Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.
NAME AND ADDRESS
OF THE CANDIDATE
MS.ASHWINI K M
I YEAR M.SC. NURSING,
RAJEEV COLLEGE OF NURSING
K. R. PURAM.
HASSAN-573201.
2.
NAME OF THE
INSTITUTION
RAJEEV COLLEGE OF NURSING
K. R. PURAM.
HASSAN-573201.
3.
COURSE OF STUDY
AND SUBJECT
MASTER OF SCIENCE IN NURSING
OBSTRETIC & GYNAECOLOGICAL
NURSING.
4.
DATE OF ADMISSION
TO THE COURSE
03-06-2008
5
TITLE OF THE TOPIC
“A STUDY TO ASSESS THE EFFECTIVENESS
OF STRUCTURED TEACHING PROGRAMME
ON KNOWLEDGE REGARDING FIBROID
UTERUS AND ITS MANAGEMENT AMONG
THE WOMEN IN SELECTED COMMUNITY
AT HASSAN, KARNATAKA.
1
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION:
“An alternate approach to have a happy uterus”
--Jeanie 1
Uterus, the part of the female reproductive system in female is an
important organ for each adolescent girl in order to complete her lively womanhood in their
lifespan. Many changes occur in this organ, uterus as age advances which are pathological
in nature. Among them the uterine fibroid is one of the most common tumors of the
reproductive system.
Uterine fibroids are the slow growing tumors made up of muscles
and fibrous tissue attached to the wall of the uterus. Hence they are termed as uterine
leiomyoma, myomas or fibromyoma. They appear and grow in women during their
childbearing years. The tumor may vary in size from a pin head to the tip of a grape fruit. It
may also grow as a single tumor or in clusters. Occasionally they can cause the uterus to
grow to the size of a five month pregnancy.2
According to current studies it is estimated that leiomyoma are
present in 20-25% of reproductive age women but are 3-9 times more frequent in black
than in white women. However, epidemiological study of uterine fibroids by the National
Institute of Environmental Health Sciences (NIEHS) found that by age 50 the cumulative
incidence of uterine fibroid was over 80% for African American women and about 70% for
white women. More than 2 million women world wide are operated for hysterectomy every
year and approximately 1/3rd, that is 6, 00,000 are performed because of fibroids.3
Fast changing life style is taking toll on Indian women. The occurrence
of fibroid uterus among Indian women has sharply risen in recent years and it is estimated
to be around 25 million. 4
2
Annually, around, 150 cases are diagnosed with uterine fibroids in S C
Hospital, Hassan.
Most women with fibroids are asymptomatic. However they may become
symptomatic in the future, so it may be wiser to treat fibroids before they grow to a size
when they become symptomatic. The most commonly faced problems by the women with
uterine fibroids are usually menorrhagia, pain especially during the menstruation, pressure
symptoms such as frequency, urgency occurs. Rarely infertility and complications of
pregnancy occurs.5
Though 21st century’s medical advancement have made non-surgical
treatment of uterine treatment of uterine fibroid reach its height from which the shortfalls
of the treatment could be escaped, there exist still a negligence in awareness level among
Indian women.6
A Mumbai based fertility specialist conducted a 16 year long country wide
research and a circulation was released to gynecologists by the federation of OBG Society
of India (FOGSI).The aim of the circulation was increasing awareness among patients as
well as health care providers to promote more women to go for regular checks.
This will help doctor diagnose the problem and suggest treatment before it is too late.
Nurses do play an important role in the attainment of this goal which can be through health
visits and health teaching.7
A qualitative study was conducted to examine the illness experiences of
women with the common gynecological condition- Uterine Fibroid, using interpretive
phenomenological analysis (IPA) at London. The study enrolled semi-structured interview
guided by Leventhal’s self- regulation model to explore 18 women’s understanding and
experiences of having fibroids. The study revealed to higher-order themes-“managing
uncertainty” struggling between defeat and optimism. This illustrated the multiplicity of
experiences and meanings used by the women attempting to understand their condition
treatment options and future health outcomes .The findings revealed that importance of
considering individuals illness representations in order to facilitate the provision of
appropriate need and psychological care to women with fibroids.8
As a saying goes “a reliable messenger is refreshing to the one who
receives the message, like cold water in the hit of harvest time”-Nurses can be messengers
3
of relieving fear of women with inadequate knowledge about uterine fibroids and make
them yield a healthy life with a good harvest.
