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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
Ms. SUBIJA.D
First year M.Sc Nursing
Obstetrics and Gynecological nursing
Year 2008-2009.
PADMASHREE INSTITUTE OF NURSING
NAGARBHAVI,
BANGALORE – 560072.
0
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1
NAME OF THE CANDIDATE MS. SUBIJA.D
I Year M.Sc. Nursing,
AND ADDRESS
Padmashree Institute of Nursing,
Nagarbhavi,
Bangalore
2
NAME OF THE INSTITUTE
3
COURSE OF THE STUDY AND I Year M.Sc Nursing,
Obstetrics and Gynecological
SUBJECT
Nursing
4
DATE OF ADMISSION
30th June 2008
5
TITLE OF THE STUDY
Assessment of effectiveness of
structured teaching programme
on
knowledge
regarding
management of hyperemesis
gravidarum among primi gravida
mothers.
Padmashree Institute of Nursing
Bangalore
1
6. BRIEF RESUME OF THE INTENDED WORK:
6.1 INTRODUCTION: Hyperemesis gravidarum means excessive vomiting during pregnancy. In
pregnant women, nausea and vomiting (morning sickness) are common affecting
up to 80% of pregnancies and hyperemesis gravidarum occur in about 1% of
pregnancies. Hyperemesis is seen more often in primigravida pregnancies and
multiple pregnancies (twins, triplets etc).1
The etiology of hyperemisis is uncertain, with multifactorial causes such as
endocrine, gasterointestinal and psychological factors proposed. Rising levels of
oestrogen and Human Chorionic Gondotrophin hormones appear to be significant.
Hyperemesis occurs more often when mothers have a multiple pregnancy or a
hydatiform mole, both of which are associated with increased hormone levels.
Infection with helicobacter pylori, the organism implicated in gastric ulcers may
also contribute. Women with a previous history of hyperemisis are likely to
experience in subsequent pregnancies. 2
Many risk factors are associated with severe nausea and vomiting in
pregnancy including younger maternal age. Null parity, low socioeconomic status,
unplanned pregnancy, passive smoking, previous pregnancy with nausea and
vomiting in pregnancy, increased body mass index, eating disorders, ethnicity and
fetal female gender (suggesting an immune mechanisms). 3
Hyperemesis gravidarum remains a puzzling condition for both physicians
and patients because there is no known cause or cure. Yet, the exact causal
2
pathophysiological mechanism is unknown; the organicity of the pregnant state is
either minimized or ignored. This paper examines how hyperemesis gravidarum is
characterized in the literature and the empirical basis for psychogenesis analysis of
the literature reveals a tension in the discourse such that both biologic and
psychological approaches to hyperemesis gravidarum have existed in parallel
tracks throughout the history. Still, results support that sociocultural factors rather
than scientific evidence have shaped the overarching and predominant illness
paradigm of psychogenesis.4
The main symptom of hyperemesis gravidarum is severe vomiting, which
causes dehydration and weight loss. Women with this condition will start to show
signs of starvation including weight loss. Physical examination and laboratory
tests of blood and urine samples will be used to help to diagnose the condition.
One of the most common tests used to help diagnosis and monitor hyperemesis
gravidarum is a test for ketones in the urine. Excessive ketonuria indicate that the
body is not using carbohydrates from food as full and is inadequately trying to
break down fat as fuel. Ketonuria is a sign that the body is beginning to operate in
starvation mode.
The management of hyperemesis gravidarum based on three main principles
are to control vomiting, to correct the fluids, electrolytes and other metabolic
disturbances promptly and effectively and to prevent or to detect the earliest, the
ominous complications that may arise.5
Treatment and hospitalization are often required. Intravenous fluids with
substances that help the body conduct nerve signals (electrolytes) may be given to
correct the dehydration and excessive acid in the blood (acidosis). Antinausea or
sedative medications may be given by injection to stop the vomiting. If food
cannot be tolerated at all, intravenous nutritional supplements may be necessary.
