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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
PROFORMA SYNOPSIS REGISTRATION OF SUBJECT FOR
DISSERTATION TITLE
TOPIC
A STUDY TO ASSESS THE EFFECTIVENESS OF AN INFORMATIONAL
BOOKLET REGARDING KNOWLEDGE OF CARDIAC EMERGENCY DRUGS
AMONG NURSES WORKING IN A SELECTED CARDIAC HOSPITAL AT
BANGALORE.
SUBMITTED BY:
MR. NICHOLAS PAUL
FIRST YEAR MSc NURSING STUDENT
GOLD FINCH COLLEGE OF NURSING
BANGLORE -92
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.
NAME OF THE CANDIDATE AND
ADDRESS
Mr.NICHOLAS PAUL
NO: 150/24, KODIGEHALLI MAIN
ROAD, MARUTHI NAGAR,
BANGALORE-92
2
NAME OF THE INSTITUTION
GOLD FINCH COLLEGE OF
NURSING
3
COURSE OF STUDY AND
SUBJECT
MASTERS OF SCIENCE IN
NURSING
MEDICAL & SURGICAL NURSING
SPECIALITY
4
5
DATE OF ADMISSION TO
COURSE
TITLE OF THE TOPIC
15/06/09
“ A STUDY TO ASSESS THE
EFFECTIVENESS
OF
AN
INFORMATIONAL
BOOKLET
REGARDING KNOWLEDGE OF
CARDIAC EMERGENCY DRUGS
AMONG NURSES WORKING IN A
SELECTED CARDIAC HOSPITAL
AT BANGALORE.”
6.0 BRIEF RESUME OF THE INDENTED WORK:
INTRODUCTION
“I hear, I forget; I see, I remember;
I do, I understand.”
Chinese proverb
Cardiovascular diseases are the most common cause of premature
death in developed countries. The National Service Framework for Coronary Heart Disease
(NSF CHD) sets out national standards for the prevention, diagnosis and treatment of CHD
including explicit recognition of the role of primary care teams. A further NSF chapter
'Arrhythmias and sudden cardiac death' was published in 2005,emphasising that patients with
long-term conditions may be managed in primary care. It also highlighted better access to
effective management of arrhythmias in all areas, including primary care.(1)
According to the American Heart Association the mission of many
organizations is providing optimal care to those with or at risk of developing CVD (primary
and secondary prevention), Over the past 2 decades, there have been dramatic increases in
knowledge concerning specific risk factors in atherosclerosis, hypertension, thrombosis, and
other forms of vascular dysfunction. Clinical trials have proven that strategies aimed at the
appropriate detection and modification of risk factors can slow progression of atherosclerosis,
diabetes mellitus, and hypertension and reduce the occurrence of clinical cardiovascular
events in both primary and secondary prevention settings. More recently, it has been shown
that atherosclerosis can be stabilized or even modestly reversed with appropriate cardiac
emergency drugs when followed with the right protocols specially by nurses. Finally, a new
and growing knowledge base of molecular genetics applied to the study of the cardiovascular
system has potential relevance to the clinical practice of preventive cardiovascular medicine
(ACCF/AHA/ACP 2009).(2)
The management and monitoring of prescribed medications has long been a
cause for concern. As a result of the potential adverse drug reactions associated with cardiac
emergency medication, clients are vulnerable to iatrogenic risk linked to physical health
problems.
The NASA Occupational Health Program (OHP) Principal Center
Office (PCO) is committed to ensuring the delivery of quality health services at NASA
Center OHP clinics. In order to ensure the health and safety of its employees, the OHP
clinics must follow best practices and comply with regulations in managing on site use of
medication. Policies and Procedures for the control, accountability and security of all drugs
used in NASA OH Clinics must be in place. The clinics must also ensure the competency of
their professional staff responsible for administering medications. Additionally, emergency
readiness standards and plans are a critical component to the medication management
program and must be in place.
The legal responsibility of the registered nurse in criticalcare settings
does not differ from that of the registered nurse in any work setting. The registered nurse
adheres to five principles for the protection of the patient and the practitioner. The most
common lawsuits against nurses and their employers are based on the legal concept of
malpractice, known as negligence by a professional.
Cardiac arrest teams are called upon to deal with many different acute
medical emergencies, including cardiac arrest. However, the drugs that are supplied for them
to perform their role differs vastly from hospital to hospital. The rational use of defibrillation
and drugs during cardiac emergencies has been standardised according to International
guidelines, and there is no reason why resuscitation kits could not also be standardised.
