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A STUDY TO ASSESS THE EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE REGARDING ARTERIAL BLOOD GAS (ABG) TECHNIQUE AMONG STAFF NURSES IN SELECTED HOSPITALS AT BANGALORE M.Sc. Nursing Dissertation Protocol submitted to Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. BY MS. ASWATHY VARGHESE MSc NURSING 1ST YEAR 2013 TO 2015 Under the Gudiance of MRS.RAJESWARI HOD, DEPARTMENT OF MEDICAL SURGICAL NURSING Nightingale College of Nursing Guruvana Devara Mutt, Near Binniston Garden Bangalore -23 RAJIV GANDHI UNIVERSITY OF HEALTHSCIENCE BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE AND ADDRESS MS. ASWATHY VARGHESE 1ST YEAR M.SC NURSING NIGHTINGALE COLLEGE OF NURSING BANGALORE-23 2 NAME OF THE INSTITUTION NIGHTINGALE COLLEGE OF NURING GURUVANNA DEVARA MUTT,NEAR BINNISTON GARDEN, MAGADI ROAD BANGALORE-23 3 COURSE OF STUDY AND SUBJECT MASTER IN SCIENCE IN NURSING, MEDICAL SURGICAL NURSING. 4 DATE OF ADMISSION TO COURSE 01/07/2013 5 TITLE OF THE TOPIC A STUDY TO ASSESS THE EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE REGARDING ARTERIAL BLOOD GAS (ABG) TECHNIQUE AMONG STAFF NURSES IN SELECTED HOSPITALS AT BANGALORE 6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION Arterial blood is presented to all organs for their metabolic needs; its composition is uniform throughout the body. The composition of venous blood is conditioned by the metabolic activity of the tissue which it drains and therefore varies among different parts of the body. The largest difference between arterial and venous blood is its oxygen content, but pH and carbon dioxide content also vary. All differences between arterial and venous blood are magnified when the general or local circulation is impaired. Arterial blood is obtained via arterial line sample or by puncture of the radial or brachial artery in order to measure arterial blood gases and acid-base status of the patient. Only those individuals who have been certified in arterial blood gas collection may obtain arterial samples1. Many life-saving diagnostic tests which are performed in clinical set up to identify disease and are very essential tools in screening any deviations from normal functions of the body. The methods used will of course vary from assessment of radial pulse, blood pressure, and pulse oxymeter to the increasingly complex invasive hemodynamic monitoring such as interpretation of ABG sample with super specialization health care management in care of the patient. Though there are various diagnostic procedures, ABG analysis can be thought of as a window through which ventilation, respiration, metabolism and acid-base balance can be examined. Arterial blood gas (ABG) analysis is an essential part of diagnosing and managing a patient’s oxygenation status and acid–base balance. The usefulness of this diagnostic tool is dependent on being able to correctly interpret the results. Disorders of acid–base balance can create complications in many disease states, and occasionally the abnormality may be so severe so as to become a life-threatening risk factor. A thorough understanding of acid–base balance is mandatory for any physician, and intensivist, and the anesthesiologist is no exception2. ABG sampling provides valuable information on the acid-base balance at a specific point in the course of a patient's illness. It is the only reliable determination of ventilation success as evidenced by CO2 content. It constitutes a more precise measure of successful gas exchange and oxygenation. ABG sampling is the only way of accurately determining the alveolar-arterial oxygen gradient. Because the results of ABG sampling only reflect the physiologic state of the patient at the time of the sampling, it is important that they be carefully correlated with the evolving clinical scenario and with any changes in the patient’s treatment3. NEED FOR STUDY An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist,[1] but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial catheter. Pulse oximetry plus transcutaneous carbon dioxide measurement is an alternative method of obtaining similar information as well. An ABG is a test that measures the arterial oxygen tension (PaO2), carbon dioxide tension (PaCO2), and acidity (pH). In addition, arterial oxyhemoglobin saturation (SaO2) can be determined. Such information is vital when caring for patients with critical illness or respiratory disease. As a result, the ABG is one of the most common tests performed on patients in intensive care units (ICUs). The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflects gas exchange across the alveolar-capillary membrane. ABG testing also has a variety of applications in other areas of medicine. Combinations of disorders can be complex and difficult to interpret, so calculators, nomograms, and rules