diagnosis (56–61%; p = 0.45). After controlling for important variables, the prevalence of COPD in newly diagnosed lung cancer cases was six-fold greater than in matched smokers; this is much greater than previously reported. The studies conclude that COPD is both a common and important independent risk factor for lung cancer.25 P Lange, the percentage of men with normal lung function ranged from 96% of never smokers to 59% of continuous smokers; for women the proportions were 91% and 69%, respectively. The 25 year incidence of moderate and severe COPD was 20.7% and 3.6%, respectively, with no apparent difference between men and women. Smoking cessation, especially early in the follow up period, decreased the risk of developing COPD substantially compared with continuous smoking. During the follow up period there were 2912 deaths, 109 of which were from COPD. 92% of the COPD deaths occurred in subjects who were current smokers at the beginning of the follow up period. The study concludes that the absolute risk of developing COPD among continuous smokers is at least 25%, which is larger than was previously estimated.26 GENERAL REVIEWS RELATED TO COPD The World Health Organization, According to WHO estimates, 80 million people have moderate to severe chronic obstructive pulmonary disease (COPD). More than 3 million people died of COPD in 2005, which corresponds to 5% of all deaths globally. Even in those countries, accurate epidemiologic data on COPD are difficult and expensive to collect. It is known that almost 90% of COPD deaths occur in low- and middle-income countries. At one time, COPD was more common in men, but because of increased tobacco use among women in high-income countries and the higher risk of exposure to indoor air pollution (such as biomass fuel used for cooking and heating) in low-income countries, the disease now affects men and women almost equally. In 2002 COPD was the fifth leading cause of death. Total deaths from COPD are projected to increase by more than 30% in the next 10 years unless urgent action is taken to reduce the underlying risk factors, especially tobacco use. Estimates show that COPD becomes in 2030 the third leading cause of death worldwide.27 Lewis (2000) in COPD patient’s chest expansion is limited and patients use the accessory muscles for respiration clinically respiratory muscle fatigue is the common feature of COPD patients. The accessory muscles are not designed for long term use so it easily get tired. To bring back the muscle tone respiratory muscle training becomes the central part of concern. The patient with COPD develops an increased respiratory rate with a prolonged expiration to compensate for the obstruction to airflow resulting in dyspnea. In addition, the accessory muscles of breathing in the neck and upper part of the chest are used excessively to promote chest wall movement.28 REVIEWS RELATED TO HOME CARE MANAGEMENT. Rootmensen, Et,(2009) a study on the effects of additional care by a pulmonary nurse for asthma and COPD patients at a respiratory outpatient clinic in 2008 February. A double blind randomized clinical trial. Ninety-seven patients were randomized into the additional care group and 94 into the control group, of which 157 had a complete dataset.(Un) adjusted analyses did not show differences between treatment groups in terms of knowledge, inhalation technique, self-management, health-related quality of life, and satisfaction with care. Multivariate logistic regression adjusting for baseline covariates showed a significant treatment effect with regard to exacerbation rate (odds ratio-0.35l; 95% confidence limits: 0.13/0.94, p=0.04). With the exception of exacerbation rate, we could not demonstrate efficacy of additional nursing care in a broad range of outcome parameters.29. Rose Guell, MD, Pere Casan, Et Al (2011) ,a study conducted on Long term effects of outpatient rehabilitation of COPD. To examine the short and long term effect of an outpatient home care management. Programme for COPD patent on dyspnea, exercise, health related quality of life and rehabilitation rate. in Secondary care respiratory clinic in Barcelona where a randomized controlled trial with blinding of outcome assessment and follow up of 3, 6, 9, 12, 18 and 24 months. Sixty patient with moderate to severe COPD (age 65 7 years, FEV1 35 14%) were recruited Thirty patients randomized to rehabilitation received 3 month of outpatient breathing retraining and chest physiotherapy 3 month of daily supervised exercise and 6 month of weekly supervised breathing exercise. Thirty patients randomized to the control group received standard care and the