Further considerations of drug availability is needed for acute management of other collapsed
patients without cardiac arrest, most commonly vaso-vagal syncope, anaphylaxis,
hypoglycaemia, fits and respiratory arrest. A standardised format of drug kits and nurses
knowledge of these drugs for use by emergency health team could speed effective delivery of
emergency care.(3)
6.1 NEED FOR THE STUDY
It’s 3 AM on the cardiac unit. The night is progressing quietly when suddenly you hear
the nurse’s aide frantically yelling. “Call a code blue!” Immediately, your stomach begins to
turn inside out and your heart begins to race. Sound familiar?(nurse spectrum-emergency
drug therapy)
Quite often, the main fear experienced by nurses is related to administration of
emergency drugs. Familiarity with Advanced Cardiac Life Support (ACLS) emergency drug
therapy guidelines for treatment of cardiac arrhythmias can diminish your apprehension. The
American Heart Association (AHA) has formulated algorithms — protocols that prioritize
treatment modalities for life-threatening cardiac arrhythmias.
During a code, drug therapy is not your first priority. Your first priority is Airway,
Breathing, Circulation, Defibrillation, and determining a Differential Diagnosis. The AHA
Emergency Cardiac Care approach uses the mnemonic, ABCD, to remind us what to do in an
emergency situation. It is essential that first responders to a code perform high-quality CPR.
Good quality CPR skills are essential to all ACLS interventions.
Drugs, when required, play an important role in management of an arrest situation. Drug
administration should not interrupt CPR. Instead, drugs should be delivered during CPR if at
all possible. Drug therapy should be implemented after the ABCD survey, and after
accurately assessing the cardiac rhythm. In the event emergency cardiac drug therapy is
necessary, nurses will probably encounter one or more of the emergency cardiac drugs
during a code. Selection and timing of drugs for an arrest situation has been organized and
simplified by standards provided in the ACLS algorithms. They are evidence-based practices
that guide the use of emergency drugs derived from the American Heart Association and can
be found at (3)
Stead(2006) studied that every nurse can expect to be involved in the diagnosis
and treatment of medical emergencies during the course of clinical practice. These
emergencies may be directly related to hospital therapy, or they may simply occur by chance
in the external environment. Although minor medical emergencies occur predictably, a lifethreatening emergency may arise as infrequently and it is mandatory for nurses to have a
thorough knowledge in the cardiac unit.(4)
R.N. Krishnan et.al studied the the knowledge of staff nurses related to nursing
activities to be carried out in an emergency department (ED) and to compare their
demographic variables.The findings on knowledge of nursing activities to be carried out in an
ED revealed that most (34.78%) of staff nurses had average knowledge. Highest mean score
(1.94 ±1.54), which is 48.64%, was obtained by staff nurses in the area ‘equipment of ED’
and more or less similar mean score (5.72±2.12) which is 46.47% was in the area ‘records
and reports maintained in ED’. Average knowl edge and lowest mean score (4.2±2.3), i.e.
30% was obtained by staff nurses in the area ‘regular nursing activities of ED’. No significant
association (P<0.05) was found between knowledge scores of staff nurses in relation to their
demographic variables. Conclusions: From the findings, it can be concluded that level of
knowledge of staff nurses regarding nursing activities to be carried out in an ED was
inadequate. Hence, it can be suggested to have various educational sessions with practical
demonstration based on the learning needs of the staff nurses.
It is essential that Registered Nurses are able to treat patients effectively and promptly
in all emergency situations. The purpose of this study is to give the clinical information in
one document on the cardiac emergency drugs to staff nurses in an emergency situation, It is
recommended that this guideline is kept close to the resuscitation equipment and emergency
drugs. It will then be readily available in emergency situations.(5)
6.2. REVIEW OF LITERATURE
A review of literature is an essential aspect of research. One of the major functions of
review of literature is to ascertain what is already known in relation to the problem of interest
and will help in developing a broad conceptual framework in to which a research problem
will fit.(Polit and Hungler 2003)
Literature is presented under following headings
Section-A: Literature related to cardiac emergency drugs and its administration.
Section-B: Literature related to nurses working in the cardiac unit.
Section-C: Literature related to nurses knowledge regarding cardiac emergency drugs.
