.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. Name of candidate and MISS. TSERING DISKIT

address 1st YEAR M.Sc (N)
GOUTHAM COLLEGE
OF NURSING,
RAJAJINAGAR,
BANGALORE-560010

2. Name of the institute GOUTHAM COLLEGE

OF NURSING- 560010
3. Course of the study and 1st YEAR M.Sc
subject NURSING
MEDICAL SURGICAL
NURSING

4. Date of admission to the 16-05-2012

course
5. Title of the study TO ASSESS THE
EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAM ON
KNOWLEDGE AND
PRACTICE OF DEEP
BREATHING EXERCISE
AND INCENTIVE
SPIROMETRY AMONG
PATIENTS WITH COPD IN
SELECTED HOSPITALS AT
BANGALORE.

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6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY:-

Chronic obstructive pulmonary disease (COPD) is the life threatening lung disease

that interferes with normal breathing- it is more than a “ smoker’s cough”. It is estimated

that 64 million people have COPD worldwide in 2004. More than 3 million people died of

COPD in 2005, which is equal to 5% of all deaths globally that year. Almost 90% of

COPD deaths occur in low and middle income countries. WHO in 2000 estimated that

prevalence of 2.7 million died of chronic obstructive pulmonary disease. About 1.5

million emergency department visits by adult 25 age and older made for chronic

obstructive pulmonary disease in 2000.More emergency visits of COPD made by female

than adult male.1

Mortality rate of chronic obstructive pulmonary disease is more than 3 million people

every year, making it 4th largest cause of death in the world. It has been reported that by

the year 2030 COPD will become the third biggest cause of death. World health

organization leads the global alliance against chronic respiratory disease (GERD) a

voluntary alliance of national and international organization, institution and agencies

working towards the common goal of reducing the global burden of COPD. Its vision is a

worldwide where all the people breath freely.2

In America between 3 and 7 million are currently diagnosed with chronic obstructive

pulmonary sides and true prevalence is probably greater than 16 million.3

The recent statistics in 2011 says that almost 26 million adult over the age of 40 in

India had COPD data monitor expect this number to increase 34% to approximately 32

million by 2020.2

Chronic obstructive pulmonary disease in India is now recognized in 4 to 10% of adult

male population of India and several other Asian countries. The regional COPD working

group for 12 Asian pacific country and region used COPD prevalence model and

estimated an overall prevalence rate of 0.3%. The smoking association with COPD were

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high from most countries that is 2.65 in India, 2.57 in China and 2.12 in Japan in larger

multi centre study from in India, the population prevalence of COPD was 4.1% of 35295

subjects with male to female ratio of 1.56:1.3

The data revealed that the total burden had increased tremendously because of an

increase in the total population. Although the prevalence rate reported from south India

were consider as low, almost similar findings reported in population survey 9946

inhabitants from rural south India that is a prevalence of 40.8/1000 from male and 25.5 for

female.2

India is facing various environmental problems. 70% of respiratory suspended

particular matter is high in Indian environment. The source of respiratory suspended

particular matter are diesel vehicle, power plant, cook stoves and industrial process

emission. Mostly, individual particle cannot be seen with the naked eye, but collectively

they appear as what is called “black spot”, dust clouds, or grey hazes. Particular matter

less than 2.5 micro meter in diameter is known as “fine” particles. Fine particles result

from fuel combustion, residential fire places and wood stone. These are suspected to be

respiratory toxicant individual with pre-existing lung diseases can develop adverse health

effect by routing finer particles. It reduce lung function and increase lung disease.

Solution to the above mention health problem can be drawn by giving priority to

preventives and promotive measures, several studies suggested the possibility that the

respiratory function in normal individual also can be improved by introduction of

respiratory muscles exercise. An average adult human being breaths 22,000 cu.cm of air

and along with it 1600 million dust particles daily.3

In Karnataka prevalence of chronic obstructive pulmonary disease is 64.3% of

COPD. Prevalence of chronic cough is an important indicator of respiratory morbidity in

the community.