6.2. NEED FOR THE STUDY
“Uterine Fibroid- A cause for menopause to hit earlier than usual.”
-Sureka Sinha.1
Uterine fibroids are a major public health issue. It is the one of the condition
which will deteriorate the women’s health. It may affect any phase of life but commonly
during the reproductive age. Rarely there may be a benign metastazing leiomyoma without
any indication of malignancy.
In previous trends of treating fibroid uterus, hysterectomy was considered to be
the only effective treatment. Today many women with symptomatic fibroids who fail
medical therapy assumed that hysterectomy is their only recourse – despite the general
availability of uterus sparing procedure such as myomectomy and embolisation. Women,
for who child bearing remains an option, need to be aware of option other than
hysterectomy.9
Uterine fibroid research and education act of 2003 would have directed the
Director of NIH to expand and intensify research efforts on fibroids and to authorize the
doubling of current expenditures for research on this condition. The developed an
disseminate information regarding uterine fibroids to the public including information on
the following

The elevated risk for minority women and

The availability of a range of treatment of treatment option.10
A case was also reported with rupture uterine leiomyoma presenting as
an acute abdomen at Mumbai, India, in 2001.A women with a larger anterior wall
uterine leiomyoma underwent a dilation and curettage for a threatened abortion. She
had an uneventful recovery 3 weeks later, she represented with peritonitis. Computed
tomography and magnetic resonance imaging optimally depicted the rupture fibroid
4
and excluded other causes of acute abdomen. This reported case conclude that their
may be a ruptured degenerated fibroid causing acute abdomen outside of pregnancy.11
With over 25% of women aged 18-50 being affected by fibroids and
exclusive clinic led by Dr. R. Sinha to remove uterine fibroid through
laproscopy.Through the patients attending this clinic some of the associated factors
were ruled out such as late marriage and child birth and sedentary lifestyle. Most of
the women in reproductive age with fibroids feared that it could hamper pregnancy
and child birth. According to Dr. R. Sinha, the availability of minimally invasive
technique like laparoscopy has made an easy run away in the management. The
success of laparoscopic surgery as extended to the removal of 3.4kg weighing fibroid.
Dr. R Sinha from his clinical experience suggested that there is a need to create
awareness among women about fibroids and the need of getting it removed.12
About 40% of the women residing in rural area do not perceive
specifically that causation of gynecological disorder while some of them relate them
as abnormality.50% of the women thought that no treatment was required for these
problems. Scanty periods were deemed to be an important issue. Some population of
women didn’t relate the bleeding usually associated with this problem as a prerequisite
of good health-“as the washing away of bad blood”. Hence, prevalence of such
believes shows that there is a need to create awareness among women in rural areas.9
With reference to the ignorance of the women, especially in rural areas
regarding the problems associated with gynecological disorder among which fibroid
uterus does one of the common, there exist an indication to create awareness. The
investigator, during her community visits, experienced that the women residing in that
particular region feared about uterine fibroid, for which they believed that it is
cancerous and there exist no treatment. Indeed the investigator felt, though
management is not something “IMPOSSIBLE”, prevention before curing, rather is
more essential.
6.3 STATEMENT OF THE PROBLEM
5
“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON KNOWLEDGE REGARDING FIBROID UTERUS
AND ITS MANAGEMENT AMONG THE WOMEN IN SELECTED COMMUNITY AT
HASSAN, KARNATAKA”.
6.4 OBJECTIVES OF THE STUDY
1) To assess the level of knowledge about fibroid uterus and its management among the
women before and after structured teaching programme.
2) To compare the level of knowledge between the pretest and post test scores.
3) To associate the post test level of knowledge score with selected demographic
variables among women.
6.5
HYPOTHESES
H I: There is a significant difference between the pre and post level of knowledge
regarding the fibroid uterus and its management.
6.6
OPERATIONAL DEFINITIONS
1. ASSESS:
It is the method of estimating the level of knowledge regarding the fibroid
uterus and its management among the women.
2. EFFECTIVENESS
It is the significant increase in the level of knowledge after STP on fibroid
uterus among the women . it will be assessed through semi-structured
questionnaire. The score will be interpreted as below average (<50%), average (5175%) and excellent (>75%).
3. STRUCTURED TEACHING PROGRAMME
The planned instructions regarding fibroid uterus and its
management, which includes definition, types, symptoms, investigations and
treatment. It will be given to the women systematically
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4. KNOWLEDGE
It refers to the information possessed by the women before and after
STP as measured through questionnaire.