of thumb are commonly used4. Blood gas studies are concerned with repatriation of the exchange gases between the lungs and blood and between blood and tissues. The term blood gas strictly refers to the measurement of the tension or partial pressure of oxygen, CO2 and the estimation of H+ ion concentration or PH is an integral part of blood gas measurement. Arterial bloodgas (ABG) analysis is one of the most basic tests of pulmonary function, performed routinely in hospital inpatient floors and in intensive care units, pulmonary clinics, emergency departments, surgical suites, and pulmonary function laboratories throughout the world3. The measurement of arterial blood gases (ABG) has assumed an increasingly important role in the process of clinical evaluation, and has been widely used during the past three decades5. ABG measurements have been increasingly used in different medical conditions both in pulmonary and non-pulmonary disease conditions for accurate diagnosis14. Alteration in oxygen, carbon dioxide, pH, and HCO3- level leads to conditions like respiratory or metabolic acidosis or alkalosis. These conditions if not early diagnosed and treated may lead to several complications and may unable to restore normal health. Clients who manifest with hyper-metabolic states such as fever, sepsis, burns, client receiving total parenteral nutrition or enteral tube feedings high in carbohydrate, mechanically ventilated clients, clients with insulin- dependent diabetes mellitus, clients with vomiting, diarrhea or enteric drainage are subjected for ABG analysis 6. Nurses play an important role in early detection of high risk clients with acid base imbalance in critical care units. The nurses collaborate in the administration drug therapy, oxygen therapy and mechanical ventilation when indicated. In extreme circumstances in which therapeutic compensation is required, the nurse should be knowledgeable about potential risk of this therapy (drug, oxygen therapy) and able to carefully monitor administration rates and therapeutic responses7. Nursing as a profession is now responsible to account for its competence and performance. This has seen the birth of the language of outcome. Outcome is mechanism to evaluate quality, improve effectiveness and link practices to professional accountability. ABG analysis requires skillful observations and careful analysis by competent nurses, which can prevent fatal complication in ill patients. The nurse plays an important role in monitoring the patient’s progresses. A nurse has to be competent and skillful in handling situations that will result in effecting the ABG analysis of the patients. A nurse has to make a decision which is beneficial to the client life. By carefully analyzing the nurse is able to recognize early causes and manage problems before they arise. When ABG analyses have been done properly, the patient experience more rapid positive outcomes8. 6.2 REVIEW OF RELATED LITERATURE Review of literature is a key step in the research process. The typical purpose of analyzing a review of existing literature is to generate questions and to identify what is known and what is unknown about the topic. The major goals of review of literature are to develop a strong knowledge base to carry out research and non-research scholarly activity. Review of literature for the study has been organized under following headings. 6.2.1 Review related to the general information about ABG technique 6.2.2 Review related to the nurses knowledge about ABG technique 6.2.3 Review related to the effectiveness of self-instructional module 6.2.1 Review related to the general information about ABG analysis. A study on the evaluation of an on-demand-bedside-blood-gas monitor on pulmonary artery blood gas determinations on critically ill patients often having cardiopulmonary disturbance and who required rapid and frequent assessment for optimal care, cardiac output determinations and arterial blood gas analysis has been done. The study suggested that the blood gas monitoring provided rapid and accurate determinations of arterial blood gases allowing optimal therapeutic interventions in critically ill patients9. A study about decision support alerts for clinical laboratory and blood gas data stated that half of all critical alerts were detected caused by altered blood gas values from amongst approximately 115,000 laboratory data10. A study to observe utilization of ABG measurements portrayed that during the study period of two weeks, 98 ABG sample were requested from adult patients (acute care general wards). The researcher summarized that ABG measurements from acute care wards in a tertiary-care teaching hospital were found to be used more frequently11. Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition of critically ill patients; however, arterial puncture or insertion of an arterial catheter may cause many complications. This study evaluated whether pH, partial pressure of carbon dioxide (PCO2) and bicarbonate (HCO3-) values of venous blood gas (VBG) could accurately predict their ABG analogs for patients with acute respiratory failure treated by mechanical ventilation in an intensive care unit (ICU). Forty six patients who were admitted to the ICU due to acute respiratory failure and treated by mechanical ventilation were included in this study. Blood for VBG analysis was sampled from the cubital or dorsal palmar veins, while ABG was sampled simultaneously from the radial or brachial arteries via an arterial catheter at the other upper extremity. Validation of the regression equations and mean percentage-difference equations revealed only a small (clinically insignificant) variation between the actual and predicted ABG values.12 6.2.2 Review related to the nurses knowledge about ABG technique A study to examine attitudes and beliefs among nurses and third-year undergraduate nursing students in hospital training regarding the use of local anesthesia when performing arterial puncture and to assess their knowledge of the technique with a questionnaire declared that local anesthesia was used routinely by 7 nurses (5%), of whom 3 (27%) belonged to the respiratory medicine department; local anesthesia was not used by any of the nursing students. The main reasons given by nurses for not using local anesthesia were lack of knowledge (54%), need to perform 2 punctures when anesthesia is used (11%), belief that the same amount of pain is caused with anesthesia (8%), and success on the first attempt at arterial puncture (7%). The main reason given by student nurses for not using local anesthesia was also lack of knowledge (53%), followed by the fact that it was not used by the nurses (24%). Most of those surveyed (63%) indicated a desire to receive anesthesia should they undergo arterial puncture. Local anesthesia is used very little in arterial puncture. Knowledge about how to perform arterial blood extraction for blood gas analysis is insufficient and needs to be improved among both nurses and nursing students13. Arterial blood gases sampling is one of the most common laboratory tests in intensive care units and might be corrupted by pre-analytical factors that influence the validity of results. Arterial blood gases are valuable only if obtained properly and measured carefully. Corrupted factors in arterial blood gas sampling change significantly the results and adversely affect patient-care decisions when the magnitude of the error is clinically important .Therefore the nurses’ role is very important to control these factors. A descriptive exploratory study to assess the different pre- analytical factors affecting ABGs results’ validity among critically ill patients at Cairo University Hospitals showed that all the studied subjects (100%) demonstrated unsatisfactory knowledge and practical level in relation to ABG sampling and controlling the different factors that might affect ABG results’ validity. Moreover, There were no significant statistical difference between knowledge scores regarding educational level (F=2.73; P=0.07), working area (F=1.07;P=0.34), and gender (F=1.096;P=0.29) among the studied subjects. Results of the current study indicated a real gap between nurses' knowledge and practices as compared to the evidence based guidelines of American Association for Respiratory Care in management of ABG sampling. The current study recommends an enrichment of critical care nurses’ knowledge and practices related to this essential procedure in addition to consideration of the different corrupting factors by hospital authorities to keep with the related evidence based guide lines that will be great benefits for patient, hospital, and all health professionals14. A study on arterial blood gas (ABG) technique for health care professionals and stated that arterial blood gas analysis is a critical skill required by the nurses in order to provide safe and competent patient care. Nursing interventions focus on maintaining patient alveolar exchange of CO2 or O2 by analyzing arterial blood gas concentration. The results indicated that the teaching programme promoted better understanding by the health care professionals about ABG analysis and aided in the application of knowledge in the clinical setting15. 