Present study is planned with COPD patients admitted in the hospital as the

Population may have less respiratory muscle strength. They may have hospital acquired

infection. There will be close contact in between the patients. Therefore the patients with

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low level and poor exercise habits require to strengthen their respiratory muscle capacity

for maintaining physical health like any other of muscles, the respiratory muscles also can

be strengthened through regular exercise can be performed with or without the use of

Mechanical devices.3

Deep breathing exercise selected in this study for improving the pulmonary function

of the patients are simple, can be performed without any expenses or complex devices and

does not require a particular area in a hospital for the practices.3

Second exercise included is the incentive spirometry is a simple device. The use of this

spirometry requires simple instructions and individual can handle it easily. Both the

exercises are found to be practice. Hence the investigator had selected these exercise as

intervention straggles for improving the pulmonary function of the patients and their effect

a patient ‘s well being through health promotion.

Pulmonary disease is more prevalence in the modern day due ti various types of pollutants

in the environment and climate change due to this makes person handicapped. Deep

breathing exercise helps to increase lung capacity. By doing this study, it helps to the

client with respiratory problem to promote their respiratory system. Hence researcher felt a

need to conduct the study to find the effectiveness of structured teaching program on

knowledge regarding incentive spirometry and deep breathing exercise among COPD

patients.4

6.2 STATEMENT OF PROBLEM:-

A study to assess the effectiveness of Structured Teaching program on knowledge and

Practice regarding Deep Breathing Exercise and Incentive spirometry among chronic

Obstructive pulmonary Disease patients in selected hospital in Bangalore.

6.3 OBJECTIVES:-
1. To assess the knowledge and practice of COPD patients regarding deep breathing

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Exercises and Incentive spirometry.

2. To assess the effectiveness of structured teaching program on deep breathing exercise

and intensive spirometry among the chronic obstructive disease patients.

3. To find out the relationship between knowledge and practice.

4. To associate the knowledge level of COPD patients with their demographic variables.

6.4 REVIEW OF LITERATURE:

Review of literature is organized under following categories:

1. Studies related to chronic obstructive pulmonary disease.

2. Studies related to knowledge of COPD patients regarding deep breathing exercise and

incentive spirometry.

3. Studies related to practice of COPD patients.

4. Studies related to effectiveness of structured teaching program on deep breathing

exercise and incentive spirometry.

1) Studies related to chronic obstructive pulmonary disease.

A study was conducted in international variation in the prevalence of COPD. COPD

is growing cause of morbidity and mortality worldwide , and accurate estimates of the

prevalence of the disease are needed to anticipate the future burden of COPD, target risk

factor, and plan for providing COPD-related health services. We aimed to measure the

prevalence of COPD and its risk factor and investigate variation across countries by age,

sex, and smoking status. The participants from 12 sites(n=9425) completed spirometry

testing plus questionnaries about respiratory symptoms, health status and exposure to

COPD risk factors. COPD prevalence estimated based Global Initiative for COPD staging

criteria were adjusted for the target population. Logistic regression was used to estimate

adjusted odds ratios for COPD associated with 10 years increments and 10 year pack

increment. Meta-analysis provided pooled for these risk factors. The findings of stage 2 or

higher COPD was 10.1% for men and 8.5 % for women. The ORs for 10 years age

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increments were much the same across sites and for women and men. The pooled estimate

was 1.94% per 10 years increment . Sites- specific pack year ORs varied significantly in

women , but not in men. 11

A study was conducted on COPD is a common diseases , the early diagnosis of which

allows effective management and treatment. The prospective observational longitudinal

study comprised 164 high risk smokers aged 40 and 76 years. Age , sex, weight, height

and smoking habits were recorded and spirometry was performed . Patients were informed

of their result and given brief advice on how to stop smoking . After 3 years, the patients

underwent the same evaluation. The result of the study reveled that 22% of the smokers

were diagnosed with COPD. Three year later, an additional 16.3 % were diagnosed as

having COPD, and disease had worsened in 38% of those already diagnosed. Of the

patients with FEV1 less than 90% , 44.8% develops COPD. And accelerated decrease in

FEV1 was found in 18% of the patients. Mean tobacco consumption in 1999 was 28.1

pack years in subject without COPD and 31.7 packs years in those with COPD, whereas in

2002, consumption was 30.6 packs in the patients with COPD and 31.9 packs year in those

without . In the years, 22.8% had stopped smoking(20.5% without COPD and 30.3% with

COPD). T he study concluded that many smokers managed to give up smoking after

learning their spirometric result.12

2) Studies related to knowledge of COPD patients regarding deep

breathing exercise and incentive spirometry.