result shows that there was a significant differences, between groups in perception of dyspnea ( P < 0.0001) is 6 minute walking test distance (P< 0.0001) and in day to day dyspnea fatigue and emotional function measured by the chronic respiratory Questionnaire (P< 0.01). The improvements were evident at the 3rd month and continued with somewhat diminished magnitude in the second year of follow-up. The PR group experienced a significant (P < 0.0001) reduction exacerbation, but not the numbers of hospitalization. Out Patient rehabilitation programme can achieve worthwhile benefits that persist for period of 2 years.30 Effing T, Monninkhof EM, et al (2009), a study on Self- management education for patients with chronic obstructive pulmonary disease (Review) in August 2007. There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterized by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programme on health outcomes and use of health care services. Selection criteria is Controlled trials (randomized and non-randomized) of self management education in patients with COPD, studies focusing mainly on home care management and studies without usual care as a control group were excluded. The result shows the broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 89). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD – 2 58. 95 percentage CI (-5.14 to 0.02) and impact domain (WMD- 2 83; 95% CI (-565 5o 0.02) but these difference did not reach the clinically31. Jorgen Thron, Maria Norrhall (2011) ,a study conducted on Management of chronic obstructive pulmonary disease (COPD) in primary care: a questionnaire survey in western Sweden. It aims to assess the primary care management of COPD disease in relation to COPS guidelines. A postal questionnaire was sent out to all Primary Health Care Centers (PBCCs) in western Sweden (n=232). The response rate was 75%. The result shows a majority of the PHCCs has a nurse and physician responsible for COPD care. They used spirometry equipment regularly, but only 50% reported that they calibrated it at least weekly. Less than 30% of the PHCCs reported access to a dietician, Occupational therapist or physiotherapist. There was a structured smoking cessation program in 50% of the PHCCs. Larger PHCCs were more likely to use spirometry equipment regularly and to have specific personnel for COPD care. There is a need to establish structured programs for COPD care including smoking cessation programs for COPDs patients with special trained staff. Larger PHCCs have a batter infrastructure for providing guideline-defined COPD care.32 Kozui Kida,Ritsuko Vakabayashi,et al,(2010) a study conducted on Efficacy of education program in patients with chronic obstructive pulmonary disease assessed by the lung information needs questionnaire. The aim is to study the efficacy of an education program in COPD patients assessed by the Lung information Needs questionnaire ( LINQ, 2005, Hyland et al) Two hundred ten COPD patients without cognitive impairment were enrolled. All subjects received pulmonary function tests (PFT,) MRC scale, St. George Respiratory Questionnaire and Moral scale for assessing depression t the beginning. Patients received educational interventions including the six components in LINQ: disease knowledge, smoking cessation, exercise, medication, nutrition, and the avoidance of exacerbation with leaflets, for 30-60 minute at every visit by a trained nurse. The results shows the subjects (age 70. 7 yrs, FEV1/FVC 63. 4% on average) composed of 40” at risk.” 22 stage, 1, 22 “II” 80, III and 52 IV”. The number of visits differed significantly among the severity groups: at risk (5.0 1.6) 1 (5.5 1.8), II (5.8 1.5) III (6.6 1.4) and IV (6.3 1.4) total LINQ score significantly improved by the end of 6 months only in stages III and IV (p < 0.0). The MRC and Morale scales were significantly related to improvement of LINQ score (p=0.03. 0.02. Respectively) 33. Corry A.J.Ketelaars,et, et (2011) a study conducted on Long term Outcome of home care management in patients with COPD (Chest 1997). This Study investigates the long –term benefits of home care management in terms of health–related quality of life (HRQL.) . Such information is of particular importance in developing strategies for aftercare at home. HRQL was assessed by the St. George Respiratory Questionnaire and the component “well being” from the Medical Psychological Questionnaire for Lung Diseases. Patient characteristics included lung function parameters such as FEV, the diffusion capacity for carbon monoxide and maximal inspiratory month pressure, age socioeconomic variables, and exercise