SECTION-A: LITERATURE RELATED TO CARDIAC EMERGENCY DRUGS AND
ITS ADMINISTRATION
Jane H. MS et .al said that medical errors have received a great deal of attention in
recent years. The phrase medical errors is an umbrella term for all errors that occur within the
health care system, including mishandled surgeries, diagnostic errors, equipment failures, and
medication errors. This article was a review and discussion of the literature on the scope of
medical errors, with a focus on drug-related problems and medication errors. Cost and quality
ideas for addressing these issues were provided.(6)
Bimla Sharma et.al studied the magnitude of the problem related Medical injuries
which account for 44,000-98,000 deaths per year in the United States and over 7000 of the
deaths are attributed to medication errors alone.The data may be reported under various
headings such as ADRs (adverse drug reactions), ADEs (adverse drug effects), medication
errors and adverse events (AEs). ADEs account for up to 7.5% of hospital admissions, 28%
of all emergency department visits and 5% of hospital deaths.6-8 In a comparative study of
in- tensive care and general care units, Cullen et al. Reported that the preventable and
potential ADEs in ICUs to be nearly twice that of non-ICUs.The purpose of this bachelor's
thesis was to chart scientific research articles to present contributing factors to medication
errors done by nurses in a hospital setting, and introduce methods to prevent medication
errors. Additionally, international and Finnish research was combined and findings were
reflected in relation to the Finnish health care system. Literature review was conducted out of
23 scientific articles. Data was searched systematically from CINAHL, MEDIC and
MEDLINE databases, and also manually. Literature was analysed and the findings combined
using inductive content analysis.Findings revealed that both organisational and individual
factors contributed to medication errors. High workload, communication breakdowns,
unsuitable working environment, distractions and interruptions, and similar medication
products were identified as organisational factors. Individual factors included nurses' inability
to follow protocol, inadequate knowledge of medications and personal qualities of the nurse.
Developing and improving the physical environment, error reporting, and medication
management protocols were emphasised as methods to prevent medication errors. Investing
to the staff's competence and well-being was also identified as a prevention method. The
number of Finnish articles was small, and therefore the applicability of the findings to
Finland is difficult to assess. However, the findings seem to fit to the Finnish health care
system relatively well. Further research is needed to identify those factors that contribute to
medication errors in Finland. This is a necessity for the development of methods to prevent
medication errors that fit in to the Finnish health care system.(7)
Elizabeth A.Henneman et.al made a study to gain insight into how nurses recover
medical errors in the emergency department (ED) setting. Methods The research method was
of exploratory descriptive design with qualitative analysis. Subjects who signed the informed
consent participated in one of four focus groups centering on nurse's role in recovering errors.
Questions were asked during the focus groups to elicit information regarding nurse's role in
the three phases of error recovery, namely, identifying, interrupting, and correcting the error.
Results Five themes emerged to describe methods used by nurses to identify errors in the ED
setting. These themes included: surveillance, anticipation, double checking, awareness of the
“big picture,” and experiential “knowing.” Five themes emerged as methods used to interrupt
errors: patient advocacy, offer of assistance, clarification, verbal interruption, and creation of
delay. The themes for correcting an error were assembling the team and involving leadership.
Conclusion, the results of this study provide preliminary evidence of the strategies used by
ED nurses in the recovery of medical error. Further research is needed to generalize these
findings to other ED settings. Knowledge of effective recovery strategies can ultimately be
used to develop interventions for reducing medical error and improving patient safety.(8)
Nancy M. Allen LaPointe et.al Background The Institute of Medicine's report To Err
Is Human: Building a Safer Health System recommends pharmacist participation in patient
rounds as an immediate approach to reducing medical errors. In the same report and in prior
publications, cardiovascular drugs have been commonly associated with severe adverse drug
events. Methods We systematically reviewed the experience of a clinical pharmacist on the
cardiology wards between September 1, 1995, and February 18, 2000. We classified
medication errors according to the type of error, medications involved, personnel involved,
stages of drug administration involved, and time of year most frequently associated with
errors. Results Among 14 983 pharmacist interventions, 4768 were related to medication
errors, or 24 medication errors per 100 admissions. The most common errors involved the
wrong drug (36.0%) or wrong dose (35.3%), and cardiovascular medications were involved
in 41.2% of the errors. Prescribers were associated with most of the errors, and the transition
from outpatient to inpatient was the most common point in the system for the occurrence of
these medication errors. Higher numbers of errors were also identified during the transition
period of house staff, and the total number of errors increased during the study period.