5. FIBROID UTERUS
It is the extra growth of muscles and fibrous tissue within the uterine
cavity.
6.7 ASSUMPTIONS

Focused teaching on fibroid uterus will prevent the complications.

Knowledge will influence the attitude and practice of the women.
6.8 CRITERIA FOR SELECTION OF SAMPLES
1. INCLUSION CRITERIA
Women who are:
-between age group of 30-45years.
-willing to participate in the study.
-belonging to selected community area.
.
2. EXCLUSION CRITERIA

Women who have developed fibroid uterus.

Women with systemic diseases like hypertension, diabetes mellitus etc
6.9 DELIMITATIONS
* Sample size is limited to 80 women between the age group of 30-45years.
* Prescribed data collection is 4-6 weeks.
6.10. SIGNIFICANCE OF THE STUDY
The significance of this study is to increase the knowledge of
7
women regarding fibroid uterus which will help them to prevent the complications
and decision making about the surgery and also prevent the maternal mortality and
morbidity.
6.11.CONCEPTUAL FRAMEWORK
It is based on Pender’s Health Promotion model.
.
6.12 REVIEW OF LITERATURE
Literature review helps to lay the foundations for the study. It provides
readers with a background for understanding current knowledge on a topic and illuminates
the significance of the new study13.
The investigator assembles knowledge by reviewing the literature of a
selected problem and is presented under the following headings:
a) Studies related to incidence and risk factors of fibroids.
A study was conducted was conducted to observe the frequency
of leiomyoma in relation to age, parity and clinical manifestation along with a review of its
management at Manipal, India. A total 150 cases were observed during the study period.
Greater frequency was found in the fourth (51%) and fifth (30%) decades of life.95% of
women were parous and 5% were nulliparous. The commonest mode of presentation was
menstrual disturbances (80.5%), such as menorrhagia and dysmenorrhea .Leiomyoma were
multiple in 65% and commonest variety was intramural (52%) Therefore the study
recommended that leiomyoma is a common benign gynecological tumor encountered by
gynecologist.14
A longitudinal study was conducted to determine the incidence,
etiology and epidemiology of uterine fibroids at UK, in 2008.Risk of fibroids in women
over the age of 45 years is more than 60% with the incidence higher in blacks than in
whites. The cause of fibroids remains unclear and their biology is poorly understood. The
key regulators of fibroid growth are ovarian steroids. Black race, heredity, null parity,
obesity, polycystic ovarian syndrome, diabetes and hypertension are associated with
increased risk of fibroids and there is emerging evidence that familial predisposition to
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fibroids is associated with a distinct pattern of clinical and molecular features compared
with fibroids in families without this prevalence.15
A prospective study was conducted with an objective to
investigate the risk of uterine leiomyoma in relation to reproductive factors and oral
contraceptive use at USA. Premenopausal nurses (n=95,061) aged 25-42 years with intact
uteri and no history of diagnosed uterine leiomyoma or cancer. Self reported leiomyoma
were in 243 cases. During 326,116 persons years of follow up, 3006 cases of uterine
leiomyoma was confirmed. The only notable association with any aspect of oral
contraceptive use was significantly elevated risk among women who first used oral
contraceptives at ages 13-16 years compared with those who had never used oral
contraceptives. Therefore, the study recommended that reproductive factors and oral
contraceptive use at a young age influence the risk of uterine leiomyoma among
premenopausal women.16
A systematic literature review was performed to determine whether
leiomyoma are associated with decreased fertility rates and whether surgical removal
increases fertility rates postoperatively in Virginia in 2001.results of studies comparing
women with fertility and fibroids versus infertile controls showed widely disparate results.