tolerance evaluated by a 12 min walking test. The result shows complete data sets were obtained from 77 patients. Two groups of cases were clustered. Patient characteristics were essentially the same in both groups. Group analysis revealed that patients in group 1 (n=44) had “moderate” scores on HRQL on admission, a significant improvement between admission and discharge, followed by a significant deterioration of HRQL at follow-up. Group 2 (n-33) had “severely” impaired HRQL on admission, little improvement after rehabilitation, and remained in fairly stable condition 9 months post discharge34. Lawlor Maria, Kealy Sinead, et al (2010) a study conducted on early discharge care with ongoing follow – up support may reduce hospital readmissions in COPD, April 15th 2009. Early discharge care and self –management education, although effective in the management of COPD is the back ground. Early discharge care followed by continued rapid-access out –patient support would reduce the need for hospital readmission in these patients. Two hundred and forty six patients, acutely admitted with exacerbations of COPD, were recruited to the respiratory outreach programme. The result shows that frequency of both emergency department presentations and hospital admissions was significantly reduced after participation in the programme. The provision of the respiratory outreach service that includes early discharge care followed by education, support and ongoing rapid access to outpatient clinics is associated with reduced readmission rates in COPD patients35. Marry L Carison et al(2010) a comparative descriptive study to examine the perceived learning needs and preferred learning styles of patients with COPD, August 2006. Patient’s education for COPD. Patient’s education is a criteria component of COPD management and fundamental to sing a patient’s ability to self manages the disease (Bourbeau, Nault and Dany tan, 2004, Gold 2005) is the back ground. The purpose of those comparative descriptive study were to (a) describe the perceived learning needs of patients with COPD (b) describe to preferred learning style of patients with COPD (c) describe the educational topics care provides believe are important for COPD patients (d) compare the educational topic of category rankings of patients and providers. A Non experimental, comparative descriptive study design utilizing written survey instruments was used to answer the research questions. A convenience sample if 83 patients and 65 provides participated in this study. The result shows that the sample of 202 potential patients identified and approached regarding the study, 115 agreed to participate. Eighty three surveys were returned (72% response rate) the mean age of the respondents was 07.8 years and 57 % were men. Most participants had completed high school and had some college and education. The majority of participates ad been aware of their diagnoses more than 6 years. Electronic survey was emailed to 119 providers, and 65 surveys were returned (55% response rate). The sample consisted of 27 registered nurses (42%) 123 physicians (35%) and 15 respiratory therapists (23%) 36. Elaine Mackay, et al (2009) a study on the value of maintenance home care management classes in COPD. The value of maintenance classes following the initial course is not clear. It assessed whether maintenance rehabilitation classes improved endurance shuttle walk test (ESWT), Borg score, quality of life, anxiety and depression in COPD. All patients who successfully completed 8 weeks of home care management were offered maintenance classes for the rest of the year is the method used. An ESWT, O2 saturation, modified Borg score, Chronic Respiratory Questionnaire (CRQ-SR), hospital anxiety and depression scale (HAD) been performed at baseline, after 8 weeks of rehabilitation and after a year. The result shows the 120 patients who completed home care management, 67 opted for maintenance classes and 53 declined. There was no significant baseline difference, except a higher CRQ fatigue score in the maintenance group. At the end of the year, the maintenance group had a improvement in the ESWT, compared to the group who did not attend maintenance classes37. Oshana Hermiz, et al (2010) a study to conducted a “randomized controlled trial of home based care of patients with Chronic Obstructive Pulmonary disease”. Objective is to evaluate usefulness of limited community based care for patients with chronic obstructive pulmonary disease after discharge from Hospital.In Liverpool Health service and Macarthur Health service on outer metropolitan Sydney between September 1999 and July 2000. 