Conclusions - Through the clinical pharmacist's identification and correction of medication
errors, 2 areas of improvement that may reduce medication errors were identified. First is
ensuring accurate knowledge of a patient's outpatient medication regimen. The second
involves improving the education and support of new interns during their initial months of
training. This work exemplifies the approach recommended by the Institute of Medicine to
reduce medical errors through systematic analyses rather than ascribing fault to individuals or
the group.(9)
SECTION-B: LITERATURE RELATED TO NURSES WORKING IN THE
EMERGENCY UNITS
Lyn Dyson et.al studies show that ongoing education for the nursing workforce is
necessary to ensure currency of knowledge in order to enable evidence based client care. The
cost of education is high to the organisation and the individual, and must therefore be costeffective, relevant and appropriate. According to research, education for nurses is not always
systematically planned and developed and often relies on the interest area and assessment of
the nurse educators.Aim was to survey the learning needs of clinically based registered nurses
within an acute care setting. An anonymous questionnaire was used to collect the data. Two
groups completed the questionnaire: all eligible registered nurses in two acute care hospitals
located in urban New Zealand and their senior nurses such as clinical nurse managers,
specialists and educators. The study found agreement on learning needs and also noted
differing opinions between the Registered Nurses (RNs), and their senior RNs, RNs initially
registered overseas and between levels of practice, on selection and ranking of learning
needs. Conclusion -This survey identified a number of high learning needs for RNs working
within acute care settings. Differences in perception of learning needs for RNs, between the
nurses themselves and the Senior RNs exist, as well as among sub groups of RNs. As a result,
educators and managers are encouraged to collaborate to realise the opportunity which exists
for the provision of education across specialty areas and to work with the different groups
and the individual to ensure unique learning needs are met. (1)
Eliza Mi-Ling Wong et.al made a study research paper which aims to share with the
readers about the experience of emergency nursing development and related roles in Hong
Kong. The roles of emergency nurses are evolving and triggered by three major historical
milestones. The three milestones consist of: (1) Transition of nursing education from hospital
training to nursing degree program at universities in 1990; (2) The re-evolution after the
establishment of Hospital Authority in 1993; (3) Hong Kong’s return to China in 1997. These
milestones have contributed immensely to the development of quality nursing education,
nursing professionalism with emphasis on specialty knowledge and skill training in Accident
and Emergency departments (AED) in Hong Kong. Since 1991, the emergency nursing role
has been expanded and extended. Wound management remains one of the major extending
roles for emergency nurses, who confine themselves to manage simple wounds. Nurse
initiated tetanus immunization, intravenous access; investigations such as electrocardiogram,
blood glucose, and urinalysis are well implemented in all AEDs under the governance of
guidelines and protocols. Initial triage analgesic for the minor musculoskeletal injury and
fever are also part of the triage care in some AEDs in Hong Kong now. To meet the demand
and challenge, innovative role development such as lecturer practitioners and emergency
nurse practitioners have been piloted and implemented recently.Besides the normal duty,
emergency nurses also participate in the work outside the hospitals such as involvement in
emergency medical teams to assist in various rescue missions or volunteer for Flight Nursing
(Government Flying Services).However, the nursing shortage is another common problem
faced by the Hong Kong health care body. With the help of advanced technology, better pregraduate and specialty-training programs, Hong Kong health care strives to achieve the
highest standards of quality care. Emergency nursing role development in Hong Kong is
evolving and starts to chart its way to meet the demand.(11)
Hamilton, Rosemary presented this paper that reports a literature review examining
factors that enhance retention of knowledge and skills during and after resuscitation training,
in order to identify educational strategies that will optimize survival for victims of
cardiopulmonary arrest.Poor knowledge and skill retention following cardiopulmonary
resuscitation training for nursing and medical staff has been documented over the past 20
years. Cardiopulmonary resuscitation training is mandatory for nursing staff and is important
as nurses often discover the victims of in-hospital cardiac arrest. Many different methods of
improving this retention have been devised and evaluated. However, the content and style of
this training lack standardization. A literature review was undertaken using the Cumulative
Index to Nursing and Allied Health Literature, MEDLINE and British Nursing Index
databases and the keywords 'cardiopulmonary resuscitation', 'basic life support', 'advanced
life support' and 'training'. Papers published between 1992 and 2002 were obtained and their
reference lists scrutinized to identify secondary references, of these the ones published within
the same 10-year period were also included. Those published in the English language that
identified strategies to enhance the acquisition or retention of Cardiopulmonary resuscitation
skills and knowledge were included in the review. Results: One hundred and five primary and
157 secondary references were identified. Of these, 24 met the criteria and were included in
the final literature sample. Four studies were found pertaining to cardiac arrest simulation,
three to peer tuition, four to video self-instruction, three to the use of different resuscitation
guidelines, three to computer-based learning programmes, two to voice-activated manikins,
two to automated external defibrillators, one to self-instruction, one to gaming and the one to
the use of action cards.Resuscitation training should be based on in-hospital scenarios and
current evidence-based guidelines, including recognition of sick patients, and should be
taught using simulations of a variety of cardiac arrest scenarios. This will ensure that the
training reflects the potential situations that nurses may face in practice. Nurses in clinical
areas, who rarely see cardiac arrests, should receive automated external defibrillation training
and have access to defibrillators to prevent delays in resuscitation. Staff should be formally
assessed using a manikin with a feedback mechanism or an expert instructor to ensure that
chest compressions and ventilations are adequate at the time of training. Remedial training
must be provided as often as required. Resuscitation training equipment should be made
available at ward/unit level to allow self-study and practice to prevent deterioration between
updates. Video self-instruction has been shown to improve competence in resuscitation. An
in-hospital scenario-based video should be devised and tested to assess the efficacy of this
medium in resuscitation training for nurses. (12)
SECTION-C: LITERATURE RELATED TO NURSES KNOWLEDGE REGARDING
CARDIAC EMERGENCY DRUGS.