Subgroups analysis failed to indicate any effect on fertility of fibroids that did not have a
sub mucous component. Conversely, women with sub mucous myomas demonstrated
lower pregnancy rates (RR 0.3; 95%CI 0.3—0.70) and implantation rates (RR 0.28: 95%
CI 0.10—0.72) than infertile controls. Therefore the study data suggested that only those
fibroids with a sub mucosal or an intra cavitary component are associated with decreased
outcome, and that hysteroscopic myomectomy may be of benefit.17
b) Studies related to knowledge of women regarding fibroids and its management
A study was conducted to discover how women found out about uterine
fibroid embolisation for treatment of symptomatic uterine fibroids, at Durham, North
Carolina, in 2007.The study retrospectively tracked women from the beginning of their
illnesses and analyzed their information- seeking behaviors. 28 women who had the
9
procedure were interviewed. Median values and frequencies were calculated to represent
information needs, sources and perceived helpfulness. Although women expressed a great
need for almost all types of information, those with higher levels of education need to
know the reasons that their doctor had for suggesting treatments.Theefore the study
recommended that there is need to educate women through health sciences, librarians
about their health and treatment options.18
A survey was conducted to evaluate the opinions of gynecological and
interventional radiologist regarding uterine fibroid embolisation, at Toronto in 2006.The
study evaluated whether they educated patients regarding uterine fibroid embolisation,
together with their opinion of current and future effectiveness of uterine fibroid
embolisation, self related knowledge of fibroid treatment options. A total of gynecologist
(46.4% response rate) and 28 interventional radiologists (51.9% response rate) completed
the survey. After applying exclusion criteria the final study population was 82
gynecologists and 17 radiologists. Therefore the study recommends that need to educate
patients regarding uterine fibroid embolisation as a treatment option for fibroids.19
A study was conducted to develop the organized and effective
implementation of uterine fibroid embolisation at Canada in 2004.Uterine fibroid
embolisation has been evaluated in terms of patient satisfaction, risks of complications,
and risks in subsequent frequency and rate of hysterectomy within a few months of the
procedure .Patient preference is an important component of this evaluation. In evaluating
costs of uterine fibroid embolisation, the calculations should take into consideration the
cost of managing complications including subsequent hysterectomy. The study
recommended that women considering the treatment of fibroids should be counseled that
while the early results of uterine fibroid embolisation are encouraging and those who
choose uterine fibroid embolisation as an alternative to hysterectomy should be counseled
regarding complication of uterine fibroid embolisation.20
c) Studies related to management of fibroid
10
A study was conducted to determine the effectiveness of
uterine artery embolisation as a primary treatment of symptomatic fibroids, at, New Delhi,
India. The study was carried out in total of 32 patients aged 25-49 years (mean
40.9).Procedure was carried out through unilateral femoral puncture using poly vinyl
alcohol particles 355-500 micron in size. All the 32 patients had successful procedures.
Overall patients responded, giving a clinical success rate of 78.12%. Therefore the study
revealed that uterine artery embolisation leads to good technical success and fibroid
volume reduction.21
A prospective study was conducted to evaluate the
feasibility, complication and conversion rate of laparoscopic excision of very large
myomas at private endoscopic center, Mumbai, India. The patients were total 51 women
with at least one myomas larger than 9 cm were selected to perform laparoscopic
myomectomy.They removed 78 myomas lapraroscopically in these 51 patients. Three
patients had two myomas larger than 9 cm, three had two myomas between 5 and 9 cm and
one had three myomas between 5 & 9 cm. The largest myomas removed were 21 cm.
Therefore the study recommended that myomectomy by laparoscopy is a safe alternative to
laparotomy for very large myomas.22
A retrospective study was conducted to evaluate the pregnancy
outcome following laparoscopic myomectomy and single layer myometrial closure at,
Kerala, India. They evaluated outcomes of 115 women who had pregnancies subsequent to
laparoscopic myomectomy.Of the 217 women followed up, 115 had pregnancies
subsequent to laparoscopic myomectomy.Of 141 pregnancies, there were 87 caesarean
section, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no
incidents of uterine scar rupture in any of these pregnancies. Therefore the study concluded
that uterine rupture during pregnancies following laparoscopic myomectomy is rare
following single-layer myometrial closure.23
7. MATERIAL AND METHOD OF STUDY:
11
7.1 SOURCES OF DATA:
The data will be collected from the women in selected community
at Hassan.
7.2 RESEARCH DESIGN
A Pre- experimental, one group pre test and post test design.
Group
Pretest
Intervention
Post test
O1
X
O2
Purposively selected
women in a selected
community.
Key:
O1 = Pretest on knowledge.
X = Structured teaching programme regarding fibroid uterus
and its management.
O2 = Post test on knowledge.
7.3 METHODS OF DATA COLLECTION:
The collection of data will be through
SECTION A- Structured questionnaire to seek information about
Demographic data.
SECTION B- Structured closed ended questionnaire to seek
information on knowledge regarding various aspects of
fibroid uterus.