3
Injections of vitamin B6, in particular, may help overcome nutritional deficiencies
that often occur. The alternative treatments for these severe vomiting associated
with hyperemesis gravidarum require medical attention. Milder episodes of nausea
or vomiting may be reduced with deep breathing and relaxation exercises. The use
of other balance remedies should be done with extreme caution during pregnancy,
especially in the first trimester.6
Natural remedies to reduce nausea include a teaspoon of cider vinegar in a
cup of warm water or tea made from anise, fennel seed, red raspberry, and a
ginger. Wristbands can be positioned over acupressure points on both writs.
Aromatherapy with lavender, large or chamomile can be soothing as can smelling
ground ginger. Homeopathic remedies which age extremely diluted solutions, as
treatments can be safe and effective for controlling symptoms in some women.
Prognosis, in virtually all cases the pregnancy can continue to the successful
delivery of a healthy baby.
Prevention although there is no evidence that
hyperemesis gravidarum can be prevented; vomiting during pregnancy sometimes
may be lessened.
Maintaining a healthy diet, getting adequate sleep and
controlling stress may contribute to prevention of improvement as systems.
Several strategies may help lessen the nausea and vomiting. Eating dry foods
and limiting fluid intake may also be helpful. Small meals should be eating
frequently throughout the day, with a protein snack at night. Eating soda crackers
before rising from bed in a morning may help prevent early morning nausea. Iron
supplements may cause nausea and can be eliminated until the nausea is controlled
Sitting upright for 45 minutes after meals may also help.
Hyperemsis gravidarum is one of the high-risk problems during the antenatal
period. Mainly it occurs in first and second trimester of pregnancy. If the antenatal
4
mother knows the complication and its management of hyperemsis gravidarum, it
can prevent the maternal and fetal from complications.
6.2 NEED FOR THE STUDY
Excessive nausea and vomiting that start between 4 to 10 weeks gestation
and resolve before 20 weeks, requiring intervention are known as hyperemesis
gravidarum. It affects 0.3-3% of all pregnant women, this is associated with
dehydration, electrolyte imbalance and weight loss of up to 10% of prepregnant
weight and should not be confused with the common symptoms of nausea and
vomiting of pregnancy that are self-limiting.
Hyperemesis gravidarum causes uncontrollable vomiting, severe dehydration
and muscle wasting in pregnancy and usually requires weeks or months of
intravenous fluid therapy.7 If hyperemesis gravidarum is left untreated the
mother’s condition worsens. Wernicke’s encephalopathy is a complication
associated with a lack of vitamin B1 (thiamine). Hepatic and renal involvement
leads to coma and death. Termination of pregnancy may reverse the condition and
has a place in preventing maternal mortality. Hyperemesis gravidarum persisting
into the third trimester should be further investigated.
The biggest danger with hyperemesis gravidarum is that the women will
become dehydration and no longer be able to provide the fetus with essential
nutrients for growth. Prolonged hospitalization or home care with this disorder
may result in social isolation. 8
Hyperemesis gravidarum is a high-risk problem because it increases chances
for pregnancy loss, intra uterine growth retardation, maternal activity restriction,
fatigue and depression.9
5
The impact of nausea and vomiting on the women and her daily life
should not be underestimated. The midwife should enquire of all women attending
early antenatal whether they are experiencing nausea and vomiting. Causes of
vomiting not due to pregnancy, such as thyroid problem, urinary tract infection or
gastroenteritis, need to be excluded. Diagnosis is made where there is a history of
persistent, severe nausea and vomiting in early pregnancy. A mother suspected of
suffering from hyperemesis presents, as being unable to retain food or fluids. She
may have lost weight and be distressed and debilitative by her symptoms. The
woman requires admission to hospital for assessment and management of
symptoms.
Mothers need information to ensure they can make informed choices about
care and consent to treatment. If mothers have knowledge regarding management
of hyperemesis gravidarum they may be able to prevent from the above
complications. Hence the investigator felt need to conduct the study and educate
the primi gravida mother regarding management of hyperemesis gravidarum.