A study was conducted on the evaluation of knowledge of deep breathing and

incentive spirometry to the patients with COPD. Knowledge of deep breathing and

incentive spirometry is important to the patients who use deep breathing and incentive

spirometry in their treatment of chronic obstructive pulmonary disease. The study includes

a total of 13897 subjects, population group studies 9083 from one city and 4814 from

another city population studies, were followed for 7-16 years. Based on cross sectional

data, in the CCHS the estimated excess loss of forced expiratory volume in one second per

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pack year of smoking was 7.4 mL in female smokers who inhaled. In the GPS, the

corresponding excess loss of FEV1 was10.5 and 8.4 mL in females and males

respectively. 218 subjects in the CCHS and 23 in the GPS were hospitalized during follow

up. Risk associated with pack year was higher in female than male. Result was similar in

GPS . After adjusting for smoking for more detail, female in both cohorts had an increased

risk of hospitalization for COPD compared to males with RR of 1.5 in the CCHS and 3.6

in the GPS. Result suggested that adverse effect of smoking on lung function may be

greater in females than in males.11

A quasi experimental study was conducted to investigate the effect of deep breathing

exercise on pulmonary function, arterial blood gases, dyspnoea and health related quality

of life in the patients hospitalized for COPD. A total of 27 consecutive (mean age, 68.4 +/-

7.9 years ; 26 males) admitted for COPD exacerbations were recruited for the study. In

total , 15 (IS treatment group) used IS for 2 months, together with medical treatment. The

remaining 12 (medical treatment group) were given only medical treatment. Pulmonary

function and blood gases were measured. Assessment of dyspnoea by visual analogue

scale and quality of life using the St. George"s Respiratory Questionnaire (SGRO) were

performed at admission and after 2 months of treatment. Result, the activity , impact and

total scores for the SGRO improved (all p≤ 0.0001), PaCO2 values decreased (p=0.02 and

p=0.01, respectively) in the IS treatment group. However , there were no significant

differences between the measurement made pretreatment and after 2 months of medical

therapy n the medical treatment group, with regard to pulmonary function, blood gases,

SGRO scores and VAS. The study concluded that , the use of incentive spirometry and

deep breathing appears to improve ABG and health related quality of life in patients with

COPD exacerbation , although it does not alter pulmonary function parameters.8

A study was conducted on the knowledge of COPD patients. The study includes 256

patients were followed for 8.7+/- 0.4 years after the index hospitalization in 2000-2001.

Prior to discharge, the St George Respiratory Questionnaire was administered and data on

therapy and consent obtained. Information on long term mortality was obtained from

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national register in the country. The result revels that, in total, 202 patients (79%) died

during the follow up period, whereas 54 (21%) were still alive. Primary cause of death was

respiratory (n=116), cardiovascular (n=43), malignancy (n=28), other (n=5). Mortality was

related to old age, with a hazard risk ratio of 1.75 per 10 years. The concluded almost four

out of five patients died within 9 years following an admission for COPD exacerbation.13

3) Studies related to practice of COPD patients regarding deep

breathing exercise and incentives spirometry.