7.4
SAMPLING TECHNIQUE
Purposive sampling technique will be used.
7.5
POPULATION
All women aged between 30-35years.
7.6
SAMPLE
12
Women who fulfills the inclusion criteria.
7.7
SAMPLE SIZE
Sample size comprises of 80 women.
7.8
SETTING
The study will be conducted in selected community, Hassan.
8. VARIABLES
8.1 INDEPENDENT VARIABLE
Structured teaching programme on knowledge of fibroid uterus.
8.2 DEPENDENT VARIABLE
Knowledge of women regarding fibroid uterus.
9. PLAN FOR DATA ANALYSIS
9.1. DESCRIPTIVE OF INTERVENTION
Descriptive statistics: Demographic information and level of knowledge on
fibroid uterus will be given in frequencies with their percentage.
Knowledge score will be given in mean and standard deviation
Inferential statistics: Pretest and post test knowledge differences will be
analyzed using paired t- test and McNemars test.
Association between demographic variables and level of knowledge will be
analyzed using Pearson chi-square test.
9.2. PILOT STUDY
Pilot study is planned with 10% of population.
10. ETHICAL CONSIDERATION:
1. Does the study require any intervention to be conducted on women in a selected
community at Hassan?
13
Yes.
2. Has ethical clearance being obtained from your institution?
Yes.
3. Has consent taken from community area authorities?
Yes.
10. LIST OF REFERENCES
1. www.google.com
2
Philips T.Leiomyoma Uterus(Fibroid), North America, 2008 ,May 6
3 Statement by the society of Interventional radiology. Virginia.
4. Prakash T.Fibroids and infertility. Mumbai.2008, March 10.
5 Narendra K H. Research conclusion on treatment for the uterine myomas
( tumours) and ovarian cysts by Homeopathic Medicine.India.
[email protected]
6. [email protected].
7. Geetanjali J .More aware now, women check for Fibroids before Conceiving.
2008 October 19.
8. Nicholls.C, Glover L, Pistrang N.Jourenal of psychosomatic Obstetrics and
Gynaecology ,London 2004 September:295-304.
9.-Status of research on Uterine Fibroids (Leiomyomata uteri) at the National
Institute of Health 2006 March.
.
.
10. Stephenie T J, Mikulski.Uterine Fibroid research and Education Act of 2003.
2003 May 28.www.google.com
11. Nikil V K, Hemanth B. T Subash K R, Ajay P T.Obstetrics and Gynaecology
2001:98:[email protected].
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12. The HINDU- Staff Reporter Exclusive clinic to treat fibroid in Bangalore.
Friday September 22, 2008..
13. Polit D. F, Beck C T,Hungler B.T.Essentials of Nursing Research-Methods appraisal
utilization.5th edition.Pliadelphia: Lipiincot; 2001.
14.Rani A B, Pratap K N.Journal of Gynaecologic Surgery.2006 December 1;22(4):143150.
15. Okolos. Best practice Research Clinical and Obstetrical Gynaecology.2008 August:24
(4):571-88,E Pub 2008 June 4.
16 .Marshall L M.A prospective study of reproductive factors and oral contraceptive use
in relation to to the risk of Uterine Leiomyomata.1998.
17 . Pritts E A. Fibroids and Infertility: a systemic review of the evidence.2001 August:
56(8):483-91.
18. Ankem K. Information-seeking behavior of women in their path to an innovative
alternate treatment for symptomatic uterine fibroids. USA. 2006 June: 57(3):140-6.
[email protected].
19. Plaskos N P, Kachura J R. Survey of Gynaecologist and Interventional Radiologist
opinion of Uterine Fibroid Embolisation. Toronto.2000 March- April;29(2):188-91.
20. Kaiser P. Women hear about Uterine Fibroid Embolisation Treatment Option
Directly from Gynaecologist.2008 March.www.google.com.
21. Jain T P, Srivastava D N,Thulkar S, Sherma S, Mittal S et al. Uterine Artery
Embolization for Symptomatic fibroids with imaging follow up.India.2007 Jan- Feb:
14(1):123-7.
22. Sinha R, Hegde A, Warty N,Patil N.Laproscopic Exicision of very large
myomas.India.2007 Jul-Aug:14(4):453-62.
23. Paul P G, Koshy A K, Thomas T.Pregnancy outcomes following laproscopic
Myomectomy and single layer myometrial closure. India.2006 December:21(12):327881.E pub 2006 July 31.
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