6.2.3 Review related to the effectiveness of self-instructional module A study about effectiveness of a need based teaching protocol on nurse’s responsibility in ABG analysis for the nursing personnel working in the critical care units revealed that the teaching programme was effective and increasing the knowledge on ABG analysis as the computed “t” test was significant at 0.05 level. The nursing personal were motivated to learn and continuing nursing education is the key to up to date the knowledge of the nursing personal which will help to provide comprehensive nursing care16. A research on demonstrating the effectiveness of an online, computer-based learning module for arterial blood gas analysis envisaged that staff nurses' knowledge increased significantly after viewing the computer-based learning module (t = 6.3; P < .001). This improvement was irrespective of experience or department. Computer-based, online learning has emerged as a means of providing continuing education to nurses. Such a teaching strategy helps to overcome barriers pertinent to traditional classroom settings17. A study on comparison the effect of two clinical teaching models on performance of nursing students in intensive care unit for assessment of nursing students’ clinical performance in selected procedures (suctioning the airway, inserting naso-gastric tube, rapid neurological examination, and taking arterial blood sample) was done. In comparison the pretest-posttest differences of two groups, the average score of experimental groups in all procedures was further than control groups (p = 0.001). Also, in the end of clinical education many of experimental students reached to mastery level, but, few students in control groups reached to mastery level. Due to significant effect of mastery learning method on clinical performance of nursing students, we suggest that nursing trainers use this method as a basic clinical teaching method especially to educate fundamental nursing skills18. STATEMENT OF THE PROBLEM “A study to assess the effectiveness of Self-instructional module regarding Arterial Blood Gas (ABG) technique among staff nurses in selected hospitals at Bangalore.” . 6.3. OBJECTIVES OF THE STUDY To assess the existing level of knowledge regarding Arterial blood gas (ABG) technique among staff nurses in selected hospitals To evaluate the effectiveness of the structured teaching programme regarding Arterial blood gas among staff nurses in selected hospitals To find out association between knowledge level of the staff nurses with their selected demographic variables. 6.4 HYPOTHESES OF THE STUDY The study attempted to examine the following hypothesis, H1: The mean post- test knowledge level will be significantly higher than the pre-test knowledge level regarding Arterial Blood Gas (ABG) technique among staff nurses in selected hospitals. H2: There will be significant association between knowledge level of the staff nurses with their selected demographic variables. 6.5 VARIABLES UNDER THE STUDY Independent variable Self-instructional module on ABG analysis. Dependent variable Knowledge about ABG analysis. 6.6 OPERATIONAL DEFINITIONS Effectiveness: refers to the extent to which the structured teaching program on ABG (Arterial Blood Gas) techniques achieves desired effect in improving the knowledge of staff nurses as evident from gain in knowledge scores. Knowledge: Refers to correct responses from the staff nurses about ABG Analysis elicited through Structured Knowledge Questionnaire. Self-instructional module: Refers to planned instructional material regarding systematic ABG technique which can be used oneself to improve knowledge. Arterial Blood gas analysis: Refers to a lifesaving diagnostic procedure to determine O2, CO2, HCO-3, PH balance and related abnormalities. Staff nurses: Refers to an individual who is qualified as a registered nurse and is working in a selected hospital. 6.7 ASSUMPTIONS Nurses may have some knowledge regarding ABG technique. Nurses may have interest to know more about ABG technique. This self-instructional module would enhance knowledge of nurses about ABG technigue. 6.8 DELIMITATIONS This study is delimited to: The staff nurses working in selected hospitals at Bangalore Who knows Kannada or English Who are willing to participate in the study 6.9 PROJECTED OUTCOME This study will help the staff nurses to gain more knowledge about ABG techniques and thus to improve their nursing capabilities 7.0 MATERIAL AND METHODS 7.1 SOURCES OF DATA The data will be collected from the staff nurses in a selected hospital at Bangalore. 7.2 METHODS OF COLLECTION OF DATA Structured Questionnaire will be used to collect the data. 7.2.1 RESEARCH APPROACH An evaluative research approach will be used to conduct the study. 7.2.2 RESEARCH DESIGN Quasi experimental one group pre-test post-test design will be used to carry out the study. 7.2.3 SETTING OF THE STUDY Study will be conducted in selected hospitals, Bangalore. 7.2.4 POPULATION The population of the present study comprises of staff nurses who are working in selected hospital, Bangalore. 7.2.5 SAMPLE SIZE Sample size of the study will be 40 staff nurses working in selected hospitals. 7.2.6 SAMPLING TECHNIQUE Purposive sampling technique will be used to select the samples for the present study. 