A study was conducted to find the effectiveness of breathing retraining in eagerly

patients with COPD in rehabilitation institute. A sample of 56 patients (age < 60 years)

and 27 older patients (age ≥60 years) in the out patient setting was selected. Breathing

exercise capacity were assessed by using pulmonary function test, 12 minutes distance

walk test and self-assessment score. The finding suggested that there was no difference

between older and young out patients with respect to FEV1, FEV1/FVC1, maximum

inspiratory pressure, baseline 12 minutes distance and self assessment score improved

significantly in both groups. They concluded that comprehensive outpatient pulmonary

rehabilitation programs are as beneficial in elderly patients with COPD as they are in

younger with similar lung function abnormalities.21

A study was conducted on prevalence of chronic obstructive pulmonary disease,

during survey period ( which ranged from 3 months to 6 months in the various locations)

we collected daily calibration data from the 70 easy one spirometry used in the survey

cities. The calibration were conducted with a 3-L syringe, and the calibration data were

stored in the spirometer"s database. The result of the study revels that 97% of the

calibration volume were within +/- 64 mL (2.1%) of the 3 mL calibration signal.

replaced, 98% of the calibration checks were within +/- 50 mL(1.7%)The study concluded

that in these 70 easy one spirometers neither calibration nor linearity changed during the

study. Such calibration stability valuable feature in spirometry surveys and in the clinical

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setting.22

A study was conducted on the management of patients with COPD and evaluate the

effectiveness of a specialized treatment, in this one year prospective study of a group of

patients for whom historical control data were available .The mean (SD) descriptive data

for the124 patients(105 men) were as follows: 69(7) years; forced vital capacity, 64.9%

(16.1%); forced expiratory volume in the first second (FEV1), 35.6% (12.8%); Pao2,

56.6(8.3)mm Hg; PaCo2, 49.8(6.7) mm Hg. Forced spirometry and arterial blood gas

analysis were performed at 3-monthly visits. Participants completed quality-of-life

questionnaire at the beginning and end of the study. The following variables were

analyzed: forced spirometry , arterial blood gases, quality of life , number of emergency

visit and hospital admission, mean length of stay in hospital , reduction in the no. of

impatient bed-days, mean cost of emergency visits. The result were compared with data

for the preceding year taken from the hospital records. The result revels that the significant

improvement was found in forced vital capacity and PaO2 (which went from 56.6 [8.2]

mm Hg during the prospective part of the study);FEV1 also tended to improve (875

[282]mL as against 912 [321] mL), but this change was not significant(p=.17). A

significant reduction was observed in the following variables: PaCO2; hospital admission,

1.16 (1.15) in the historical control period compared to 0.67 (1.7) during the prospective

study; emergency visits, 2.06(1.9) as against 1.5(2.1); mean length of stay in hospital,

14.2(19) compared to 8.1 (16) days. The quality-of-life score improved, but the change

was not significant. The study concluded that the change in the health care model used to

manage these patients led an improvement in care(effectiveness) as well as marked

reduction in cost(greater efficiency) for both the funding entity (CHS) and for the care

provider (hospital). No change was observed in the quality of life as reported by the
22
patients.

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4) Studies related to effectiveness of structured teaching program

on deep breathing exercise and incentive spirometry.

A study was conducted on pulmonary rehabilitation is recommended for the

treatment of COPD in international guidelines. However , patients education as an

important part of pulmonary rehabilitation has nor been addressed sufficiently to show its

benefit . The aim of this study was to find out whether education improves the

effectiveness of rehabilitation with regard to quality of life and morbidity in the year

following rehabilitation.COPD patients of multidisciplinary pulmonary inpatient

rehabilitation programmed participated in this prospective , randomized and controlled

trial. To the education group we offered a program of patients education and an individual

l action plan on how to cope with exacerbation . pulmonary function test and QoL as

measured by SGRQ were tested at baseline and at follow up after 1 year. The results revels

90 patients were randomly assigned to the multidisciplinary rehabilitation program with

the usual care and 94 patients received additional patient education. In the both groups

total no. of hospital admission was diminished after 1 year. The study concluded patient

education for COPD has been shown the effectiveness of an impatient rehabilitation

program regarding quality of life. It also reduces morbidity and supports.21

A study was conducted to evaluate the effectiveness of screening program for COPD

in primary care. Subjects aged 65 years or older registered with a general practitioner were

asked to complete a questionnaire on smoking status and symptoms of COPD. If they

were smoker or former smoker of if morning cough with sputum or dyspnoea was

examination. The result revels that of the 7103 subjects who met the study criteria , 81.2%

responded to the questionnaire . Of these, 58.5 % were at risk of COPD . Of those at risk