Pharmacology education in nursing has become increasingly important as nurses' roles
in administering, prescribing and educating patients about their medications have grown.
Some authors have expressed concern at the lack of science teaching in nurse education, and
others have suggested that there is a theory–practice gap in this area of the curriculum. This
paper reports a study to explore nurses' pharmacology education needs by identifying nursing
roles that require pharmacology knowledge, and nurses' preparation for practice from
preregistration pharmacology education. Method. A qualitative approach was used to collect
data from a purposive sample of 10 qualified nurses from an emergency admissions unit in a
city in the north of England. Semi-structured interviews were transcribed verbatim and
categorized using Burnard's 14 stages. Findings. This study revealed a limited understanding
of the subject, and dissatisfaction with the teaching of pharmacology, with resulting anxiety
on qualifying. Nursing roles identified as requiring pharmacology knowledge included drug
administration, patient assessment, nurse prescribing, and patient medication education.
Conclusion. The findings suggest that, although nurses have a limited understanding of
pharmacology, they recognize the need for pharmacology knowledge in practice. Improved
pharmacology teaching might increase nurses' confidence in performing drug administration,
patient education, and nurse prescribing, and decrease anxieties related to these roles.(13)
The effects of an educational program designed to improve nurses' knowledge of the
use of emergency medications in the pediatric intensive-care unit (PICU) are reported. The
clinical pharmacist for a six-bed PICU and a clinical nurse educator developed a program to
assess and extend PICU nurses' knowledge of emergency medications with respect to
calculations of bolus and continuous infusions, pharmacology, and proper dosage and
administration route. The program consisted of a pretest, a pharmacology lecture, calculation
problems, a hands-on practicum, and a posttest. Drugs covered were atropine sulfate, sodium
bicarbonate, calcium gluconate, calcium chloride, dopamine hydrochloride, dobutamine
hydrochloride, epinephrine hydrochloride, isoproterenol hydrochloride, lidocaine
hydrochloride, sodium nitroprusside, and norepinephrine bitartrate. A retest was given 13
months after the pretest. The program was completed by 21 nurses over seven months. There
was a significant difference between the mean pretest score, 69.5%, and the mean posttest
score, 87.3%, due to improvements in scores for the calculation questions. There was no
significant difference in the mean time required to complete the pretest and the posttest. A
significant correlation was observed between pretest score and months spent practicing in the
PICU. Time to take the retest was significantly shorter than the posttest time, and scores
continued to improve. An educational program developed cooperatively by pharmacy and
nursing improved specific measures of PICU nurses' knowledge of emergency drugs.(14)
Older adults continue to experience problems with their medications, such as adverse drug
events, incorrect use of prescription medications, and nonadherence to drug therapy. Using
the qualitative approach of naturalistic inquiry, 27 community-dwelling adults over age 74
were interviewed and encouraged to describe situations or variables that help or hinder in
their cardiovascular medication management processes. Helpful strategies included
simplification, use of visual and tactile cues, and development of a medication routine.
Hindering situations included decreased mental or sensory alertness, getting out of the
routine, and not feeling well. Nurses can devise assessment and interventional methodologies
from the themes described.(15)
This paper explores clinical nurses’ perceptions and experiences of graduate nurses’
pharmacology knowledge. Six focus group interviews were conducted with clinical nurses of
various appointment levels at two metropolitan public and two regional public hospitals in
Victoria, Australia. Four major themes emerged from the study. First, participants indicated
that graduate nurses had an overall lack of depth of pharmacology knowledge. While clinical
nurses indicated that graduate nurses had enormous deficits in their pharmacology education,
these deficits were not confined to graduate nurses—all nurses experienced difficulties in
understanding and demonstrating pharmacological concepts in the clinical practice setting.
Second, there was an unstructured approach to addressing the continuing education needs of
graduate nurses. Third, theoretical and clinical principles of pharmacology knowledge were
perceived to be important for practice. Fourth, improvements for nursing education involved
the need for undergraduate students to take greater responsibility in monitoring and
administering medications and the need for more structured learning experiences. The
ultimate goal of consolidating pharmacology knowledge for graduate nurses is to optimise
medication use, thereby improving the health outcomes of patients. Current teaching and
learning opportunities appear to be inadequate in their efforts to enhance and improve gradu ate nurses’ pharmacology knowledge. These inadequacies need to be addressed if the
ultimate goal is to become a reality.(16)
Cardiovascular diseases constitute the most common health problems in very old
people. Consequently, cardiovascular drugs are the medicines that are most frequently used
by elderly subjects. Although many studies have examined the physiological effect and
adverse reactions of these drugs, knowledge on their effect on emotional well-being is
missing. The present study aims to examine the association between cardiovascular diseases
and their medical treatment on the emotional well-being of very old people. We investigated
a representative group of elderly subjects gathered from a population-based study (n = 235).