7.2.7 SAMPLING CRITERIA Inclusion criteria Staff nurses who are willing to participate in the study. Staff nurses who are available during the period of data collection. Exclusion criteria Staff Nurses who are on leave during the period of data collection 7.2.8 TOOL FOR DATA COLLECTION Structured knowledge questionnaire will be used to collect the data: It consists of 2 parts i.e. part I and part II Part I: items on demographic variables like, age, sex, educational qualification, total years of experience, exposure to in-service education. Part II: knowledge items on ABG technique. 7.2.9 DATA ANALYSIS METHOD The data analysis through descriptive and inferential statistics. Descriptive statistics Frequency, mean, mean percentage and standard deviation will be used to describe demographic variables and interpreted knowledge scores. Inferential statistics Paired ‘t’ test will be used to compare pre and post-test knowledge scores. Chi square (χ2) test will be used to find out the association between knowledge scores with selected demographic variables. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON NURSES OR OTHER HUMANS OR STAFF ANIMALS? Yes, the intervention will have effect on staff nurses knowledge level regarding ABG technique. 7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTIONS? Yes, the Ethical Clearance Certificate has been enclosed. 8. LIST OF REFERENCES: 1. National Committee for Clinical Laboratory Standards: Percutaneous Collection of Arterial Blood for Laboratory Analysis, Second Edition, Document H11-A2. 2. Pramod Sood, Gunchan Paul, and Sandeep Puri.Interpretation of arterial blood gas, Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine 2010 Apr-Jun; 14(2): 57-64 3. Mauricio Danckers, MD: Arterial Blood Gas Sampling, Pulmonary and Critical Care Fellow, New York University Medical Center. ( available on: http://emedicine.medscape.com/article/1902703-overview ) 4. Kofstad J (1996). "Blood Gases and Hypothermia: Some Theoretical and Practical Considerations". Scand J Clin Lab Invest. (Suppl) 224: 21–26. PMID 8865418. 5. Raffin T. indications for arterial blood gas analysis. Ann International Medicine 1986;105:390-8. 6. Severinghaus W.John, Astrup Paul et al. Blood gas analysis and critical care medicine. American Journal of Respiratory and critical care medicine, 1998 April; 154(4). 7. Fine M J, Smith MA, et all. The incidence and effect of hypoxen hospitalized medical patients. American Journal of Medicine 1994; 97:38-46 8. S Dodds, et al. Nurse – led arterial blood gas sampling for patients, Nursing Times 2007 february; 103(8):44-45. 9. M L Franklin,T W Peruzzi,S G Moen,B A Shapiro. Evaluation of an on-demand , ex-vivo bedside blood gas monitor on pulmonary artery blood gas deter minations. Anesthasia Analog 1996 sep; 83(3): 500-4. 10. M M Shabot, Bue .M Lo,Leyerle B J. Decision support alerts for clinical laboratory and blood gas data . Int Journal Clinical Computer1990 ; 7(1):27-31 11. Moamary Al Mohamed, Daniel Diane, et al. Appropriateness of Arterial blood gas measurements in acute general wards. Annals of Saudi Medicine 1999;19(2):153 12. Taylor L, Stephens D : Arterial Blood Gases, Clinical Application. The American Journal Of Emergency Medicine, Volume 26, Issue 1, Pages 24-30 (January 2008) 13. Mr A.V. Valero Marco: Local Anesthesia in Arterial Puncture: Nurses' Knowledge and Attitudes, Arch Bronconeumol. 2008;44:360-3. - Vol. 44 Num.07( available on http://www.archbronconeumol.org/en/local-anesthesia-in-arterial puncture/articulo/13124793/) 14. Warda youssef, Ahmed Yahia, Nahla Shaaban Ali, Sameh Elhabashy: Factors Affecting Validity of Arterial Blood Gases Results among Critically Ill Patients: Nursing Perspectives, journal of education and practice Vol 4, No 15 (2013) 15. Maag M M . Arterial blood gas (ABG) interpretation: an online learning activity for health care professionals. Computers and advanced technology in education 2005;24:506. 16. Schneiderman J, Corbridge S, Zerwic JJ. Demonstrating the effectiveness of an online, computer-based learning module for arterial blood gas analysis. J Clin Nurse Spec. USA 2009 May-Jun;23(3):151-5 17. Antonio Vicente Valero Marco, Carmen Martínez Castillo and Loreto Macia Soler Local Anesthesia in Arterial Puncture: Nurses' Knowledge and Attitudes. Spain: Archivos de Bronconeumologa (English Edition) 2008 44,(7), , 360-3 18. Azad Rahmani, Alireza Mohajjel Aghdam, Eskandar Fathi Azar. Iranian Journal of Nursing and Midwifery Research Comparison the effect of two clinical teaching models on performance of nursing students in intensive care unit. Iran: IJNMR 2008; 13(2): 81-86 2008 13, No 2 16. 9. 10. 11. SIGNATURE OF THE CANDIDATE REMARKS OF THE GUIDE NAME AND DESIGNATION OF 11.1 GUIDE 11.2 SIGNATURE 11.3CO-GUIDE 11.4SIGNATURE 11.5 HEAD OF DEPARTMENT 11.6 SIGNATURE 12 12.1 REMARKS OF THE PRINCIPAL 12.2 SIGNATURE