40% underwent a spirometric examination. COPD was classified as mild in 252(42.3%) ,

moderate in 258(43.3%) and severe -very severe in 86 (14.4%). The participants rate was

significantly heifer among subjects invited for spirometry at a health centre compared to

general practice. The concluded that our findings suggested that a questionnaire can be

10
used as a screening tool to identify subjects at risk of COPD. 8

A study was conducted on self management education and associated with

improvement in quality of life and reduction of hospital admission of COPD patients. The

study included selected COPD patients and out patients referred to rehabilitative hospitals.

The study was divided into two parts: a pre study phase and a study phase. All COPD

subjects received one educational brochure and were invited to attend seven 30-min group

lessons to complete the educational program. Learning effect was evaluate by a 20-

questions multiple choice learning questionnaire (LQ). The result revels that enrolled 158

subjects of whom 44.9% had previous formal education lessons on COPD management

and 69.6% had previous rehabilitative hospitalization. At baseline, the LQ total score

was15.2 +/- 3.5 points, which increased to 16.9 +/- points post COPD-EP (P<.001). Pre-

to-post change of LQ score significantly correlated with adherence (R= -0.22, P=.002) and

severity Index of Cumulative Illness Rating Scale Score (R= - 0.22, P= .001). Subject with

low baseline knowledge were more likely to have improved LQ scores than subject with

greater levels of knowledge. Subjects without prior educational COPD lessons improved

more than subjects who had attended previous education. The study concluded that a

formal COPD-EP is feasible and effective in improving subject knowledge and self

management. S pacific learning instruments to follow up this population should be

validate. 8

6.5 RESEARCH HYPOTHESIS

H1:- There will be a significant difference in the mean pretest and post test knowledge

score after structured teaching program.

H2:-There will be a significant association between pre-test and post-test knowledge

Score of COPD patients with their selected demographic variable.

6.6 ASSUMPTIONS:-
1. Chronic obstructive pulmonary disease patient’s knowledge and practice may vary with

11
their Selected demographic variables.

2. Structured teaching program may enhance the knowledge of COPD patients about deep

breathing exercise and incentive spirometry.

6.7DELIMITATION:-
The study is delimited to:

1.COPD patients admitted in the selected hospitals.

2.The data will be collected between 4-6 weeks.

7. MATERIAL AND METHODS

7.1 SOURCES OF DATA:-

The data will be collected by administering of knowledge questionnaire among COPD

patients before and after planned teaching program in the selected hospital at Bangalore.

7.1.1 RESEARCH DESIGN:-

Pre experimental (one group pre and post test) design will be used for the study. The

Schematic representation of the study design is given below:

Pre test Intervention Post test

Structured

Teaching

Program

Group O1 X O2

7.1.2 RESEARCH SETTINGS:-

The study will be conducted in the selected hospital in Bangalore.

7.1.3 POPULATION:-

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 The population included in this study are all the available COPD patients admitted in

hospital at Bangalore.

7.1.4 Sample:-
Patients who fulfill the inclusion and exclusion criteria. Sample size is 60.

7.2 METHOD OF DATA COLLECTION:-

7.2.1 SAMPLING PROCEDURE:-

Purposive sampling technique will be used to select the sample for the study.

7.2.2 SAMPLE SIZE:-

60 patients who are fulfilling inclusive criteria admitted in a selected hospital at

Bangalore.

7.2.3 INCLUSIVE CRITERIA:-

-Patients who diagnosed with COPD and admitted in selected hospital.

-Patients who are willing to participate in the study.

-Both male and female patients.

-Patients who can able to speak Kannada , English or Hindi.

7.2.4 EXCLUSIVE CRITERIA:-

-Patients who are in mechanical ventilation.

-Patients who are admitted for other problems like heart failure, hypertension and

Diabetic mellitus.

-Patients who are previously trained.

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7.2.5 INSTRUMENTS INTENDED TO BE USED:-

PART-1: Demographic variables.

PART-2: Knowledge questionnaire.