Participants were 84 years or older and cognitively intact (mini-mental state examination
(MMSE) ≥24 points). Well-being was assessed with the positive and negative affect schedule
(PANAS), measuring different mood categories. Cardiovascular diseases were diagnosed
following the International Classification of Diseases. In this population the prevalence of
cardiovascular diseases was high (62%). Multivariate regression analysis showed that while
being affected by a cardiovascular disease did not affect the emotional well-being of the
subjects (PANAS-PA, p = 0.171; PANAS-NA, p = 0.209), the use of some cardiovascular
drugs showed an association. Cardiac glycosides (p = 0.006) and nitrates (p = 0.008) were
associated with increased negative feelings. Due to high prevalence of cardiovascular
diseases and use of cardiovascular medicines, this finding has relevance on the quality of life
of elderly people. However, due to the nature of this study we cannot assess cause–effect
relationship of this positive association. Therefore, the present findings suggest that there is a
need for clinical studies in this increasing and limited studied age group.(17)
Adverse drug reactions (ADRs) occur frequently in modern medical practice,
increasing morbidity and mortality and inflating the cost of care. Patients with cardiovascular
disease are particularly vulnerable to ADRs due to their advanced age, polypharmacy, and the
influence of heart disease on drug metabolism. The ADR potential for a particular
cardiovascular drug varies with the individual, the disease being treated, and the extent of
exposure to other drugs. Knowledge of this complex interplay between patient, drug, and
disease is a critical component of safe and effective cardiovascular disease management. The
majority of significant ADRs involving cardiovascular drugs are predictable and therefore
preventable. Better patient education, avoidance of polypharmacy, and clear communication
between physicians, pharmacists, and patients, particularly during the transition between the
inpatient to outpatient settings, can substantially reduce ADR risk.(18)
The National Emergency Department Safety Study (NEDSS) responded to the need for
methods to reduce error with a focus on the correction of suboptimal safety processes in
emergency health care. The effects of an educational program designed to improve nurses'
knowledge of the use of emergency medications in the pediatric intensive-care unit (PICU)
are reported. The clinical pharmacist for a six-bed PICU and a clinical nurse educator
developed a program to assess and extend PICU nurses' knowledge of emergency
medications with respect to calculations of bolus and continuous infusions, pharmacology,
and proper dosage and administration route. The program consisted of a pretest, a
pharmacology lecture, calculation problems, a hands-on practicum, and a posttest. Drugs
covered were atropine sulfate, sodium bicarbonate, calcium gluconate, calcium chloride,
dopamine hydrochloride, dobutamine hydrochloride, epinephrine hydrochloride,
isoproterenol hydrochloride, lidocaine hydrochloride, sodium nitroprusside, and
norepinephrine bitartrate. A retest was given 13 months after the pretest. The program was
completed by 21 nurses over seven months. There was a significant difference between the
mean pretest score, 69.5%, and the mean posttest score, 87.3%, due to improvements in
scores for the calculation questions. There was no significant difference in the mean time
required to complete the pretest and the posttest. A significant correlation was observed
between pretest score and months spent practicing in the PICU. Time to take the retest was
significantly shorter than the posttest time, and scores continued to improve. An educational
program developed cooperatively by pharmacy and nursing improved specific measures of
PICU nurses' knowledge of emergency drugs.(19)
6.3. STATEMENT OF THE PROBLEM
“ A STUDY TO ASSESS THE EFFECTIVENESS OF AN INFORMATIONAL
BOOKLET REGARDING KNOWLEDGE OF CARDIAC EMERGENCY DRUGS
AMONG NURSES WORKING IN A SELECTED CARDIAC HOSPITAL AT
BANGALORE.”
6.4. OBJECTIVES OF THE STUDY
1. To assess the pre test scores of staff nurses regarding cardiac emergency drugs among
nurses working in cardiac hospital
2. To develop an informational booklet
3. To assess the post test scores of staff nurses regarding cardiac emergency drugs
among nurses working in the cardiac hospital.
6.5. HYPOTHESIS

H 1: There will be significant difference in the pre and post test knowledge
scores regarding cardiac emergency drugs among staff nurses working in cardiac
hospitals.