6
6.3 STATEMENT OF THE PROBLEM: A study to assess the effectiveness of structured teaching programme on
knowledge regarding management of hyperemesis gravidarum among primigravida mothers in selected hospitals, Bangalore.
6.4 OBJECTIVES: 1) To assess the pretest knowledge regarding management of hyperemesis
gravidarum among primi gravida mothers.
2) To assess the posttest knowledge regarding management of hyperemesis
gravidarum among primigravida mothers.
3) To assess the effectiveness of structured teaching programme regarding
management of hyperemesis gravidarum among primi gravida mothers.
4) To associate the posttest knowledge regarding management of hyperemesis
gravidarum among primigravida mothers with their selected demographic
variables.
6.5 OPERATIONAL DEFINITIONS: 1) Effectiveness: It refers to the increase in the level of knowledge of primi gravida mothers
after receiving structured teaching progamme on management of hyperemesis
gravidarum.
2) Structured teaching programme: It refers to systematically developed instructional aids designed for
primigravida mothers on aspects of management of hyperemesis gravidarum.
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3) Knowledge: It refers to the level of understanding and the ability to answer on the
management of hyperemesis gravidarum by the primi gravida mothers as elicited
through structured questionnaire.
4) Hyperemesis gravidarum: This refers to severe type of vomiting of pregnancy which has got
deleterious effect on the health of the mother and incapacitates her in day to day
activities.
5) Primigravida mother: It refers to the women who are pregnant for first time.
.6.6 ASSUMPTIONS: -
1) The primigravida mothers may have inadequate knowledge on management
of hyperemesis gravidarum.
2) Administering the structured teaching programme may improve the
knowledge regarding management of hyperemesis gravidarum among primi
gravida mothers.
6.7 RESEARCH HYPOTHESIS: H1 – There is significant difference between mean pretest and posttest knowledge
regarding the management of hyperemesis gravidarum in primi gravida mothers.
H2 – There is significant association between the posttest knowledge regarding
management of hyperemesis gravidarum among primi gravida with their selected
demographic variables.
8
6.8 REVIEW OF LITERATURE
Review of literature is an important source for development of research
project. It helps to gain insight into the research problem and provide information
of what has been done previously. It helps the researchers to be familiar with the
existing studies, provide basis for future investigation and helps to develop the
methodology, tools for data collection and research design.10
A comparative study was conducted to assess the three out patient regimens in
the management of nausea and vomiting in pregnancy. This study compares
pyridoxine-metoclopramide
combination
therapy to
prochlorperazine
and
promethazine monotherapies in the outpatient treatment of nausea and vomiting in
pregnancy. In total, 174 first trimesters, singleton pregnancies were evaluated for
nausea and vomiting. The study conclude that their were no differences in the
number of emesis responses to treatment differed among the objective responses
to treatment differed among the three groups when comparing combination
therapy to the monotherapies. 11
A descriptive study was conducted to identify factors commonly reported by
women that alleviate their symptoms of Nausea and vomiting in pregnancy. It
state that nausea and vomiting in pregnancy is a multi faceted condition. Lifestyle
changes including validation, supportive counseling and dietary adjustments are
important components that can be used to council women with nausea and
vomiting in pregnancy, concomitantly with safe and affective treatment.12
An experimental study was conducted about hyperemesis Beliefs Scale
(HBS), a new instrument for assessing patient perception factors of hyperemesis
gravidarum (HG) that influence reported patient satisfaction with medical care.