PART-3: Structured teaching program on deep breathing exercise and incentive

spirometry.

7.2.6 DATA COLLECTION METHOD:

1. Data will be collected after obtaining prior permission from the hospitals.

2. Objective of the study will be explained and informed consent will be taken from the

patients.

3. Data will be collected through demographic profile and structured knowledge

questionnaire to assess the knowledge regarding problem and its management.

4. Pre test knowledge measured by administering the structured knowledge questionnaire.

5. Structured teaching program will be administered to the patients same day.

6. Post test will be conducted with same structures knowledge questionnaire on seventh

day.

7.2.7 PLAN FOR DATA ANALYSIS:

1. Differential: Mean, median, standard deviation, frequency and percentage will be

used.

2. Inferential: T test will be used to evaluate the effectiveness of planned teaching

program.

3. To find the relationship R value will be identified.

4. (x2) Chi Square used to find and association between knowledge and practice score with

demographic variables.

7.3 Does the study require any investigation or

14
interventions to be conducted on patient or other human
being or animals?
-Yes, the study will be conducted to assess the effectiveness of planned teaching
program of incentive spirometry and deep breathing exercise to promote on pulmonary

function among COPD patients.

7.4 Has ethical clearance been obtained from your institution:-

-Yes, permission will be obtained from the concerned authorities of selected hospital
and informed consent from the sample obtained. Confidentiality and privacy of data will

be maintained.

8. LIST OF REFERENCES:-
1) http://www.google.com

2)http://en.wikipedia.org/wiki/adhd.

3) Catham k, Balduien J. et al. Fix load incremental Respiratory muscle training: pilot
study and physiotherapy, 1996 New York USA; 83(7); 422-6

4) Suzanne c Smelter, Brenda Burnner Bare. Medical Surgical Nursing. 1oth edition.

Philadelphaic: Lippencott Williams and Wilkins: 2004

6) http:/allnurses.com/general-nursing discussion/Adhd

7) http:/www.ncbi.nlm.nih.gov/pubmed/23055707

8) http:/www.esrj.org.uk/content/10/4/822

9) http:/ Levis, Collier and heithmper, medical surgical nursing:(4th edition) Missouri

Mosby: 1996, 121-141

10) Craven JL, Evans et. al. The evaluation of incentivespirometry in the management of
post-operative pulmonary complication. Brj surg1974;61:793-797

11)http:/www.thelncet.com/journals

12)http:/www.ersj.org.uk/content

13)http:/www.rcjournals/contents

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 14) Petz Tj. Physiologic effect of IPPB,Blow bottles and incentive spirometry. Curo

rev respire ther 1979; 110:567-583

15) Collins EG et al. breathing pattern retaining and exercise training and exercise

training in patients with chronic obstructive pulmonary diseases journal of resipiratory

medicine 2008 Aug; 98(13): 1234-40.

16) Jerkins and Souter C, a survey into the use of incentive spirometry following

CABG survey, physio theory pract 1990 London UK;6,117-126

17) Orfanos P, Ellis E, Johnston C, effect of deep breathing exercise and ambulation

on pattern in ventilation in post operative patient , aust j physiotherapy 1999 Sydney

Australia 45(3); 172-182

18) Southan Dj diaphragmatic or abdominal breathing in asthmatic and physiotherapy;

its value in physiotherapy 1995 New York USA; 73(8); 427

19) Black and Jacob medical surgical nursing (5th edition) WB sounder’s company
Philadelphaic

20) http:/www.medicine.com

21) http:/ www.pubmed.com

22) http:/ www.medscap.com

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1.Signature of candidate:

2.Remarks of the Guide :

3.Name of the Designation of the . Mrs. Manimala. R

Guide: Asso. Proffessor
HOD, Medical Surgical Nursing
Goutham College of Nursing
Bangalore.

4. Signature

5. Head of the department: Mrs. Manimala.R

Asso. Proffessor
HOD, Medical Surgical Nursing
Goutham College of Nursing
Bangalore.

6. Signature:

7. Remarks of chairman and the

principal:

8. Signature of principal:

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