H 2: There will be significant association between the selected demographic
variables and pre test knowledge scores of staff nurses

H 3: There will be significant association between the selected demographic
variables and post test knowledge scores of staff nurses.
6.6. OPERATIONAL DEFINITIONS:
Assess- Statistical measurement of cardiac nurses knowledge regarding cardiac emergency
drugs and their usage
Effectiveness- The maximum efficiency with which a tool measures the knowledge of
cardiac staff nurses
Informational Booklet – It refers to the well-planned information regarding cardiac
emergency drugs and their proper usage
Knowledge- It refers to knowledge or awareness of staff nurses regarding cardiac
emergency drugs and thier usage.
Cardiac emergency drugs- It refers to drugs used as a life saving agents in the cardiac
hospitals which have therapeutic and preventive actions on the cardiovascular system.
Cardiac hospital- it refers to a hospital specialized in treating cardiac patients.
6.7. ASSUMPTIONS:
Staff nurses are expected to have minimum knowledge regarding cardiac emergency
drugs. By providing an informational booklet the knowledge of staff nurses regarding cardiac
emergency drugs are expected to increase.
6.8. DELIMITATIONS:
Study is delimitated to
- individual staff nurses who are working in a selected cardiac hospital.
- staff nurses who are working in cardiac hospitals.
6.9. PROJECTED OUTCOME:
 The study will reveal the statistical difference of pre and post test knowledge scores
regarding cardiac emergency drugs. The informational booklet will provide adequate
information regarding cardiac emergency drugs.
7.0. MATERIALS AND METHODS
7.1 SOURCE OF DATA:
Staff nurses working in a cardiac hospital
7.1.1.RESEARCH DESIGN AND APPROACH:
Experimental design and evaluative approach
7.1.2. SETTING
Selected cardiac hospital at Bangalore
7.1.3. POPULATION
Staff nurses working in cardiac hospital
7.2 METHODS OF DATA COLLECTION
7.2.1 SAMPLING TECHNIQUE:
Simple random sampling technique
7.2.2 VARIABLES:
DEPENDENT VARIABLE-Knowledge of staff nurses working in a cardiac hospital
INDEPENDENT VARIABLE-Informational booklet regarding cardiac emergency drugs
7.2.3. SAMPLE SIZE: 60
7.2.4. DURATION OF STUDY- 4 weeks
7.2.5. INCLUSION CRITERIA FOR SAMPLING
- Staff nurse who are available at the time of data collection.
Hospital which is specialised in cardiac care
7.2.6. EXCLUSION CRITERIA FOR SAMPLING
- Staff nurses who are not willing to participate.
7.2.7 INSTRUMENT INTENDED TO MEASURE:
-Structured knowledge questionnaire will be used to assess the knowledge level of nurses
regarding cardiac emergency drugs used in the cardiac hospital.
7.2.8 DATA COLLECTION:
Permission will be obtained from the concerned authorities. Written consent will be obtained
from the study participants.
7.2.9 DELIMITATIONS
The study is delimited to
- individual staff nurses who are working in a selected cardiac hospital.
- staff nurses who are working in cardiac hospitals.
7.2.10 PILOT STUDY PLAN
A sample of 6 staff nurses who are working in cardiac hospital will be selected and
informational booklet will be provided and pilot study will be performed
7.2.11. PLAN FOR ANALYSIS
- the collected data will be entered in a master sheet,the mean median and mode will be used
to analyze the percentage distribution of selected demographic variables. The chi square test
will be done to analyze the association between selected demographic variables and
knowledge regarding cardiac emergency drugs.
7.3. Does the study require any investigation or interventions to be conducted on
patients or other humans or animals? If so, please describe briefly.
NO
7.4.Has ethical clearance been obtained from your institution in case of 7.3?
- Informed consent from the subjects will be sought. Permission from authorities will be
sought before the study is progressed
LIST OF REFERENCES:
1. (NSF CHD) 2005 National Service Framework for Coronary Heart Disease journal.
2. (ACCF/AHA/ACP 2009). American Heart Association clinical practice of
preventive cardiovascular medicine.
3. NASA Occupational Health Program (OHP) Principal Center
Office,http://circ.ahajournals.org/content/vol112/22_suppl.