177 patients randomized into an intervention group (84 patients) a control group (93 patients) which received current usual care. The result shows Intervention & cultural groups showed no differences in presentation or admission to hospital or in overall functional status. However, the intervention group improved their activity scores and the control group worsened their symptom scores. While intervention group patients received more visits from community nurses and were more satisfied with their care, involvement of general practioners was much less (with only 31% (22) remembering receiving a care plan) patients in the intervention group had higher knowledge scores and were more satisfied. There were no differences in guard practitioner visits or management38. Vittorio Cardaci, et al,(2010) a study to conducted a study on effects of respiratory rehabilitation in patients with different stages of COPD severity. This study was design to identify the possible benefits of home care management (pr) on lung function, exercise tolerance, dyspnea, and quality of life in patient with different stages of COPD. 110 patients with stable COPD were enrolled in this study, Patients were subdivided for the first point according to the GOLD guidelines: 36 moderate, 36 severe and 38 very severe. All patients perform a respiratory rehabilitation programme for 4 weeks. Assessments included anthropometric measurements, pulmonary function tests, MRC and Borg scale, BODE index, 6 minute walking test (6MWT) and St. George’s Respiratory Questionnaire (SGRO). All these parameters were taken before and after the rehabilitation programme. The result shows that Comparing with pre-rehabilitation value, a significant improvement (p<0.05) of Borg Scale, BODe index, MRC Scale and SGRQ was observed in all the stages of the diseases, with no differences between patient with or without lung failure. FEV1 value was increased only in moderate and in patients with no respiratory failure. In our study we observed that respiratory rehabilitation programme improves exercise performance and quality of life in patients with any stages of COPD39. METHODOLOGY 6.3. STATEMENT OF THE PROBLEM: A study to assess the effectiveness of structured teaching programme regarding self – care management in terms of knowledge and practice among patients with chronic obstructive pulmonary disease (COPD) in selected hospital, Bangalore. 6.4. OBJECTIVES 1) To assess the pre existing knowledge and practice regarding home care management among patient with chronic obstructive pulmonary disease. 2). To evaluate the effectiveness of structured teaching programme regarding home care management patient with chronic obstructive pulmonary disease. 3). To find the association between knowledge and practice score with selected socio demographic variables 6.5. HYPOTHESIS H1: There will be significant difference between pre-test and post test knowledge of home care management . H2: There will be a significant association between knowledge and practice with selected socio demographic variables . 6.6 OPERATIONAL DEFINITION Assess:- It refers to the measurement of knowledge by using appropriate tool developed by the investigator. Effectiveness:- It refers to significant gain in difference between pre-test and post-test. Structured teaching programme: Refers to systematized organized teaching strategies to the COPD clients with audio visual aids. Practice: It is the frequently repeated customary action related home care management. Knowledge:- It refers to the correct responses given by the patients attending regarding Home care management of COPD which is elicited through structured Multiple choice questionnaire. Home Care Management:- It refers to the practice of using inhaler, smoking cession, exercise, breathing training and Bronchial hygiene techniques, nutrition and diet, self care activity and follow-up by the patients in home. COPD (Chronic Obstructive Pulmonary Diseases):-It refers to the lung disease in which airway (wind pipe or bronchi) and lung substances (air sacs or alveoli) are affected due to harmful particle or gases. Patients: - Individuals who are admitted in hospital with COPD. 6.7 ASSUMPTION An information booklet helps to improve or enhance the knowledge levels of COPD clients regarding the home care management. Socio demographic variables will have an influence on the knowledge level of COPD clients regarding the home management. 6.8 LIMITATIONS OF THE STUDY 1. This study is limited to patients who are attending medical opd and inpatient of selected hospital at Bangalore. 