The findings revealed that exploratory factor analyses of patient and physician
versions of the hyperemesis beliefs scale demonstrated broad support for the
9
hypothesized factor structure. First, the patient items exhibited two causal factors
(general and personal), whereas the physician items showed only a single causal
factor. Second, in the patient version, items assessing the impact of hyperemesis
gravidarum on the babies' health loaded separately from the rest of the items in the
HBS, whereas the analyses of the corresponding physician items indicated that the
baby items loaded well on the degree of seriousness factor.13
A descriptive study was conducted to determine what advice and support to be
given for women experiencing nausea and vomiting in pregnancy, with a
particular interest in and how herbal and alternative therapies are prescribed. The
finding revealed that advice most commonly given to women experiencing and
vomiting was to eat frequent small meals and snacks (91%). avoid of fatty/spicy
foods (53%); eating before rising in the morning, e.g. consumption of dry
biscuits/toast (51%); and keep hydrates (49%). Most midwives (39*46, 85%)
included some for of vitamin or herbal supplement in their advice for nausea and
vomiting in pregnancy; however, many were unaware of potential harmful side
effects or what would constitute appropriate doses.14
A comparative study was conducted to evaluate the obstetric and medical
complications with hypermesis gravidarum, comparing those who are supported
with total parental nutrition (TPN group) and who did not receive total parental
nutrition (Non-TPN group). The study concludes that the parental nutrition group
had a marked and significant increase in serious complication directly related to
parental nutrition use. These data suggest that great care should be taken to assess
the need for parental therapy in patients with hypermesis gravidarum.15
A descriptive study was conducted to assess the effects of different
methods of treating nausea and vomiting in early pregnancy. The findings revealed
that the twenty-eight trials met the inclusion criteria. Nausea treatments were
10
different antihistamine medications, Vitamin B6 (Pyridoxine). The combination
tablet dehendox occurrence and ginger based on R trials; there was an overall
reduction in nausea for antiemetic medication. The study concludes that antiemetic mediation appears to reduce the frequencies of nausea in early pregnancy.16
A descriptive study was conducted about the high prevalence of severe
nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives
of affected individuals. At the results, approximately 29% of cases reported their
mothers had severe nausea and vomiting or hyperemesis gravidarum while
pregnant with them of the 721sisters with a pregnancy history 137 (19%) had
hyperemesis gravidarum. The finding revealed that the most severe cases, those
requiring total potential nutrition or naso gastric feeding tube, the proportions of
effected sisters was even higher, 491 198 (25%) nine percent of cases reported
having at least two confected relatives including sister, mothers, grand mothers,
daughters, aunt and causing.17
A descriptive study was conducted to determine evaluate maternal and
neonatal outcomes among women with hyperemesis during pregnancy.
Hyperemetic pregnancies were defined as those requiring one or more antepartum
admissions for hyperemesis before 24 weeks of gestation. Severity of hyperemesis
was evaluated according to the number of antenatal hospital admissions (1 or 2
versus 3 or more) and according to weight gain during pregnancy (< 7 kg [15.4 lb]
versus 7 kg). The finding revealed that maternal outcomes evaluated included
weight gain during pregnancy, gestational diabetes, gestational hypertension, labor
induction, and cesarean delivery. Neonatal outcomes included 5-minute Apgar
score of less than 7, low birth weight, small for gestational age, preterm delivery,
and perinatal death.18
A cohert study was conducted to assess whether
maternal pregnancies
body mass index was associated with the use of antimetric drugs in early
11
pregnancy and or with the occurrence of hypermesis gravidarum. The findings
revealed that underweight pregnant women were more likely to use antimetric
drugs to become hospitalized hypermesis gravidarum compared to over weight
women. Obese women were less likely to use antimetric drugs less likely to
require hospitalization because of hypermesis gravidarum.19
An experimental study was conducted to determine if ginger syrup mixed
in water is an effective remedy of the relied of nausea and vomiting in the first
trimester of pregnancy. The finding revealed that after days 10 of the 13(77%)
subjects receiving ginger had at least a 4-point improvement on the nausea scale
only 2 of the 10 (20%) remaining subjects in the placebo group had the same
improve conversely, no women in the ginger group but 7(70%) of the women in
the placebo group, had a 2 point or less improvement on the nausea scale. Right of
the 12(67%) women in the ginger group who were vomiting daily at the beginning
of the treatment were vomiting daily at the beginning of the treatment stopped
vomiting by day 6. only 2 of the 10(20% women in the placebo group who were
vomiting stopped by day. The findings concluded that the ingestion of 19 of ginger
in syrup in a divided dose daily may be useful in some patients experiencing
nausea and vomiting in the first trimester of pregnancies.20
12
7. MATERIALS AND METHODS OF STUDY:
7.1 SOURCES OF DATA: The data will be collected from the primigravida mothers attending antenatal
OPD and admitted in the antenatal ward in selected hospitals, Bangalore.