4. Stead et.al emergency medicine- home-school 2006
5. R.N. Krishnan, P. Krishnan, K. Darshan (Vinayaka Missions Annapoorna College of
Nursing, Salem) Int J Emerg Med (2009) pg:59–65DOI 10.1007/s12245-009-0094-y
6. Jane H. MS, RN; Warnick, Myrna L. MSN, RN Medical Errors, Drug-Related
Problems, and Medication Errors: A Literature Review on Quality of Care and Cost
Issues Lassetter, © 2003 Lippincott Williams & Wilkins.http://www.lww.com/
7. Bimla Sharma1, Abhijit Bhattacharya2, Ranju Gandhi3, Jayshree Sood4, B K Rao5
Indian Journal of Anaesthesia 2008; 52 (4) pg:373-384 Pharmacovigilance in
Intensive Care Unit An Overview
8. Elizabeth A. Henneman, RN, PhDa , Fidela S.J. Blank, RN, MN, MBAb1 ,
Anna Gawlinski, RN, DNScc2 , Philip L. Henneman, MDd Strategies used by nurses
to recover medical errors in an emergency department setting May 2005
9. Nancy M. Allen LaPointe, PharmD; James G. Jollis, MD Medication Errors in
Hospitalized Cardiovascular Patients Arch Intern Med. 2003;163:1461-1466.
10. Lyn Dyson, Bronwyn Hedgecock , Sharon Tomkins, Gordon Cooke Accepted 9
April 2009. published online 20 May 2009.Learning needs assessment for registered
nurses in two large acute care hospitals in Urban New Zealand
http://www.nurseeducationtoday.com/article/S0260-6917%2809%290008
11. Eliza Mi-Ling Wong, MN, MHA, RN, RM, RTN (Teaching Consultant, Former AED
Lecturer Practitioner and Ping Fat Lau, MPh, BScN, RN (Nurse Specialist) .Evolving
towards professionalism in emergency nursing in Hong Kong. 20 November 2007;
12. Hamilton, Rosemary MSc RN.Nurses' knowledge and skill retention following
cardiopulmonary resuscitation training: a review of the literature. Journal of
Advanced Nursing. 51(3):288-297, August 2005.
13. CRETRY.Nurses' perceptions of their pharmacology educational
needshttp://www3.interscience.wiley.com/journal/118779209/abstract=1&SRETRY ,
21October 2003
14. DM Kraus, J Stifter, and HT Hatoum-Program to improve nurses' knowledge of
pediatric emergency medications. Article 32.p 67-69.August 2007
15. Susan L. Swanlund, PhD, RN Successful cardiovascular medication management
processes as perceived by community-dwelling adults over age 74. pg 06-10. 16th
January 2009.
16. Elizabeth Maniasa, Shane Bullockb. The educational preparation of undergraduate
nursing students in pharmacology: clinical nurses’ perceptions and experiences of
graduate nurses’ medication knowledge. 21 December 2001.
http://www.journalofnursingstudies.com/article/S0020-7489%2802%2900008-1
17. Margareta Westerbotnabc , Hedda Agüero-Torresbc, Johan Fastbombc,
Pernilla Hilleråsabc. A population-based study on well-being in the very old: the role
of cardiovascular diseases and drugs ,article 13.14 March 2005.
18. Michael D. Faulx, MD, FACC, Gary S. Francis, MD, FACC, FAHA, FACP
Adverse Drug Reactions in Patients with Cardiovascular Disease articleId
medlinePmidWithoutMDLNPrefix=nurses+knowledge+on+cardiovascular+drug
http://www.cpcardiology
19. DM Kraus, J Stifter, and HT Hatoum.Program to improve nurses' knowledge of
pediatric emergency medications.The National Emergency Department Safety Study
(NEDSS) journal
WEBSITES:
1. http://circ.ahajournals.org
2. http://circ.ahajournals.org
3. http://www.lww.com
4. http://www.appliednursingresearch.org
5. http://www.nurseeducationtoday.com
6. http://www.internationalemergencynursing.com
7. http://www3.interscience.wiley.com
8. http://www.journalofnursingstudies.com
9. http://www.cpcardiology.com
10. http://www.nedssjournals.org
9.
SIGNATURE OF THE CANDIDATE
10.
REMARKS OF THE GUIDE
It helps to improve the knowledge of
staff nurses regarding cardiac
emergency drugs
11.
NAME AND DESIGNATION OF
(in block letters)
11.1. GUIDE
Prof.Mr. PAULRAJ. S
ASSOCIATE PROFESSOR,
GOLDFINCH COLLEGE OF
NURSING, BANGALORE.
11.2. SIGNATURE
11.3.CO-GUIDE( IF ANY)
11.4. SIGNATURE
NIL
NIL
11.5. HEAD OF THE
Prof.Mr. PAUL RAJ. S
DEPARTMENT
ASSOCIATE PROFESSOR,
GOLDFINCH COLLEGE OF
NURSING, BANGALORE.
11.6. SIGNATURE
12.
12.1. REMARKS OF THE
It helps to update staff nurses
CHAIRMAN/ PRINCIPAL
knowledge regarding drug
administration
12.2 .SIGNATURE
1.