2. The duration of the study is limited for four weeks only. 3. Sample size is limited to 30 only. 4. The study is limited only to those who can read and write Kannada. 7. MATERIALS AND METHODS 7.1 Source of Data:The data will be collected from patients who will be attending medical OPD and IPD in selected hospital in Bangalore. 7.2 Methods of Data Collection:i) Research Approach:Quasi Experimental and evaluative approach. ii) Research Design:One group pre-test, - post-test design. iii) Sample Technique:Non Probability convenience sampling technique I. Research variables a. Independent variables: In present study the independent variable is structured teaching programme. b) Dependent variables: In this study the dependent variables is home care management of COPD patients. b. Socio-Demographic variables Characteristics of patients such as age, gender, educational status, experience, type of pneumonia effected, marital status, religion, type of family, socioeconomic status and income. II. Setting Study is planned to conduct in selected hospitals at Bangalore.. III. Population The patient with COPD admitted in selected hospitals at Bangalore. IV. Sample The patient with COPD clients admitted in selected hospitals at Bangalore.. For pilot study sample size will be 3. For main study the sample size will be 30. 7.2.1 CRITERIA FOR SELECTION OF SAMPLE (a) Inclusion Criteria:Patients of both sexes who will be, 1) Attending medical OPD and IPD to get treatment for COPD. 2) Able to read and write Kannada. 3) Available during the period of data-collection. 4) Willing to participate in the study. (b) Exclusion criteria:Patient of both sexes who will not be, 1) attending medical OPD to get treatment for COPD. 2) able to read and write Kannada. 3) available during the period of data collection. 4) willing to participate in the study. 7.2.2 DATA COLLECTION TOOL Section 1 > Socio- Demographic Performa, it include sample number, age, sex, educational status, occupation, income, socioeconomic status and information obtained about Home Care Management of COPD Section 2 - Structured questionnaire to assess the knowledge of patients attending medical OPD regarding homecare management of COPD. Section 3- STP regarding homecare management of COPD. Content validity of the tool will be obtained in consultation with guides and experts in the field of Pulmonology, Cardio- thoracic nursing, medical surgical nursing, education and bio-statistics. Reliability of the tool will be established by test re-test method. METHOD OF DATA COLLECTION: After obtaining permission from concerned authority, researcher will take an informed consent from samples and will collect the data. Phase 1 Pre-test will be conducted to assess the knowledge of diabetic clients on prevention of coronary artery disease using an interview schedule. Phase 2 Information booklet on prevention of coronary artery disease will be distributed to the diabetic clients. Phase 3: After 1 week post-test will be administered to evaluate the level of knowledge on prevention of coronary artery disease with the help of interview schedule. Duration of the study is 4 weeks 7.2.3 METHOD OF DATA ANALYSIS Data will be analyzed by means of descriptive and inferential statistics. (a) Descriptive Statistics: mean, Median, Mode, Standard Deviation, percentage distribution will be used to assess the knowledge of patient on Home Care Management of COPD. (b) Inferential statistics: Chi-square test and T –test will be used to associate the knowledge of patients with selected socio demographic variables. 7.3 Does the study requires any investigation or intervention to be conducted on the patient or other human being or animals if so please describe briefly? NO 7.4 Has ethical clearance been obtained from your institution in case of the above? NO Permission will be obtained from the concerned authority of selected hospital’s to conduct the study and informed consent will be taken from the sample, selected on the basis of selection criteria. PROJECTED OUTCOMES After the study, the investigator will able to know the knowledge of diabetic clients on prevention of coronary artery disease, based on the findings information booklets will be given to the subjects. It will help them to be aware of the common actions to prevent coronary artery disease. 8. 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Vittorio Cardaci,et al,(September 2009) A study on effects of respiratory rehabilitation in patients with different stages of COPD severity Page no:71-75. 9. 10. Signature of the Candidate Remarks of the guide 11. 11.1 Name and designation of Guide 11.2 Signature Head of department 11.3 11.4 Signature 12 Remarks of Principal 12.1 Signature