7.2 METHOD OF DATA COLLECTION: -
I. Research design:
Quasi-experimental - one group pretest post test design.
II. Research variables:
a) Independent variable: - Structured teaching programmme on knowledge
regarding management of hyperemensis gravidarum.
b) Dependent variable: -level of knowledge of primigravida regarding
management of hyperemesis gravidarums.
III. Settings:
The study will be conducted in antenatal OPD and antenatal ward in the
selected hospitals in Bangalore.
IV. Population:
All the primi gravida mothers who are attending OPD and admitted in
antenatal ward in the selected hospitals in Bangalore.
13
V Sample:
The sample consists primi gravida mothers who fulfill the inclusive criteria and
the sample size is 60.
VI. Criteria for sample selection: Inclusive criteria:-The study includes
1. The primigravida mothers who are in first and second trimester.
2. The primigravida mothers who are attending OPD and who are admitted in
antenatal ward.
3. The primigravida mothers who can understand Kannada or English.
Exclusive criteria: -The study excludes
1. Primigravida mother who are not willing to participate in the study.
2. Primigravida mothers with complications like hypertension, diabetic
mellitus, preeclamsia and cardiac disease.
VII. Sampling technique: Non-probability convenience sampling technique.
VIII. Tool for data collection: A structured questionnaire will be prepared as a tool. The questionnaire will
consist of the following section.
Section A: - Demographic proforma of primi gravida mothers include age,
occupation, education, religion, family income.
Section B: - Structured questionnaire on management of hyperemesis gravidarum
will be used to assess the knowledge level of primi gravida mothers.
14
IX Method of data collection : After obtaining permission from the concerned authority and informed concerned
from the samples, the investigator will collect the data. The data will be collected
in the following phases.
Phases I: Structured questionnaire will be administered to assess the pretest
knowledge of primi gravida mothers regarding the management of hyperemsis
gravidarum.
Phases II: On the same day structured teaching programme will be conducted to
primi gravida mothers regarding management of hyperemesis gravidarum by the
help of instructional aids for 45 mt-1 hr duration.
Phases III: Same questionnaire will be administered after 7 days of
structured
teaching programme.
Data will be collected for duration of 4 to 6 weeks.
X Plan of data analysis: The data collected will be analyzed by using descriptive and inferential statistics.
Descriptive statistics: -Frequency, mean, percentage distribution and standard
deviation will be used to analyze knowledge regarding management of
hyperemesis gravidarum.21
Inferential statistics: - Paired‘t’ test will be used to compare pretest and posttest
knowledge and chi-square test will be used to analyze the association between
posttest knowledge and with their selected demographic variables.22
15
XI Projected Outcomes: After administering the structured teaching programme, there will be increase in
the level of knowledge among primi gravida mothers regarding the management
of hyperemesis gravidarum. This will enhance the primi gravida mothers to
improve the management of hypermesis gravidarum and prevent the further
complications.
7.3 Does the study require any investigations or intervention to the patient or
other human being a animals?
Yes, structured teaching programme will be administer as intervention for the
antenatal mother.
7.4 Has ethical clearance been obtained from your institutions?
Yes, permission will be obtained from the concerned authorities in the selected
hospitals. Informed consent will be obtained from the samples. Confidentiality and
privacy of data will be maintained.
16
8. LIST OF REFERENCES
1. The gale group. Gale encyclopedia medicine. Third edition, available from:
URL: http\\www.answerbag.com.
2. Diane.M.Fraser, Margaret.A.Cooper. Myles textbook for midwifes. Fourteenth
edition: Churchill livingstone; 2003: P. 214-18
3. Susan.A.Orghan. Maternity, newborn and women’s health nursing: First
edition .New York; Lippincott Williams and Wilkins; 2007 P 522-23
4. Shari Munch. The biological-psychological controversy surrounding
hyperemesis gravidarum. Social science& medicine, 2002/October/ 7; (7): 126778.
5. D.C.Dutta. Textbook of obstetrics. Sixth edition.2004; Calcutta: new central
book agency (P) LTD; 2004. P. 100-04.
6. Sally B Olds, Marcia.L.London, Patricia A Ladewig. Maternal newborn
nursing. Second edition. California; 1984 P. 328.
7. R.Taylor, P.Moran. Successful management of hyperemesis gravidarum.
Department medicine, oxford university press; 2002/February /1, volume 95
(2):103-07.
8. Adele Pilliter. Maternal and child health. Third edition. New York: Lippincott
Williams and Wilkins; 2004 P. 295.
9. C.S.Dawn.Text book of obstetrics, neonatology and reproductive and cnild
health education. Sixteenth edition.Kalkata: Dawn books; 2004.P.136
.
10. Basavantha B.T. Nursing research: New Delhi: Jaypee Brothers.medical
publishers (P) LTD; 1998
11. Fadi .A.Bsat, Despina .E. Hoffman, David .E.Seubert. Journal of perinatology:
2003; volume 23; P 531-35.
12. K.Chandra, L. Magee, A.Kinarson,G. Koren. Journal of psychosomatic
obstetrics and gynecology. 2003/June; Volume23 (2): 71-75.
13. Share Munch,Mark F.Schmitz. Journal of psychosomatic obstetrics and
gynecology.2007; volume 28 ;( 4) 219-29
.
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14. Gemma Wills, Della Forster. Midwifery. Nausea and vomiting in
pregnancy.2007/ September/11; available from:
URL: http\\www.interscience.wiley.com.
15. JJ Folk, HF Leslie- brown, JT Nasovitch, R.k. Silverman. Division of maternal
fetal medicine.1998/ December; available from
URL: http\\www.interscience.wiley.com.
16. Jewell.D, Young.G. Interventions for nausea and vomiting in early pregnancy.
2007/September.volume 36.(9).P.698-701.Available from :
URL: http\\[email protected].
17. Marlena S.Fejzoa, Sue Ann Inglesb, Melissa Wilsona, Wei Wanga. High
prevalence
of
severe
vomiting of
pregnancy and
hyperemesis
gravidarum.2008/August/26.Elsevier Ireland Ltd. Available from URL: http\\
www.cure-morning-sickness.com.
18. Linda Dodds, Deshayne B.Fell, K.S.Joseph, Victoria M.Allen. The American
college of obstetrics and gynecology. 2006; volume107: 285-92
19. Lill I.S.Trogstad, Camilla Stoltenberg, Per Magnus. Medical Birth Registry.
2005/August/1.Available from URL: http\\ www. Inter science.wiley.com.
20. Keating A, chez RA. Ginger soup as a anti emetic in early pregnancy. 2003.
Available from URL: http\\ www. Inter science.wiley.com.
21. Polit .E, Beck. T. Nursing research: Describing data through statistics. New
yolk; Lippincott Williams and Wilkins; 2008. P-556-83.
22. Barbara Hazard Munro. Statistical methods for health care research: inferential
statistics. Philadelphia; Lippincott; 3rd edition.1997. P.73.
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09. Signature of the candidate
:
10. Remarks of guide
:
11.1 Name and designation of the guide:
11.2 Signature
:
11.3 Co-guide
:
11.4 Signature
:
11.5 Head of the department
:
11.6 Signature
:
12.1 Remarks of the principal
:
12.2 Signature
:
19